New CDC survey results echo report from IOM
A new report from the Centers for Disease Control and Prevention's (CDC) reinforces the assertions of a report on the state of emergency medicine by the Institute of Medicine (IOM) that crowding in the nation's EDs has reached nearly epidemic proportions.1
The CDC report, based on data from the 2003-04 National Hospital Ambulatory Medical Care Survey (NHAMCS), notes that almost half of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times. About one-third of U.S. hospitals reported having to divert an ambulance to another ED due to overcrowding or staffing shortages at their ED. Crowding in metropolitan EDs was associated with a higher percentage of nursing vacancies, higher patient volume, and longer patient waiting and treatment durations, the report says. Half of EDs in metropolitan areas had more than 5% of their nursing positions vacant. According to NHAMCS figures, the United States had an average of 4,500 EDs in 2003 and 2004, more than half of which saw fewer than 20,000 patients annually. However, one in 10 EDs had an annual visit volume of more than 50,000 patients.
"I think our findings jibe with the IOM's virtually everywhere," says Catharine W. Burt, EdD, chief of the Ambulatory Care Statistics Branch at the National Center for Health Statistics at the CDC and lead author of the report.
Not an aberration
If anything, Burt says, the CDC's report has even greater statistical underpinnings. "A lot of the IOM report was based on some studies about crowding and ambulance diversion done in different states, while this report is national — saying it's true everywhere, and not just in the places that 'talk' the loudest," she explains.
The validity of national statistics emphasizes that this trend "is not the result of an aberration in Los Angeles, or Massachusetts," Burt says. "The higher your daily occupancy rate, the more likely you are you will have to go on ambulance diversion."
There was one area in which her statistics differed from the IOM's, says Burt, although she is quick to add it doesn't detract from the significance of the problem. In the IOM report, the authors quote a study that found that 91% of hospitals were crowded in the opinion of the ED director, she says.
"But this report is objective: We actually count how many diversion there were, how many left without being seen, and how many urgent cases that should have be seen had to wait longer than an hour on average," Burt says. "Our statistics show that 50% of EDs were crowded — not 91% — but it's still a common thing."
James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group based in Canton, OH, says, "I thought they may actually be underestimating what's going on in the market. It depends on how they surveyed the participants." What Augustine means is that at present there are no nationally accepted definitions for diversion, rerouting, and so forth. "At this point those are all community definitions," he says.
However the figures are calculated, Burt also notes that because 8% of the hospitals nationwide are not allowed to go on diversion, ED crowding is not just a diversion issue. Besides, she asserts, "diversion is not a best practice."
More solutions-oriented
Burt says that in the future her surveys are going to expand to address potential solutions to the problems it identifies. For example, in the 2007 survey they have added questions for hospital and ED directors about some of the things that were in the IOM report, such as electronic whiteboards; zone nursing, in which a nurse sees patients in a very specific set of locations, all next to each other; and some technology issues such as radio frequency identification (RFID), she shares.
The formulation of questions is critical in such surveys, Burt says. In 2002, it appeared that about 32% of EDs had electronic medical records (EMRs), she says. "But in 2005, we asked about specific system features, and when we started looking at those answers, and at what experts say EMRs really have to have, that number comes down to 5%," Burt says.
EMRs are another area in which the emergency field doesn't have good definitions, Augustine says. "We may have some EMR pieces in place, yet the entire EMR has not been perfected yet and certainly not implemented yet in the ED." The most developed system is the one at the Veterans Affairs (VA) medical centers, he says. "They are very far ahead on this," Augustine notes. "Their EMR is as functional and friendly as system makers can design them now."
The EMR at the VA is an internal product, developed with the Massachusetts Institute of Technology in Boston. The name given the basic database that all VA medical centers throughout the nation access is VISTA (Veterans Health Information and Technology Architecture).
Reference
- Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2004-04. Adv Data 2006; 376:1-23.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content