Center for Studying Health System Change

Emergency Room Demand Outstrips Supply; Patients Potentially at Risk

Ambulances Increasingly Diverted as Hospitals Reach Overload

News Releases
May 9, 2001

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ASHINGTON, D.C. - Too many patients, too few beds and a severe nursing shortage mean hospitals across the country must increasingly divert critically ill patients to other emergency rooms, according to a study released today by the Center for Studying Health System Change (HSC).

"As emergency room crowding increases, and any given community’s hospitals experience overload simultaneously, serious threats to patient care are emerging," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded solely by The Robert Wood Johnson Foundation.

While hospitals have always experienced sporadic spikes in demand for emergency services, especially during the winter flu season, recent HSC site visits to 12 nationally representative communities show emergency room diversions are now a year-round problem. The findings are detailed in a new HSC Issue Brief - Emergency Room Diversions: A Symptom of Hospitals Under Stress - available at www.hschange.org. According to the study, emergency room overflows stem from both increased patient demand and a diminished supply of inpatient hospital beds.

Although excess capacity has long been considered a major problem for U.S. hospitals, daily emergency room overloads and overall inpatient capacity strains across the country suggest market forces are driving a rapid and significant change in hospitals’ ability to serve emergency patients.

"The emergency room logjam needs to be on policy makers’ radar screens and requires careful monitoring," Ginsburg said. "Policy makers need to assess whether stopgap measures at the community level, such as diverting ambulances and postponing elective surgeries, are enough to bring supply and demand into balance or whether policy intervention is needed.

"Emergency departments offer vital care 24 hours a day, seven days a week, and this stand-ready capacity is expensive," Ginsburg said. "Converging market forces raise serious questions about emergency departments’ ability to meet the demand for these critical community services without additional assistance."

Demand for emergency services has increased because of looser care management by health maintenance organizations (HMOs); more uninsured patients seeking care in emergency rooms; and increased enforcement of the federal Emergency Medical Treatment and Labor Act (EMTALA).

Responding to the consumer backlash against managed care and the passage of "prudent layperson" laws in more than 40 states, many HMOs have curtailed restrictive care management practices and have recently seen double-digit increases in the use of emergency services. At the same time, the number of uninsured Americans has increased by almost 10 million in the last decade to nearly 43 million, increasing pressure on emergency rooms.

Stepped up EMTALA enforcement by the federal Health and Human Services’ Office of Inspector General (OIG) also has played a role in increased demand. The 1986 law requires all Medicare-participating hospitals to screen patients to determine if they have an emergency condition, provide stabilizing treatment within the hospital’s capability and make appropriate transfers regardless of patients’ ability to pay.

Supply-side constraints include fewer emergency rooms to respond to the growing demand and a sharp reduction in the number of inpatient beds. Between 1994 and 1999, the number of emergency departments across the country declined by 8 percent from 4,547 to 4,177, while the total number of inpatient beds dropped 15.6 percent from 621,450 to 524,489, according to data from the American Hospital Association. Hospitals also have cited reduced hospital discharge options as a factor in the tight supply of inpatient beds as skilled-nursing facilities and home health agencies struggle to adapt to new Medicare payment systems mandated by the Balanced Budget Act of 1997.

Hospitals in many communities have developed coordinated ambulance diversion programs to help ensure patients can access timely care, and some are expanding emergency room and inpatient capacity. In Boston, for example, Massachusetts General and Brigham and Women’s hospitals have reopened about 300 beds, including most of the beds closed in the mid-1990s to reduce operating costs.

HSC research focuses on 60 nationally representative communities across the country and includes household, physician and employer surveys and site visits every two years. During site visits to 12 of these communities, researchers interview key local stakeholders and chronicle the changes in the health care market. The 12 communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

Gail Shearer, director, health policy analysis, Consumers Union
"The back ups in hospital emergency rooms are literally life and death issues for critically ill patients, and having ambulances circle cities looking for an open ER is no solution."

Robert Schafermeyer, M.D., F.A.C.E.P., president of the American College of Emergency Physicians
"Emergency physicians are on the frontlines 24-hours-a-day, 7-days-a-week and see first hand how hospital capacity problems can and do jeopardize patient care, and stopgap measures are not going to fix the problem."

James Bentley, senior vice president for strategic policy planning, American Hospital Association
"This study provides an independent systematic look at the challenges hospitals are facing as they try to deal with a severe nursing shortage, overflowing emergency rooms and inadequate inpatient capacity, at the same time demand for services is increasing."