Original Contributions
Trends in the use and capacity of California's emergency departments, 1990-1999*,**,*,*

Abstract presented at the CAL/ACEP Scientific Assembly, San Jose, CA, June 2001.
https://doi.org/10.1067/mem.2002.122433Get rights and content

Abstract

See editorial, p. 430. Study Objective: Concerns over the ability of the nation's emergency departments to meet current demands are growing among the public and health care professionals. Data supporting perceptions of inadequate capacity are sparse and conflicting. We describe changes in the use and capacity of California's EDs between 1990 and 1999, as well as trends in severity of patient illness or injury. Methods: Data from California's Office of Statewide Health Planning and Development (OSHPD), which describe all hospital and health service use in the state, were analyzed and later verified using a telephone survey of all 320 open EDs in California. Six variables were analyzed: hospital's ownership type (public or private), total number of annual ED visits, severity of patient illness or injury (percentage of visits categorized as critical, urgent, or nonurgent), number of ED beds, proximity to a closed ED, and teaching status. We tested 2 main hypotheses: (1) Have statewide ED visits, ED beds, visits per ED, and visits per bed increased or decreased between 1990 and 1999? and (2) Has severity of patient illness or injury, as reported to OSHPD, changed over the past decade? State level data were analyzed using ordinary least-squares regression. Hospital level data were analyzed using repeated measures analyses. Results: The number of EDs in California decreased by 12% (P <.0001). The number of ED treatment stations (ie, physical spaces for the treatment of patients) increased by 687 (16%) statewide (P =.0001), or an average of 79 beds per year. The average annual change in ED visits was not statistically significant (P =.5), whereas visits per ED increased by 27% for all EDs (P <.0001), although with differing trends noted at public and private hospitals. At private hospitals, the average increase was 512 visits/ED each year, whereas at public hospitals, visits decreased by an average of 1,085 visits/ED each year (P <.0001). Overall, critical visits per ED increased by 59% (P <.0001), and nonurgent visits per ED decreased by 8% (P <.0001). Conclusion: The number of EDs in California decreased significantly during the 1990s, whereas the number of ED beds increased. Increases in visits per ED, beds per ED, and in the proportion of patients categorized as critical may help explain the perception that ED capacity is inadequate to meet growing demand. [Lambe S, Washington DL, Fink A, Herbst K, Liu H, Fosse JS, Asch SM. Trends in the use and capacity of California's emergency departments, 1990-1999. Ann Emerg Med. 2002;39:389-396.]

Introduction

Both the public and health care professionals have become increasingly concerned about the ability of the nation's emergency departments to meet the perceived growing demand for care, charging that inadequate capacity may be leading to long waiting times, an unpleasant therapeutic environment, and possibly unsafe medical care.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 As a result, a number of states have begun to formulate legislation to address some of these issues, with mixed success.14, 15

Although the public's concern and the number of proposed legislative solutions have increased in recent years,6, 7 there is a lack of objective data validating ED overcrowding in California. There is clear evidence, however, that the use of emergency services throughout the United States is increasing16, 17 and that disquiet has arisen over the health care system's capacity to meet this growing demand.

In California, data regarding the adequacy of the state's EDs have been sparse and conflicting. The only publicly available report on the use and capacity of California's EDs over the past decade comes from the California Emergency Medical Services Authority (EMSA) Task Force,18 which reported that between 1990 and 1997 the number of ED beds increased by 15% and the proportion of critically ill patients increased by 24%, but the total number of visits and admissions to EDs remained unchanged. On the other hand, 96% of respondents in a 1999 survey of California ED directors reported overcrowding and prolonged waiting times for care as problems, and two thirds of the respondents believed that these problems have worsened during the past 5 years.19

Although this survey and an increasing number of media reports suggest a growing problem with the availability of prompt emergency care in California, a systematic evaluation has not yet been conducted to identify the characteristics or extent of the problem. Many questions remain unanswered, including whether the capacity of California's EDs is sufficient to meet the needs of critically ill patients throughout the state. This study aims to address some of these questions by analyzing data from California's Office of Statewide Health Planning and Development (OSHPD), which describe all hospital and health service use in the state. Using OSHPD data from 1990 to 1999, the study evaluates changes in the capacity and use of California's EDs and trends in severity of patient illness or injury.

Section snippets

Materials and methods

We used OSHPD's Annual Utilization Report of Hospitals to obtain data on variables relevant to emergency care in California's hospitals. All California hospitals are required to submit a standardized data reporting form to OSHPD describing annual use of services. The form includes 490 variables related to a wide range of hospital resources (eg, psychiatric services, cardiac catheterizations, hospice, radiation therapy, birth, abortion data). OSHPD defines the variables to be collected but does

Results

Of the 731 facilities that reported to OSHPD between 1990 and 1999, we excluded from our analysis 96 acute psychiatric facilities, 36 psychiatric health facilities, 27 federal hospitals (primarily Veteran's Administration hospitals), and 20 chemical dependency recovery hospitals. Of the remaining 552 facilities, according to the OSHPD data, as of January 1, 1999, there were 357 EDs statewide. Of these, 301 were basic, 47 were standby, and 9 were comprehensive facilities.

On the basis of the

Discussion

From 1990 to 1999, the number of EDs in California decreased by 12%. During this same period, the number of visits per ED increased by 27%, the number of ED beds increased by 16%, and severity of patient illness or injury intensified, with a 59% increase in patients categorized as critical and an 8% decrease in patients categorized as nonurgent per ED. However, this increase was not consistent across the decade: visits per ED increased markedly between 1990 and 1993, stabilized in the

Acknowledgements

We thank Marianne Laouri, PhD, and the California HealthCare Foundation for commissioning and generously supporting this project. We also thank the following individuals for their shared expertise and commitment to the investigation: Douglas Bagley, MS; Demetrios Demetriades, MD, PhD; Kelly Hubbell, RN; Brian Johnston, MD; Roneet Lev, MD; James Lott, MBA; Daniel R. Marguiles, MD; Beth Osthimer, JD; Bruce Spurlock, MD; and Cheryl Starling, RN. We are extremely grateful to Marlene

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    *

    Author contributions are provided at the end of this article.

    **

    This work was commissioned by the California HealthCare Foundation. Dr. Lambe is a research fellow in the Robert Wood Johnson Clinical Scholars' Program.

    *

    Reprints not available from the authors.Address for correspondence: Susan Lambe, MD, Division of Emergency Medicine, University of California at San Francisco, Box 0208, 505 Parnassus Street, San Francisco,CA 94143; 415-353-1634,fax 415-353-1799; E-mail [email protected].

    *

    Author contributions: DLW, SMA, AF, and SL conceived the project and developed the study methodology. SL, DLW, AF, SMA, and JSF supervised the conduct of the study, data collection, quality control, and analysis. HL provided statistical advice and analysis. KH provided expertise in geoencoding and medical geography. SL drafted the manuscript, and all authors contributed substantially to its revision. SL takes responsibility for the paper as a whole.

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