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Research Forum Abstracts the relationship between disenrollment and the utilization of Emergency Department services by uninsured individuals at Vanderbilt University Medical Center’s Adult Emergency Department (ED). We hypothesize that the ED may have experienced increased visitation rates by uninsured individuals following Medicaid disenrollment, and these visits may be for nonemergent medical needs. To our knowledge, this is the first such study to examine a relationship between Medicaid reform and ED utilization. Methods: This study was approved by the Vanderbilt Institutional Review Board. It is an observational retrospective review of patient utilization data in the ED for the years 2005 and 2006. Visitation rates were delineated across time by insurance status at time of visitation. CPT codes for all visitations were examined as well, serving as a proxy for visit acuity level. Comparisons between the two periods were performed using Chi-square analysis. Results: From July 1, 2004 through June, 30 2005 (fiscal year 2005), the ED saw 47,263 patients. Of these patients, 5,515 (11.7%) were uninsured. In the first two months following TennCare disenrollment (August 1, 2005 though September 30, 2005), uninsured patients represented 15.9% of all patients in the ED. In the first four months following TennCare disenrollment (August 1, 2005 though November 30, 2005), the ED saw 15,481 patients, of whom 2,497 were uninsured (16.1%). Over the same four month period in 2004, the ED saw 15,330 patients, of whom 1,702 were uninsured (11.1%). The uninsured patient volume increased by 795 patients, or 47%, from the four month period in 2004 to the same period in 2005 (p ⬍ 0.0001). Among the 2,497 uninsured visits between August 1, 2005 though November 30, 2005, 422 (17.0%) were coded for a limited or brief exam. Over the same period in 2004, 380 (22.3%) of the 1,702 visits were coded for a limited or brief exam (p⫽0.0003). Conclusion: Visits to the ED by the uninsured are increasing. Both the proportion and absolute number of uninsured patients seen in the ED increased in the first four months after TennCare disenrollment. The percentage of brief or limited visits among the uninsured did not increase. Such findings may imply that individuals who lost TennCare coverage may increase their utilization of ED services. State legislatures must balance the fiscal strain of a growing public health insurance program against the rise in emergency care and lack of primary care faced by the uninsured. This is a preliminary investigation. Further research is necessary to quantify the correlation among actual disenrollees and to study confounders before causality can be assessed.

388

Current Status of US Emergency Departments

Camargo CA Jr, Ahn C, Clark S, Sullivan AF/Massachusetts General Hospital, Boston, MA

Study Objectives: Emergency departments (EDs) provide round-the-clock emergency care but also serve a “safety net” role. With a long-term goal of identifying gaps in ED coverage, we sought to determine the number, distribution, and basic characteristics of US EDs in 2003. We also explored ED-related changes between 2001 and 2003. Methods: The 2001 National ED Inventory (NEDI) was created using 2001 data from the SMG Marketing Group (now Verispan), the American Hospital Association, and original data collection by EMNet staff (www.emnet-usa.org). The 2003 Inventory was created using similar methods. Analyses were restricted to nonfederal, non-specialty hospitals. For 1,091 hospitals without ED data in 2003 (ie, 23% of 4,838 eligible hospitals), ED status was clarified by internet searches or using data collected from sites via fax/interview. Since a defining characteristic of an ED is availability 24 hr/day x 7 days/wk, we divided EDs at 8,760 annual visits (ie, 1 visit/ hr/day). Analysis used Chi2. Results: Of 4,838 hospitals in 2003, 4,790 (99%) reported having an ED. These “EDs” reported almost 113 million visits or an average of 20k visits/ED. A total of 1,345 EDs (30%) reported ⬍ 8,760 visits/year. The remaining 3,445 EDs reported 108 million visits, or 31k visits/ED, with marked regional differences (p ⬍ 0.001). Excluding the low-volume EDs, 2,434 EDs (71%) were located in metropolitan areas, and this also differed by region (p ⬍ 0.001). The Northeast had 631 EDs (18% of US total), with 78% urban and an average of 34k visits. The Midwest had 801 (24%), with 43% urban and 29k visits. The South had 1,391 (40%) EDs, with 51% urban and 32k visits. Finally, the West had 622 (18%) EDs, with 61% urban and 31k visits. Between 2001 and 2003, the total number of EDs nationwide decreased by 72, while the total number of visits increased by 12 million. The proportion of EDs with ⬍ 8,760 visits decreased from 31% to 28%. Over the two year period, the

S116 Annals of Emergency Medicine

average number of visits per ED increased (20k vs. 23k; p ⬍ 0.001), and this increase was seen in all regions (all p ⬍ 0.001). Conclusion: Annual visit volume of US EDs varies tremendously. In 2003, a total of 3,456 EDs had ⱖ8,760 visits/year and they accounted for 95% of all visits. From 2001 to 2003, the absolute number of EDs continued to decline, while ED visit volumes continued to rise. In addition to a surveillance, as provided by NEDI, the US should consider classifying EDs, as it does trauma centers. ED classification could clarify both the type of care available in this heterogeneous clinical setting and the national distribution of EDs.

389

Implementation of the Full Capacity Protocol to Relieve Crowding in the Emergency Department: Who Is Eligible?

Viccellio P, Santora C, Thode Jr HC, Horbatuk E/Stony Brook University, Stony Brook, NY

Study Objectives: Admitted patients often board for prolonged periods of time in the ED due to a lack of an inpatient bed. To alleviate ED crowding, Stony Brook University Hospital (SBUH) utilizes a full capacity protocol (FCP) to identify patients who may safely be moved to an inpatient hallway or alcove when crowded conditions exist. This practice is explicitly recommended by the NY State Department of Health (see www.hospitalovercrowding.com). The purpose of this study is to identify how many admitted patients meet the FCP criteria. Methods: Setting: University teaching hospital ED with an annual census of 72,000 patients. Design: Retrospective observational study using all patients admitted from the ED from October 2005 to March 2006. Measurements and Outcomes: The criteria for FCP, which has been in effect at SBUH since 2001, are available at www.hospitalovercrowding.com. The study population included all admissions to the medical service, excluding all Intensive Care Unit (ICU) or step-down unit admissions. For this subset of patients, the admitting ED physician completed an admission form which included an assessment for FCP eligibility, independent of whether crowded conditions existed. Results: During the 23 week study period, there were 6049 admissions from the ED. Of 4638 patients meeting eligibility criteria, 2696 patients (58%) met the FCP criteria. Triggering the FCP in circumstances where the ED and inpatient units were at maximum census, 484 (18%) of the qualified patients were redistributed to the inpatient units to relieve crowding in the ED. Conclusion: More than half of non-ICU patients admitted to the hospital are FCP eligible. The implementation of the FCP can be an important method for relieving emergency department crowding, allowing the ED to fulfill its mission of caring for patients with emergency conditions.

390

The Differential Impact of ED Volume and Boarded Admitted Patients on Waiting Times for New Patients

Viccellio P, Santora C, Thode HC Jr, Horbatuk E/Stony Brook University, Stony Brook, NY

Study Objectives: The boarding of admitted patients has been reported to significantly impact on waiting times for new patients, and be a driving force for ambulance diversion. The purpose of this study is to determine how waiting time is impacted by active ED volume vs. the boarding of admitted patients. Methods: Setting: University teaching hospital with an annual ED census of 72,000. No patients are kept in the waiting room after triage; all patients are brought into the clinical treatment area regardless of bed availability. Data: All patients entering the ED for a 10 month period in 2005, excluding those triaged to immediate care, totaling 33,362 patients. For each patient, the time of registration, time to first order entry, time to ED discharge (for non-admitted patients) and time to leaving the ED (for admitted patients) was obtained from hospital data. Time to order entry was available only for those patients who were discharged. Census data at time of patient visit, including number of active patients and number of boarded admitted patients waiting for a hospital bed were also obtained from hospital records. Data Analysis: Regression analysis of waiting times on census variables in order to see the contribution of number and type of patient to ED wait. Analyses were conducted for the hours 10 AM to 1 AM. All reported effects are significant at the 0.05 level. Results: Median time from registration until first order entry was 1 hour (IQR [Interquartile range] 35-100 minutes) and for time to ED discharge was 259 minutes (IQR 175-380). The effect of census on time to first order was 5 minutes for each

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