California Emergency Departments: Use Grows as Coverage Expands AUGUST 2018 California Emergency Departments Executive Summary California’s emergency departments (EDs) provide a critical source of health care to people experiencing acute medical CONTENTS conditions or suffering from trauma and injury, and are expected to treat all patients regardless of their ability to pay. They also provide an important entry point for inpatient hospital care. In 2016, 334 acute care hospitals in California operated Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 EDs. The number of EDs has remained relatively stable since 2006, while the number of individual treatment stations Patient Visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 within them has grown by 1,802 to reach 7,889 in 2016. California’s EDs handled 14.6 million visits in 2016, an increase of 44% since 2006. Ambulance Diversion. . . . . . . . . . . . . . . . . . . . 16 California’s Emergency Departments: Use Grows as Coverage Expands looks at the most recent data on supply, patient visits, Patients Not Seen. . . . . . . . . . . . . . . . . . . . . . . 18 and the quality of emergency departments in California, as well as trends from 2006 to 2016. Long ED stays may be a sign that the ED is overcrowded or understaffed, or that there is a lack of available inpatient beds. Wait Times. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 KEY FINDINGS INCLUDE: Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 • The supply of ED treatment stations increased in regions throughout the state, even those that experienced Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 a decrease in emergency departments. Use of EDs varied widely across California, from a low of 311 visits per 1,000 residents in Orange County to a high of 516 in Northern and Sierra Counties. • Medi-Cal was the expected payer for 43% of all ED visits in 2016, compared to 26% for private payers and 21% for Medicare. • Approximately one in every eight ED visits resulted in a hospital admission. Still, there were many serious conditions among patients who were not admitted, including one in ten visits classified as severe and posing immediate threat to life or physical function. • California ED patients who were sent home spent nearly three hours in the ED, 24 minutes longer than the median stay nationwide. California ED patients who were admitted spent over five and a half hours in the ED, an hour longer than the national median. CALIFORNIA HEALTH CARE FOUNDATION 2 California Emergency Departments General Acute Care Hospitals, by ED Level Supply California, 2016 In 2016, 80% of California’s general acute care (GAC) hospitals operated a licensed emergency department GAC Hospitals (ED). EDs provide different levels of Without service. The majority are licensed at Licensed ED 20% the basic level. Comprehensive (2%) TOTAL ED Level GAC HOSPITALS 420 Standby 8% Basic 70% Notes: Basic level emergency departments (EDs) have an ED physician on staff 24 hours a day, year-round. Comprehensive level EDs have an ED physician on staff 24 hours a day year- round, as well as other physician specialties (including, but not limited to, thoracic surgeons, neurosurgeons, orthopedic surgeons, and pediatricians) 24 hours a day year-round. The hospital must also provide burn, acute dialysis, and cardiovascular surgery services. Standby level EDs have an ED physician, at minimum, on call. Source: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2016. CALIFORNIA HEALTH CARE FOUNDATION 3 California Emergency Departments Trauma Centers, by Level Supply California, 2016 Trauma centers are an important subset of emergency departments; they treat patients with traumatic Level IV injury. Local Emergency Medical 13% Level I 19% Services Agencies designate trauma centers according to level, based Level III on the equipment and resources 16% TOTAL TR AUMA CE NTE RS available. Level 1 is the highest. 79 In 2016, California had 79 trauma centers, 15 of which were Level 1. Level II 52% Notes: Trauma centers are designated by a local Emergency Medical Services Agency (EMSA) and include personnel, services, and equipment necessary for the care of trauma patients. General requirements include a trauma program medical director, a trauma nurse coordinator, a basic emergency department (minimum), a multidisciplinary trauma team, and specified service capabilities. EMSA has established four trauma center designations, with Level 1 being the highest. Sources: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2016; California Emergency Medical Services Authority, emsa.ca.gov. CALIFORNIA HEALTH CARE FOUNDATION 4 California Emergency Departments Emergency Departments and Treatment Stations Supply California, 2006 to 2016 While the number of emergency EMERGENCY DEPARTMENTS TREATMENT STATIONS departments has remained relatively 9,000 stable over the past 10 years, the 7,889 number of treatment stations has 8,000 increased by 30%. 7,000 6,087 6,000 5,000 4,000 3,000 2,000 1,000 337 333 338 337 339 338 343 335 337 338 334 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Note: A treatment station is a specific place within the emergency department adequate to treat one patient at a time. Source: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2006–2016. CALIFORNIA HEALTH CARE FOUNDATION 5 California Emergency Departments Emergency Departments and Treatment Stations Supply by Region, California, 2006 vs. 2016 The number of treatment stations EMERGENCY DEPARTMENTS TREATMENT STATIONS increased even in regions that 2006 2016 CHANGE 2006 2016 CHANGE experienced a decrease in the Central Coast 24 24 0% 320 416 23% number of emergency departments. Greater Bay Area 64 65 2% 1,240 1,545 20% For example, San Joaquin Valley Inland Empire 32 35 9% 634 820 23% experienced a decline in the number Los Angeles County 76 75 – 1% 1,544 1,960 21% Northern and Sierra 40 38 – 5% 344 425 19% of emergency departments, but Orange County 26 26 0% 518 646 20% added more than 200 new Sacramento Area 16 15 – 6% 352 473 26% treatment stations. San Diego Area 20 20 0% 476 733 35% San Joaquin Valley 39 36 – 8% 659 871 24% California 337 334 – 1% 6,087 7,889 23% Notes: See the appendix for a map of counties in each region. A treatment station is a specific place within the emergency department adequate to treat one patient at a time. Source: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2006–2016. CALIFORNIA HEALTH CARE FOUNDATION 6 California Emergency Departments Emergency Department Visits Patient Visits per 1,000 Population and Total, California, 2006 to 2016 Between 2006 and 2016, the ■ VISITS PER 1,000 POPULATION TOTAL VISITS (IN MILLIONS) number of emergency department 16 14.6 visits increased by 44%, while the 14 state’s overall population increased by 9%. The number of visits per 12 1,000 residents increased by 33%. 10 10.1 8 6 4 2 280 284 294 315 310 317 326 332 346 366 371 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 P O P U L AT I O N ( I N M I L L I O N S ) 36.0 36.3 36.6 37.0 37.3 37.7 38.0 38.3 38.7 39.0 39.3 Sources: Author calculations based on Office of Statewide Health Planning and Development, Emergency Department Data and Patient Discharge Data, 2006–2016; United States Census Bureau, Intercensal Estimates of the Residential Population for Counties of California: April 1, 2000 to July 1, 2010, and Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2016. CALIFORNIA HEALTH CARE FOUNDATION 7 California Emergency Departments Emergency Department Visits per 1,000 Population Patient Visits by Region, California, 2016 A D M I S S I ON Emergency department (ED) visits R AT E per 1,000 residents varied widely Central Coast 355 12% across the state, from a low of 311 Greater Bay Area 339 12% in Orange County to a high of 516 in the Northern and Sierra region. Inland Empire 393 13% Despite a wide range in ED visits per Los Angeles County 364 15% 1,000 residents across regions, the percentage of ED patients admitted Northern and Sierra 516 11% to the hospital was fairly consistent. Orange County 311 16% Sacramento Area 410 12% San Diego Area 318 15% San Joaquin Valley 451 11% OVERALL: 371 13% Note: See the appendix for a map of counties in each region. Sources: Author calculations based on Office of Statewide Health Planning and Development, Emergency Department Data and Patient Discharge Data, 2016; United States Census Bureau, Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2016. CALIFORNIA HEALTH CARE FOUNDATION 8 California Emergency Departments Emergency Department Visits per Treatment Station Patient Visits California, 2006 to 2016 In 2016, the average California emergency department treatment 1,802 1,846 station handled over 1,800 visits, or 1,724 1,691 1,686 1,695 1,683 1,733 1,656 1,677 1,673 approximately five visits per day. 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: Author calculations based on Office of Statewide Health Planning and Development, Utilization Data, 2006–2016. CALIFORNIA HEALTH CARE FOUNDATION 9 California Emergency Departments Emergency Department Visits, by Expected Payer Patient Visits California, 2006 and 2016 The number of Medi-Cal emergency department (ED) visits almost doubled between 2006 and 2016, 2006 2016 while self-pay/uninsured visits Other Self-Pay/ 3% declined. In 2016, Medi-Cal was the Other Uninsured 7% 7% expected payer (i.e., the entity that Self-Pay/ Private the hospital expected to pay for the Uninsured 26% visit) for 43% of ED visits, compared 16% Private 35% Medicare TOTA L 21% TOTAL with 23% in 2006. Under the ACA, 10.1 million 14.6 million which went into full effect in 2014, Medicare 19% California expanded Medi-Cal to all Medi-Cal Medi-Cal low-income adults. Between 2006 23% 43% and 2016, the number of Medi-Cal enrollees doubled. Notes: Self-pay/uninsured includes county indigent and other indigent programs. Other includes disability, Veterans Affairs, Workers’ Compensation, and other federal/non-federal programs. Source: Author calculations based on Office of Statewide Health Planning and Development, Emergency Department Data and Patient Discharge Data, 2006 and 2016. CALIFORNIA HEALTH CARE FOUNDATION 10 California Emergency Departments ED Visits, by Expected Payer and Region Patient Visits California, 2016 The payer mix of emergency í Medi-Cal í Medicare í Private í Self-Pay/Uninsured í Other department (ED) visits varied by Central Coast 42% 23% 25% 6% 4% region. In Orange County and the Greater Bay Area, private insurance Greater Bay Area 34% 24% 30% 7% 5% coverage was the expected payer for Inland Empire 49% 19% 22% 7% 3% 30% of visits. In San Joaquin Valley, Los Angeles County 43% 19% 27% 8% 2% Medi-Cal was expected to pay for over half of ED visits. Northern and Sierra 44% 28% 19% 5% 4% Orange County 39% 23% 30% 6% 2% Sacramento Area 42% 24% 25% 6% 3% San Diego Area 40% 24% 27% 6% 4% San Joaquin Valley 56% 17% 19% 5% 2% California 43% 21% 26% 7% 3% Notes: Other includes disability, Veterans Affairs, Workers’ Compensation, and other federal/non-federal programs. Segments may not sum to 100% due to rounding. Source: Office of Statewide Health Planning and Development, Emergency Department Outpatient and Inpatient Data, 2016. CALIFORNIA HEALTH CARE FOUNDATION 11 California Emergency Departments Emergency Department Visits, by Acuity Level Patient Visits California, 2006 to 2016 Minor Low/Moderate Moderate All emergency department visits VISITS (IN MILLIONS) Severe Without Threat Severe With Threat are classified by acuity level, from 6 minor to “severe with threat,” which 5.3 means the patient’s life could be 5 in danger. While visits classified as moderate represented the largest 4 3.3 3.6 proportion of visits, the percentage of severe visits (with and without 3 2.6 2.5 threat) increased from 32% in 2006 2.1 2.3 to 42% in 2016. 2 1.2 1 1.0 0.8 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Notes: Emergency department visits are categorized based on type of history/examination and medical decisionmaking required. A minor visit requires a problem-focused history/ examination and straightforward medical decisionmaking. A low/moderate visit requires expanded problem-focused history/examination and medical decisionmaking of low complexity. A moderate visit requires expanded problem-focused history/examination and medical decisionmaking of moderate complexity. A severe without threat visit requires a detailed history/examination and medical decisionmaking of moderate complexity. A severe with threat visit requires a comprehensive history/examination and medical decisionmaking of high complexity. Excludes visits with unknown/unreported severity. Source: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2006–2016. CALIFORNIA HEALTH CARE FOUNDATION 12 California Emergency Departments Emergency Department Visits Patient Visits by Acuity Level of Those Not Admitted, California, 2016 The majority of emergency Emergency Department Visits Acuity Level of Those Not Admitted department visits did not result in N =14.6 million a hospital admission. One in ten 11% — Severe With Threat visits for patients not admitted were for conditions severe enough Admitted 25% — Severe Without Threat to be life-threatening, and an 13% additional one in four visits were for severe conditions without threat (e.g., an elderly patient who fell 40% — Moderate and was unable to walk). Not Admitted 87% 18% — Low/Moderate 6% — Minor Notes: Emergency department visits are categorized based on type of history/examination and medical decisionmaking required. A minor visit requires a problem-focused history/ examination and straightforward medical decisionmaking. A low/moderate visit requires expanded problem-focused history/examination and medical decisionmaking of low complexity. A moderate visit requires expanded problem-focused history/examination and medical decisionmaking of moderate complexity. A severe without threat visit requires a detailed history/examination and medical decisionmaking of moderate complexity. A severe with threat visit requires a comprehensive history/examination and medical decisionmaking of high complexity. Excludes visits with unknown/unreported severity. Source: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2016. CALIFORNIA HEALTH CARE FOUNDATION 13 California Emergency Departments Emergency Department Visits, by Diagnosis Patient Visits California, 2016 Injuries and poisonings were Symptoms 21.0% among the most common Injuries/Poisonings reasons for visiting the emergency 19.4% Respiratory System department, accounting for one 10.4% in five visits in 2016. Digestive System 7.1% Musculoskeletal System 6.4% Genitourinary System 5.6% Circulatory System 4.3% Mental Disorders 4.2% Infections 4.0% Skin Disorders 3.9% Pregnancies 2.6% Nervous System 2.5% Not shown: other (2.6%), ear disorders (2.0%), endocrine diseases (1.9%), eye disorders (1.0%), blood disorders (0.5%), cancer (0.5%), perinatal disorders (0.1%), birth defects/births (0.0%). Source: Office of Statewide Health Planning and Development, Emergency Department Outpatient and Inpatient Data, 2016. CALIFORNIA HEALTH CARE FOUNDATION 14 California Emergency Departments Emergency Department Visits, by Age Patient Visits California, 2016 Adults age 20 to 49 accounted for <1 four in ten emergency department 80+ 3% encounters, and adults age 50 to 7% 1 to 9 69 accounted for almost one in 70 to 79 7% 11% four visits. 10 to 19 9% TOTAL E D V IS ITS 50 to 69 14.6 million 23% 20 to 49 40% Note: Segments don’t sum to 100% due to rounding. Source: Office of Statewide Health Planning and Development, Emergency Department Outpatient and Inpatient Data, 2016. CALIFORNIA HEALTH CARE FOUNDATION 15 California Emergency Departments Ambulance Diversion Hours Ambulance Diversion California, 2006 to 2016 Ambulance diversion occurs when TOTAL NUMBER OF HOURS EDs CLOSED TO AMBULANCES a hospital redirects ambulances to 200,000 nearby hospitals. Overcrowding in 182,642 the emergency department (ED) 175,000 is the most common reason an 150,000 ambulance is diverted. Ambulance diversion can have many negative 125,000 consequences, from increasing 100,000 ambulance turnaround time, to 94,687 reducing patient quality of care, to 75,000 negatively impacting ED capacity 50,000 at nearby hospitals. Diversion hours in California decreased by 48% 25,000 between 2006 and 2016. 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Sources: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2006–2016; “Health Policy Brief: Ambulance Diversion,” Health Affairs, June 2, 2016, www.healthaffairs.org. CALIFORNIA HEALTH CARE FOUNDATION 16 TOTAL NUMBER OF HOURS EMERGENCY DEPARTMENTS CLOSED TO AMBULANCES 2006 2016 CHANGE – % % – % – % % – % – % – % – % – % ( ) “ ” emsa.ca.gov 17 California Emergency Departments ED Visits from Patients Who Left Without Being Seen Patient Not Seen California, 2006 to 2016 In 2016, 326,587 patients registered 2006 374,872 in the emergency department (ED) but left before being treated by an 2007 363,082 emergency physician. 2008 510,283 2009 444,739 2010 300,574 2011 303,654 2012 314,507 2013 311,220 2014 311,735 2015 363,152 2016 326,587 Source: Office of Statewide Health Planning and Development, Hospital Annual Utilization Data, 2006–2016. CALIFORNIA HEALTH CARE FOUNDATION 18 California Emergency Departments Emergency Department Wait Times Wait Times California, 2014 to 2016 Long stays in an emergency MEDIAN TIME (IN MINUTES) í 2014 í 2015 í 2016 department (ED) may be a sign that the ED is overcrowded or 330 343 341 understaffed, or that there is a lack of available inpatient beds. In 2016, the median stay for patients who were sent home was nearly three hours. Those being admitted stayed in the ED for over five hours on 165 167 162 average, with two of those hours 127 134 138 occuring after the doctor decided to admit them. Length of Stay Length of Stay Boarding Time Discharged Patients Admitted Patients Note: Boarding time is the amount of time patients spent in the emergency department (ED) after the doctor decided to admit them as an inpatient before leaving the ED for their room. Source: US Centers for Medicare & Medicaid Services, Hospital Compare, data.medicare.gov/data/hospital-compare. CALIFORNIA HEALTH CARE FOUNDATION 19 California Emergency Departments Emergency Department Wait Times Wait Times California vs. United States, 2016 In 2016, the median stay for MEDIAN TIME (IN MINUTES) í California í United States California emergency department patients who were sent home 341 was nearly three hours. That is 24 minutes longer than the 280 median stay nationwide. 162 138 138 100 Length of Stay Length of Stay Boarding Time Discharged Patients Admitted Patients Note: Boarding time is the amount of time patients spent in the emergency department (ED) after the doctor decided to admit them as an inpatient before leaving the ED for their room. Source: US Centers for Medicare & Medicaid Services, Hospital Compare, data.medicare.gov. CALIFORNIA HEALTH CARE FOUNDATION 20 California Emergency Departments Length of ED Stay for Admitted Patients, by County Wait Times California, 2013 to 2014 The amount of time patients spent Del Norte Siskiyou Modoc in the emergency department Time from ED Arrival to Departure Admitted Patients, by Quartile before being admitted varied by Trinity Shasta Lassen ■ 195 to 284 minutes ■ 328 to 352 minutes Humboldt ■ 286 to 320 minutes ■ 354 to 478 minutes county. Patients in Madera County Tehama Plumas Mendocino Glenn Butte Sierra had the longest wait time (nearly Nevada Overall: 340 minutes Lake Colusa Yuba Sutter Placer eight hours) while patients in Yolo El Dorado Sonoma Alpine Napa Sacra- mento Amador Colusa County had the shortest Solano Calaveras Marin San Tuolumne Mono San Francisco Contra Joaquin Costa (under four hours). Alameda Stanislaus Mariposa San Mateo Santa Merced Clara Santa Cruz Madera Fresno San Inyo Benito Tulare Monterey Kings San Luis Obispo Kern Santa Barbara San Bernardino Ventura Los Angeles Orange Riverside San Diego Imperial Notes: ED is emergency department. Data covers Q2 2013 to Q1 2014. No data are available for counties without color. Does not necessarily include general acute care hospitals exclusively. Source: “Hospital Report,” IPRO, accessed May 26, 2015, www.whynotthebest.org. CALIFORNIA HEALTH CARE FOUNDATION 21 California Emergency Departments Methodology ABOUT THIS SERIES The California Health Care Almanac is an online This analysis relies primarily on data obtained from reports submitted by licensed hospitals to clearinghouse for data and analysis examining the state’s health care system. It focuses on issues California’s Office of Statewide Health Planning and Development (OSHPD), which conducts an of quality, affordability, insurance coverage and annual standardized survey required from all hospitals in California. These include private Patient the uninsured, and the financial health of the Discharge Data, Emergency Department Data, and Hospital Annual Utilization Data. Data were system with the goal of supporting thoughtful used to evaluate emergency department (ED) capacity and utilization trends in California hospitals planning and effective decisionmaking. Learn from 2006 to 2016. All general acute care hospitals with an ED (standby, basic, and comprehensive) more at www.chcf.org/almanac. that was open at any time in the year during the study period were included. AU T H O R Renee Y. Hsia, MD, MSc, is professor of emergency medicine and health policy at the University of California, San Francisco (UCSF). ACKNOWLEDGMENTS Matthew Niedzwiecki, PhD, is assistant professor of emergency medicine and health policy at UCSF, and Sarah Sabbagh, MPH, is health policy research associate in the department of emergency medicine at UCSF. F O R M O R E I N F O R M AT I O N California Health Care Foundation 1438 Webster Street, Suite 400 Oakland, CA 94612 510.238.1040 www.chcf.org CALIFORNIA HEALTH CARE FOUNDATION 22 California Emergency Departments Appendix: California Counties Included in Regions REGION COUNTIES Central Coast Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Ventura NORTHERN Greater Bay Area Alameda, Contra Costa, Marin, Napa, San Francisco, AND SIERRA San Mateo, Santa Clara, Solano, Sonoma Inland Empire Riverside, San Bernardino Los Angeles County Los Angeles SACRAMENTO Northern and Sierra Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, AREA Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba Orange County Orange Sacramento Area El Dorado, Placer, Sacramento, Yolo GREATER BAY AREA San Diego Area Imperial, San Diego San Joaquin Valley Fresno, Kern, Kings, Madera, Merced, San Joaquin, NORTHERN Stanislaus, Tulare AND SIERRA CENTRAL COAST SAN JOAQUIN VALLEY INLAND EMPIRE LOS ANGELES COUNTY ORANGE COUNTY SAN DIEGO AREA CALIFORNIA HEALTH CARE FOUNDATION 23