Patterns in Patient Encounters and Emergency Department Capacity in California, 2011-2021

Abstract

ImportanceThe health care system has undergone major changes in the past decade, and emergency department (ED) crowding has worsened over time; however, the most recent patterns in ED capacity and use in California have yet to be studied.ObjectiveTo analyze patterns in ED capacity and utilization in California hospitals from 2011 to 2021.Design, Setting, and ParticipantsThis retrospective cohort study used data from the California Department of Health Care Access and Information and the US Census Bureau to analyze ED facility characteristics from more than 400 general acute care hospitals with more than 320 EDs in California as well as patients who presented to those EDs between January 1, 2011, and December 31, 2021.Main Outcomes and MeasuresLinear patterns (measured by percentage change) in total annual ED capacity (volume of hospital beds, EDs, ED treatment stations, and trauma centers) and ED use (ED visits by disposition and acuity) were assessed as primary outcomes. Patterns in ambulance diversion hours and the number of patients who left the ED without being seen were also examined as secondary outcomes. Visit acuity was categorized into 5 levels by increasing severity (minor, low to moderate, moderate, severe without threat, and severe with threat) based on California Department of Health Care Access and Information descriptions corresponding to Current Procedural Terminology codes.ResultsIn the prepandemic period (2011-2019), the total population of California increased from 37 638 369 to 39 512 223 (5.0%; 95% CI, 4.1%-5.8%), then decreased to 39 237 836 in 2021 (0.7%; 95% CI, −3.9% to 2.5%). Over the entire study period (2011-2021), the total California population increased by 4.2% (95% CI, 3.3%-5.2%). From 2011 to 2019, the annual number of ED visits increased from 12 054 885 to 14 876 653 (23.4%; 95% CI, 20.0%-26.8%) before decreasing to 12 944 692 in 2021 (−13.0%; 95% CI, −33.1% to 7.1%); from 2011 to 2021, total ED visits increased by 7.4% (95% CI, 5.6%-9.1%). From 2011 to 2021, the total number of EDs decreased from 339 to 326 (−3.8%; 95% CI, −4.4% to −3.2%) and the total number of hospital beds decreased from 75 940 to 74 052 (−2.5%; 95% CI, −3.3% to −1.6%), while the number of ED treatment stations in these fewer EDs increased from 7159 to 8667 (21.1%; 95% CI, 19.7%-22.4%). The number of visits rated as severe with threat also increased, from 2 011 637 in 2011 to 3 375 539 in 2021 (67.8%; 95% CI, 59.7%-75.9%), while visits rated as minor decreased from 913 712 to 336 071 (−63.2%; 95% CI, −75.2% to −51.2%) over the same period.Conclusions and RelevanceIn this cohort study, multiple measures of ED capacity did not proportionally increase with the increasing demand for services; however, the COVID-19 pandemic appears to have substantially affected some of these patterns. These findings may be helpful to policy makers and health care stakeholders when planning resource allocation of limited health care resources.

Impact of skilled nursing facility (SNF) 3‐day hospitalization requirement waiver during the COVID‐19 pandemic on emergency department and inpatient SNF discharges in California

“…For example, during the initial months following the declaration of the public health emergency, ED census across the nation fell markedly, including in California. 5,6 Similarly, COVID had a major impact on SNF and other long-term care facilities that adopted efforts to reduce disease spread within their facilities such as limiting access and admissions. 7 Second, the 3-day hospitalization rule primarily applied, and thus the waiver had the most potential impact, on fee-for-service (FFS) beneficiaries of Medicare.…”

Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study

“…Emergency departments (EDs) internationally have experienced significant increases in attendance over the past two decades from 2003 to 2023, with indications this trend will continue to escalate [1][2][3][4]. EDs are overcrowded, posing a significant challenge for the healthcare system [5,6].…”

Trends by Acuity for Emergency Department Visits and Hospital Admissions in California, 2012 to 2022

“…Emergency departments (EDs) are an integral component of the US health care system, as they care for all patients and provide an entry point . However, ED visits have outpaced population growth while the number of EDs has decreased . Between 2011 and 2021, California ED visits increased by 7.4% while the number of EDs decreased by 3.8% .…”

“…However, ED visits have outpaced population growth while the number of EDs has decreased . Between 2011 and 2021, California ED visits increased by 7.4% while the number of EDs decreased by 3.8% . Furthermore, from 2006 to 2019, high complexity treat-and-release ED visits billed as high intensity increased from 4.8% to 19.2% nationally …”