What is new in the Data World? And how does the EMDI fit?

In 1992, the CDC began to collect and report on Emergency Department (ED) visits through the National Hospital Ambulatory Medical Care Survey (NHAMCS). A group called the Emergency Department Benchmarking Alliance was formed in 1994 to assist leaders in managing emergency services and to develop consistent definitions, performance measures, and regular reports for the industry. The EDBA began annual surveys in 2004, which report on ED performance. It is a voluntary registry. The survey for 2021 provides insight into 1,500 EDs that saw almost 40 million patient visits for the year.

Another two groups do national data gathering related to emergency care.

The American Hospital Association (AHA) provides a data summary of community hospitals, which it defines as non-federal, short-term general, and other specialty hospitals. The AHA does annual comprehensive data gathering from its members and surveys a stable number of EDs. It counted 2020 visits at 123.3 million in 4,589 EDs.

The National Emergency Department Inventory (NEDI)-USA database is maintained by the Emergency Medicine Network (EMNet) at Massachusetts General Hospital in Boston, MA. NEDI-USA contains data on all US EDs opened since 2001. According to NEDI-USA, there were 5,586 US EDs and 136.9 million US ED visits in 2020. All state-specific and national summary NEDI-USA data for the year 2019 can be found at this link: https://www.emnet-usa.org/research/studies/nedi/nedi2019/

So to compare the data collected and reported by these four organizations:

• The CDC survey, beginning in 1992, uses census data and sampling to estimate ED volumes in full-service, hospital-based EDs. It samples individual patient visits to characterize ED patient demographics, the reason for visit, work-up, treatments provided, and disposition. This survey provides the best and only trending data since 1992. The CDC does not report on ED performance or measure data from freestanding EDs.
• The AHA survey reports only on the volume of patients seen in its member hospitals.
• The NEDI-USA survey does the most comprehensive identification of EDs, counts the most visits due to its comprehensive look for those facilities, and characterizes EDs into cohorts based on the volume of patients seen.
• The EDBA survey used voluntary sampling to collect and report on ED performance, arrival characteristics, use of high-frequency diagnostic tests, and disposition. The survey collects no characteristics of individual patient visits and does not attempt to count or estimate the total number of US ED visits. It does compare the same site visit volumes from year to year.

Together the four organizational surveys provide insight into the utilization of emergency services by population groups, the incidence of disease, and the changing structure of US citizens, in particular, the aging of the population, which changes the need for emergency and unscheduled services. There are issues with the timeliness of survey results. The CDC data takes three years to release their results, the NEDI-USA survey two years, and the EDBA about nine months to file the report. This gap should be shortened in future data system design.

A timely issue for ED leaders is the trend of patient visits seen over the last five years, so planning can occur for future volumes and acuity. The CDC estimates typically find the lowest visit volumes and the NEDI-USA the highest volumes.   Those estimates, and the site counts used to measure visits, are reported in Table 1.

Table 1. Emergency Departments and Emergency Visits 2001-2020, three sources. Early data estimates from these data sources indicate an ED volume loss in the US in 2020 between 13 and 14% compared to 2019. 

ED volumes increased from 2020 to 2021, and according to ED leaders monitoring their operations, they also saw more patients from 2021 to 2022. ED operations in 2021 were significantly impacted by many factors, which reduced flow and increased walkaway rates, and greatly stressed ED staff. These operational challenges are now layered onto a higher level of patients than in 2019.

The trend of EDs seeing older, sicker patients, combined with continued growth in retail clinics, telehealth, and other sources of care for non-emergent problems, has resulted in a net increase in severity/complexity for full-service EDs.

The number of patients seen in US EDs has increased steadily since World War II. Likely, the resulting changes in the American health system following this coronavirus pandemic will tremendously change the unscheduled and emergency care system.

At the present time, ED and hospital leaders should plan for ED volumes that are stable or increasing slowly. ED boarding of inpatients, and other impediments to ED flow, negatively impact the quality of ED care and result in higher walkaway rates, patient and ED staff dissatisfaction, and a gap in emergency services in the community.

Planning the future of the EMDI

So it requires a comprehensive look at more than four sources of data to do future planning for emergency services. There are still gaps in the data needed for planning and the timeliness of that necessary information. That is a future opportunity for the Emergency Medicine Data Institute. 

It will require significant hospital and ED leadership to preserve ED flow, quality of care, and high-quality ED staff. That effort is supported by great ED data, and that is the future function of the EMDI. In addition, the EMDI will need to integrate public health (mostly state and local) data to deliver timely surveillance to emergency care providers. The pandemic has resulted in major development of dashboards and subsequent action plans for community care. There are many opportunities to develop data systems to support emergency operations. 

The ACEP Clinical Emergency Data Registry (CEDR) has already developed the platform for ED data acquisition and storage, with a system for data security, privacy, and confidential dissemination, which is the model for EHR data management. The current gaps in the information needed for ED planning and quality management provide a fertile group for the EMDI.

One hundred sixty million patients a year require ED service. It is a huge responsibility to plan for those patients and the providers who are now in a very stressful position of delivering that care.