TABLE 1. Presence of 24/7 attending physicians in US emergency departments, n = 4621.
The NEDI-USA database includes basic ED character- istics such as annual visit volume, critical access hospital (CAH) status, rural location (based on presence outside of a core-based statistical area), 7 hospital-based vs freestanding ED status, and receipt of telehealth services. EDs are further characterized by special capabilities, such as having a burn center, 8 trauma center, 9 stroke center, 10 pediatric emer- gency care coordinator (PECC), 11 or geriatric ED recogni- tion. 12 Adult trauma centers and stroke center status are further characterized as “ basic ” or “ advanced ” centers. “ Basic ” adult trauma centers have certi fi cation equivalent to that of the American College of Surgeons ’ level III veri fi - cation, and “ Advanced ” adult trauma centers have certi fi - cation equivalent to that of American College of Surgeons ’ level I or II veri fi cation. 9 “ Basic ” stroke centers have certi- fi cation equivalent to that of The Joint Commission ’ s Acute Stroke Ready Hospital, and “ Advanced ” stroke centers have certi fi cation equivalent to that of The Joint Commission ’ s Primary Stroke Center, Thrombectomy-Capable Stroke Center, or Comprehensive Stroke Center certi fi cation. 10 2.4 Data Analyses Data analysis included descriptive statistics. Speci fi cally, we determined the proportion and characteristics of EDs without 24/7 attending physician coverage. Because of the potential of confounding, we also fi t a logistic regression model to determine independent predictors of lack of 24/7 attending physician coverage. All analyses were completed using Excel (Microsoft) and Stata 15 (StataCorp). To examine the national distribution of lack of 24/7 attending physician coverage, a choropleth map was created using ArcGIS (Esri). 3 RESULTS The 2022 NEDI-USA database identi fi ed 5622 EDs, of which 4621 (82%) responded to the 24/7 attending physician question. Overall, 4277 (92.6%) responded “ yes, ” whereas 344 (7.4%) responded “ no ” (ie, these EDs reported that they did not have 24/7 attending physician coverage). Although 7.4% of all US EDs reported that they lacked 24/7 attending physician coverage, their geographic distribution revealed large between-state differences (Fig). In 15 states, zero responding EDs reported that they lacked 24/7 attending physician coverage. Two states that have recently introduced legislation requiring 24/7 in-person physician coverage in EDs, Indiana and Virginia, 13,14 had no EDs that reported a lack of 24/7 coverage. However, in several states (shown in white), ≥ 30% of the state ’ s EDs lacked 24/7 coverage. The states with the highest per- centages were North Dakota (58%), South Dakota (56%), and Montana (46%). Among these 344 EDs without 24/7 attending physician coverage, the annual visit volumes were < 10,000 for 318 (92%), whereas 23 (7%) had 10,000 to 19,999 and 3 ( < 1%)
The Bottom Line We investigated US emergency depart- ments (EDs) without 24/7 attending physician coverage. Based on a national survey of ED directors, 1 in 13 EDs did not have at least 1 attending physician on duty 24/7. In several states, ≥ 30% of the EDs lacked 24/7 coverage. Among these 344 EDs, 92% had low annual visit volumes, 89% were in critical access hospitals, and 72% were rural. These observations highlight important gaps in ED care nationally. Changes in critical access hospital regulations may help address this workforce issue.
EDs with 24/7 attending physician (n = 4277; 92.6%)
EDs without 24/7 attending physician (n = 344; 7.4%)
ED characteristic
n (%)
n (%)
P value
Annual visit volume < 10,000
< .001
Yes
1073 (25) 3204 (75)
318 (92)
No
26 (8)
Region
< .001
Northeast
501 (12)
17 (5)
Midwest
1065 (25) 1904 (45)
198 (58) 66 (19) 63 (18)
South West
807 (19)
Critical access hospital
< .001
Yes
898 (21)
307 (89)
No
3379 (79)
37 (11)
Rural location
< .001
Yes
712 (17)
248 (72)
No
3565 (83)
96 (28)
Freestanding ED
< .001
2 METHODS 2.1 Study Design
Hospital-based ED Freestanding ED Adult trauma center
3623 (85)
338 (98)
654 (15)
6 (2)
We performed a cross-sectional study of US EDs. The Mass General Brigham Human Research Committee reviewed this study and classi fi ed it as exempt.
< .001
Yes
860 (20)
2 (0.6)
No
3417 (80)
342 (99)
Stroke center
< .001
2.2 National ED Inventory-USA The National ED Inventory (NEDI)-USA survey is sent annually to the ED director of every nonfederal, nonspecialty hospital US ED. Federal EDs (eg, those af fi liated with Vet- erans Administration, military, or Indian Health Service) are excluded because they are not truly “ open ” to the general public. Specialty hospital EDs (eg, the ED of a psychiatric hospital) are not generally capable of managing the broad spectrum of injury and disease that is cared for in the vast majority of US EDs. 2.3 Outcomes: 24/7 Attending Physician Coverage The NEDI-USA survey is sent fi rst by email or mail up to 3 times, and then nonresponding ED directors are contacted by telephone to complete the survey by interview. 5,6 We iden- ti fi ed EDs with the absence of 24/7 attending physician coverage through the survey question: “ Is at least one attending physician (not resident) on duty in the ED 24 h/d? ” (yes/no) If no, ED directors were asked: “ When a physician is not on duty in the ED, is any physician available to the ED by 2-way voice communication 24/7 – from within your hospital (yes/no/not applicable [eg, freestanding ED]) or from outside your hospital (yes/no/not applicable [eg, freestanding ED]). ”
Yes
2054 (48) 2223 (52)
95 (28)
No
249 (72)
Pediatric emergency care coordinator
< .001
Yes
1036 (24) 3241 (76)
41 (12)
No
303 (88)
Receives telehealth services
.03
Yes
3056 (72) 1201 (28)
266 (77)
No
78 (23)
ED, emergency department.
had ≥ 20,000. Most EDs (307 [89%] of 344) were in a CAH; 248 (72%) were rural, and 6 (2%) were freestanding. Overall, 266 (77%) of the 344 EDs without 24/7 coverage received telehealth, and 78 (23%) did not. Compared with EDs with 24/7 attending physicians, EDs without 24/7 physicians were more likely to have annual visit volumes < 10,000, to be in the Midwest and rural areas, to be a CAH, and to receive telehealth services. They were less likely to be freestanding, to be adult trauma centers, to be stroke centers, and to have PECCs (Table 1). Regarding the special capabilities of these 344 EDs, there were no adult or pediatric burn centers. Two EDs were adult trauma centers (both basic); none were pediatric trauma
centers. Ninety- fi ve (28%) were stroke centers, with 89 basic and 6 advanced. Only 41 (12%) of the 344 EDs reported having a PECC. None were recognized as a geriatric ED. In multivariable analysis, independent predictors of the absence of 24/7 attending physician coverage included annual visit volume < 10,000 and CAHs. Rural location, hospital- based (vs freestanding) ED status, receipt of telehealth ser- vices, and lack of adult trauma center certi fi cation were also associated with a lack of 24/7 coverage (Table 2). Among the 344 EDs without 24/7 attending physi- cian coverage, 50% did not have 2-way voice communi- cation 24/7 with any physician within the hospital, and 19% did not have this with any physician outside the
6
7
J LA MED SOC | VOL 177 | SPRING 2025
CAMARGO ET AL . J LA MED SOC | VOL 177 | SPRING 2025
CAMARGO ET AL .
4 of 6
3 of 6
Made with FlippingBook Digital Publishing Software