6. Boggs KM, Augustine JJ, Sullivan AF, Espinola JA, Camargo CA Jr. Changes in the number of US emergency departments and their annual visit volumes since 2001. Ann Emerg Med . 2023;82(6):760-762. 7. US Census Bureau. Core-based statistical areas. Accessed December 1, 2024. https://www.census.gov/topics/housing/housing-patterns/about/ core-based-statistical-areas.html 8. Lu LY, Boggs KM, Espinola JA, Sullivan AF, Cash RE, Camargo CA. Development of a uni fi ed national database of burn centers with co- located emergency departments, 2020. J Burn Care Res . 2022;43(5): 1066-1073. 9. Bedell BR, Boggs KM, Espinola JA, et al. Development of a uni fi ed national trauma center database, 2018. Injury . 2023;54(2):461-468. 10. Boggs KM, Vogel BT, Zachrison KS, et al. An inventory of stroke centers in the United States. J Am Coll Emerg Physicians Open . 2022;3(2):e12673. 11. Boggs KM, Espinola JA, Sullivan AF, et al. Availability of pediatric emergency care coordinators in US emergency departments in 2018. Pediatr Emerg Care . 2023;39(6):385-389. 12. Herscovici DM, Boggs KM, Swanton M, et al. Development of a uni fi ed geriatric emergency department database, 2022 [abstract]. Acad Emerg Med . 2024; in press. 13. 2024 Indiana Code Title 16. Health Article 21. Hospitals Chapter 2. Licensure of Hospitals 16-21-2-14.5 Physician to Be on Site and on Duty While Emergency Department Is Open. Accessed January 29, 2025. https://casetext.com/statute/indiana-code/title-16-health/ article-21-hospitals/chapter-2-licensure-of-hospitals/ section-16-21-2-145-physician-to-be-on-site-and-on-duty-while- emergency-department-is-open#: :text=Section%2016-21-2-14.5% 20-%20Physician%20to%20be%20on%20site,at%20all%20times% 20the%20emergency%20department%20is%20open 14. Virginia Senate Bill 392. Hospitals; emergency departments to have at least one licensed physician on duty at all times. Accessed January 29, 2025. https://legiscan.com/VA/bill/SB392/2024 15. Magi JN, Chen A, Guo R, et al. US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis. BMJ Open . 2022;12(4):e055138. 16. Chekijian SA, Elia TR, Horton JL, Baccari BM, Temin ES. A review of interprofessional variation in education: challenges and considerations in the growth of advanced practice providers in emergency medicine. AEM Educ Train . 2020;5(2):e10469. 17. Zachrison KS, Boggs KM, Hayden EM, Espinola JA, Camargo CA Jr. Understanding barriers to telemedicine implementation in rural emergency departments. Ann Emerg Med . 2020;75(3):392-399. 18. Code of Federal Regulations. 42 CFR 485.618. Accessed October 9, 2024. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/ part-485/subpart-F/section-485.618#p-485.618(d)(1)(ii) SUPPLEMENTARY MATERIALS Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. acepjo.2025.100050 How to cite this article: Camargo CA, Boggs KM, Sullivan AF, et al. Lack of 24/7 Attending Physician Coverage in US Emergency Departments, 2022. JACEP Open. 2025;6:100050. https://doi.org/10.1016/j.acepjo.2025.100050
TABLE 2. Associations between emergency department characteristics and lack of 24/7 attending physician coverage; n = 4621 US emergency departments. ED characteristic Unadjusted OR (95% CI) a Adjusted OR (95% CI) b Annual visit volume < 10,000 36.52 (24.34-54.8) 9.84 (6.17-15.69) Critical access hospital 31.22 (22.02-44.26) 4.67 (3.01-7.24) Rural location 12.93 (10.08-16.59) 1.79 (1.33-2.41) Freestanding ED 0.10 (0.04-0.22) 0.38 (0.15-0.93) Receives telehealth services 1.34 (1.03-1.74) 1.36 (1.01-1.83) Adult trauma center 0.02 (0.01-0.09) 0.16 (0.04-0.66) Stroke center 0.41 (0.32-0.53) 1.07 (0.80-1.43) Pediatric emergency care coordinator 0.42 (0.3-0.59) 0.90 (0.61-1.31)
J.A.E. provided statistical advice and analyzed the data. C.A.C. drafted the manuscript, and all authors contributed substan- tially to its revision. C.A.C. takes responsibility for the paper as a whole. FUNDING AND SUPPORT By JACEPOpen policy, all authors are required to disclose any and all commercial, fi nancial, and other relationships in any way related to the subject of this article as per ICMJE con fl ict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. CONFLICT OF INTEREST All authors have af fi rmed they have no con fl icts of interest to declare. ACKNOWLEDGMENTS The authors thank Olivia Chen for assisting with data collection and management, Carson Clay for creating the map, and the thousands of ED directors who respond year after year to the National Emergency Department Inventory-USA survey. DATA SHARING Adeidenti fi ed version of the National Emergency Department Inventory-USA data, the data dictionary, and the analytic code are available on reasonable request to Dr Camargo (ccamargo@ mgb.org). ORCID Carlos A. Camargo https://orcid.org/0000-0002-5071- 7654 REFERENCES 1. American College of Emergency Physicians. Emergency department planning and resource guidelines. Accessed August 10, 2024. https:// www.acep.org/siteassets/new-pdfs/policy-statements/emergency- department-planning-and-resource-guidelines.pdf 2. American College of Emergency Physicians. Public opinion on the value of emergency physicians. Accessed November 24, 2024. https://www. emergencyphysicians.org/siteassets/emphysicians/all-pdfs/value-and-sop- august-2021-poll- fi nal.pdf 3. Christensen EW, Liu CM, Duszak R Jr, Hirsch JA, Swan TL, Rula EY. Association of State share of nonphysician practitioners with diagnostic imaging ordering among emergency department visits for Medicare bene fi ciaries. JAMA Netw Open . 2022;5(11):e2241297. 4. Bennett CL, Sullivan AF, Ginde AA, et al. National study of the emergency physician workforce, 2020. Ann Emerg Med . 2020;76(6): 695-708. 5. Sullivan AF, Richman IB, Ahn CJ, et al. A pro fi le of US emergency departments in 2001. Ann Emerg Med . 2006;48(6):694-701.
OR > 1 indicates higher odds of lack of 24/7 attending physician coverage. ED, emergency department; OR, odds ratio. a Association between individual factor and outcome (n = 344 cases); 8 models. b One model with all factors liste.
hospital. Ten EDs (3%) reported “ no ” to both sub- questions (ie, they lacked 24/7 2-way voice communica- tion with any physician). 4 LIMITATIONS The study limitations include self-reported data from ED leadership and an 82% national response rate. We speculate that many ED directors are reluctant to report a lack of 24/7 attending physician coverage and, for similar reasons, that nonresponding EDs are more likely to lack this coverage. That said, compared with responding EDs, nonresponding EDs were more often freestanding adult trauma centers and stroke centers. They were less often CAHs and less often in rural areas (Table S1). Some of these characteristics suggest that nonresponding EDs are more likely to have 24/7 attending physicians, and others suggest that they are less likely. 5 DISCUSSION Based on a national survey of ED directors, we found that at least 7.4% of US EDs lack 24/7 attending physician coverage (approximately 1 in 13 EDs). This percentage varied widely by state. EDs that were rural and were in CAHs were more likely to lack 24/7 attending physician coverage. The geographic distribution of the 344 EDs lacking 24/7 coverage revealed a disproportionate number in the central US Indeed, the Figure closely resembles our prior work on the emergency physician workforce, where we reported lower numbers of emergency physicians in this same geographic area. 3 This prior work also found a lack of emergency physicians in rural areas, which was again consistent with the lack of 24/7 physician coverage in rural EDs, as reported in the current study. As reported previously, there has been a rise in nonphysician practitioners over the past 20 years, and they are supplementing the lack of physicians in rural EDs. 3,4 This re- mains potentially concerning, given differences in training and care patterns between physician and nonphysician practitioners. 15,16
The characteristics of EDs without 24/7 coverage are not surprising: they are low-visit volume EDs ( < 10,000 visits/y) located within a CAH and a rural area. Although 77% of these EDs receive telehealth, 23% do not. Furthermore, a small percentage (3%) of these EDs reported a lack of 2-way voice connection 24/7 with any physician, either within or outside of the hospital. In a prior survey of rural EDs, we found that most ED directors without telehealth reported that their ED, hospital, or health system leadership had considered it, but the start-up and maintenance costs were often cited for the lack of telehealth adoption. The current results remind us of this persistent, untapped opportunity for quality improvement. 17 Most (89%) EDs without 24/7 attending physician coverage were in a CAH. Brie fl y, CAH designation is given to eligible rural hospitals by the Centers for Medicare and Medicaid Services. The goal of the CAH program is to reduce the fi nancial vulnerability of these designated hospitals and to improve access to health care by keeping these hospitals open. By de fi nition, CAHs provide access to health care in areas that otherwise would have a dearth of local hospital-based care. Although CAH regulations require that each facility operates a 24/7 ED, they do not require that the ED be staffed by an attending physician 24/7. 18 A revision in CAH policy, including fi nancial support for 24/7 attending physician coverage, may help to reduce the number of EDs operating without this coverage. In summary, approximately 1 in 13 US EDs lack 24/7 attending physician coverage, which is more common in low- volume EDs and CAHs. These observations highlight critical gaps in emergency care in the US Changes in CAH regula- tions, along with increased public awareness, may help address this important workforce issue. AUTHOR CONTRIBUTIONS C.A.C. and D.D.F. conceived the study, and C.A.C., K.M.B., A.F.S., J.A.E., and M.S. designed the study. C.A.C., K.M.B., and A.F.S. supervised the study. K.M.B. and M.S. obtained the data, and K.M.B., J.A.E., and M.S. managed the data.
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CAMARGO ET AL . J LA MED SOC | VOL 177 | SPRING 2025
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