Editing Emergency department (section)

==United States==
The [[Centers for Medicare and Medicaid Services]] (CMS) classified emergency departments into two types: Type A, the majority, which are open 24 hours a day, 7 days a week, 365 days a year; and Type B, the rest, which are not. Many US emergency departments are exceedingly busy.  A study found that in 2009, there were an estimated 128,885,040 ED encounters in US hospitals. Approximately one-fifth of ED visits in 2010 were for patients under the age of 18 years.<ref>Wier LM, Hao Y, Owens P, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. Agency for Healthcare Research and Quality, Rockville, MD. May 2013. [http://hcup-us.ahrq.gov/reports/statbriefs/sb157.jsp]</ref>  In 2009–2010, a total of 19.6 million emergency department visits in the United States were made by persons aged 65 and over.<ref>[https://purl.fdlp.gov/GPO/gpo41783 Emergency Department Visits by Persons Aged 65 and Over: United States, 2009–2010.] Hyattsville, Md.: [[U.S. Department of Health and Human Services]], [[Centers for Disease Control and Prevention]], [[National Center for Health Statistics]], 2013.</ref>  Most encounters (82.8 percent) resulted in treatment and release; 17.2 percent were admitted to inpatient care.<ref>Kindermann D, Mutter R, Pines JM. ''Emergency Department Transfers to Acute Care Facilities, 2009.'' HCUP Statistical Brief #155. Agency for Healthcare Research and Quality. May 2013. [http://hcup-us.ahrq.gov/reports/statbriefs/sb155.jsp] {{Webarchive|url=https://web.archive.org/web/20161201220950/https://www.hcup-us.ahrq.gov/reports/statbriefs/sb155.jsp|date=1 December 2016}}</ref>

The 1986 [[Emergency Medical Treatment and Active Labor Act]] is an act of the [[United States Congress]], that requires emergency departments, if the associated hospital receives payments from [[Medicare (United States)|Medicare]], to provide appropriate medical examination and emergency treatment to all individuals seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay. Like an [[unfunded mandate]], there are no reimbursement provisions.

Rates of ED visits rose between 2006 and 2011 for almost every patient characteristic and location.  The total rate of ED visits increased 4.5% in that time.  However, the rate of visits for patients under one year of age declined 8.3%.<ref>{{cite journal |vauthors=Skiner HG, Blanchard J, Elixhauser A | title =  Trends in Emergency Department Visits, 2006–2011 | work =HCUP Statistical Brief |issue=179 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = September 2014 | url = https://www.hcup-us.ahrq.gov/reports/statbriefs/sb179-Emergency-Department-Trends.jsp}}</ref>

A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused by excessive waits for hospital beds by ED patients.<ref>{{cite web|url=https://abcnews.go.com/print?id=3322309|title=ER Wait Time Problems Widespread|website=abcnews.go.com}}</ref>  A 2005 patient survey found an average ED wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.<ref>{{cite web |url=http://www.medicalnewstoday.com/articles/44453.php |title=Emergency Department Wait Times Vary by State, Study Finds, USA |access-date=29 April 2013 |url-status=dead |archive-url=https://web.archive.org/web/20100425064349/http://www.medicalnewstoday.com/articles/44453.php |archive-date=25 April 2010 }}</ref>

One inspection of Los Angeles area hospitals by Congressional staff found the EDs operating at an average of 116% of capacity (meaning there were more patients than available treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the [[2004 Madrid train bombings]]. Three of the five Level I trauma centres were on "diversion", meaning ambulances with all but the most severely injured patients were being directed elsewhere because the ED could not safely accommodate any more patients.<ref>{{Citation|url=http://oversight.house.gov/documents/20080505102428.pdf |title=Snapshot of Emergency Surge Capacity in Los Angeles|date=May 2008 |access-date=23 January 2009 |archive-url=https://web.archive.org/web/20090118184357/http://oversight.house.gov/documents/20080505102428.pdf |archive-date=18 January 2009 |url-status=dead |author1=((Committee on Oversight and Government Reform Majority Staff))|publisher=United States House Committee on Oversight and Government Reform|location=Washington, D.C.|postscript=.}} [A follow-up to the report]: 
* {{Citation |title=Emergency Surge Capacity: The Failure to Prepare for the "Predictable Surprise" |date=May 5, 2008 |author1=((Committee on Oversight and Government Reform Majority Staff))|publisher=United States House Committee on Oversight and Government Reform|location=Washington, D.C.|id=Findings of the March 25, 2008 survey of thirty-four (34) Level I trauma centers in seven cities: Chicago, Denver, Houston, Los Angeles, Minneapolis, New York City and Washington, D.C.}}</ref>  This controversial practice was banned in Massachusetts (except for major incidents, such as a fire in the ED), effective 1 January 2009; in response, hospitals have devoted more staff to the ED at peak times and moved some elective procedures to non-peak times.<ref>{{cite news| url=http://www.boston.com/news/local/articles/2008/09/13/state_orders_hospital_ers_to_halt_diversions/?page=full | work=The Boston Globe | first=Liz | last=Kowalczyk | name-list-style = vanc | title=State orders hospital ERs to halt 'diversions' | date=13 September 2008}}</ref><ref>{{cite news| url=http://www.boston.com/news/health/articles/2008/12/24/fewer_patients_diverted_from_ers/?page=full | work=The Boston Globe | first=Liz | last=Kowalczyk | name-list-style = vanc | title=Hospitals shorten the waits in ERs | date=24 December 2008}}</ref>

In 2009, there were 1,800 EDs in the country.<ref>{{cite news | first=Joseph | last=Gresser | name-list-style = vanc | title=NC president found hospital a "pleasant surprise" | publisher=the Chronicle | location=Barton, Vermont | page= 21 | date=18 November 2009 }}</ref>  In 2011, about 421 out of every 1,000 people in the United States visited the emergency department; five times as many were discharged as were admitted.<ref name="Weiss AJ, Wier LM, Stocks C, Blanchard J">{{cite journal |vauthors=Weiss AJ, Wier LM, Stocks C, Blanchard J | title =  Overview of Emergency Department Visits in the United States, 2011 | journal =HCUP Statistical Brief |issue=174 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = June 2014 | pmid = 25144109 | url = https://www.hcup-us.ahrq.gov/reports/statbriefs/sb174-Emergency-Department-Visits-Overview.jsp}}</ref> Rural areas are the highest rate of ED visits (502 per 1,000 population) and large metro counties had the lowest (319 visits per 1,000 population).  By region, the Midwest had the highest rate of ED visits (460 per 1,000 population) and Western States had the lowest (321 visits per 1,000 population).<ref name="Weiss AJ, Wier LM, Stocks C, Blanchard J"/>

{| class="wikitable sortable"
|+ Most common reasons for discharged emergency department visits in the United States, 2011<ref name="Weiss AJ, Wier LM, Stocks C, Blanchard J"/>
|-
! Age (in years) !! Reason for visit !! Visits
|-
| <1 || Fever of unknown origin || 270,000
|-
| 1–17 || Superficial injury, contusion || 1.6 million
|-
| 18–44 || Sprains and Strains || 3.2 million
|-
| 45–64 || Nonspecific chest pain || 1.5 million
|-
| 65–84 || Nonspecific chest pain || 643,000
|-
| 85+ || Superficial injury, contusion || 213,000
|}

=== Freestanding ===
In addition to the normal hospital based emergency departments a trend has developed in some states (including Texas and Colorado) of emergency departments not attached to hospitals. These new emergency departments are referred to as free standing emergency departments. The rationale for these operations is the ability to operate outside of hospital policies that may lead to increased wait times and reduced patient satisfaction.

These departments have attracted controversy due to consumer confusion around their prices and insurance coverage. In 2017, the largest operator, [[Adeptus Health]], declared bankruptcy.<ref>{{Cite web|url=https://www.beckershospitalreview.com/finance/hedge-fund-takes-over-adeptus-health.html|title=Hedge fund takes over Adeptus Health|website=BeckersHospitalReview.com|date=6 October 2017 |access-date=14 May 2019}}</ref>

=== Overuse and utilization management ===
Patients may visit the emergency room for [[#Non-emergency use|non-emergencies]], which typically costs the patient and the [[managed care]] insurance company more, and therefore the insurance company may apply [[utilization management]] to deny coverage.<ref>{{cite journal | vauthors = Chou SC, Gondi S, Baker O, Venkatesh AK, Schuur JD | title = Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses | journal = JAMA Network Open | volume = 1 | issue = 6 | pages = e183731 | date = October 2018 | pmid = 30646254 | pmc = 6324426 | doi = 10.1001/jamanetworkopen.2018.3731 }}</ref> In 2004, a study found that emergency room visits were the most common reason for appealing disputes over coverage after receiving service.<ref>{{Cite journal|url=https://www.rand.org/pubs/research_briefs/RB9039.html|title=Inside the Black Box of Managed Care Decisions: Understanding Patient Disputes over Coverage Denials|last1=Gresenz|first1=Carole Roan|last2=Studdert|first2=David M.|date=2004|website=Rand.org |access-date=12 March 2020|last3=Campbell|first3=Nancy F.|last4=Hensler|first4=Deborah R.|last5=Kapur|first5=Kanika | name-list-style = vanc }}</ref> In 2017, [[Anthem (company)|Anthem]] expanded this denial coverage more broadly, provoking public policy reactions.<ref>{{Cite web|url=https://www.healthcaredive.com/news/anthem-er-policy-could-deny-1-in-6-visits-if-universally-adopted-jama-stud/540241/|title=Anthem ER policy could deny 1 in 6 visits if universally adopted, JAMA study warns|website=Healthcare Dive |access-date=12 March 2020}}</ref>