The role of emergency department physicians and leaders has been made dramatically more important due to the surges in demand and medical system challenges produced by the COVID-19 pandemic. However, it will be essential for those leaders to look at the trends present prior to the pandemic and to accurately predict how they will influence the patient populations of 2021 and beyond.

The performance of emergency departments in 2019 has been summarized for the many members of the Emergency Department Benchmarking Alliance (EDBA), who provided the data needed to characterize operations prior to the pandemic. Many trends will continue, and some will be accelerated by the pandemic. Regardless, these trends all suggest emergency departments will see higher-acuity patients with more complex medical needs and play a crucial role in determining capacity. Most communities are aware of the emergency department as the portal for critical patients and unexpected events, but now the value in public health and managing community surges is even more visible—and maybe even more appreciated!

The results of the 2019 EDBA performance measures survey say emergency departments are seeing higher-acuity patients, more adults, and more EMS patients; are making more use of diagnostic tests; are transferring more ED patients; and are absorbing the early time of patients who need inpatient services (ie, boarding). The management expertise and dedication of ED leaders are therefore ever more necessary.

Here are four results lifted from the survey:

1) Fewer children are presenting to community emergency departments.

ED visits by patients under age 18 have decreased from about 22 percent in the years before 2011 to about 15 percent in 2019 (see Figure 1).

(click for larger image) Figure 1. Percent of ED patients under age 18

2) More patients are being transferred.

There are significant differences in rates  of transfer to another hospital based on the features of emergency departments in the United States. The transfer rate is highest in small-volume emergency departments, which now amounts to 5.4 percent of the patients seen in those facilities. It appears fewer hospitals in rural communities have the resources to keep complex patients. They are closing service lines and have been unsuccessful in recruiting doctors willing to care for complex patients. Rural facilities also may incur financial penalties related to the inability to manage patients as expeditiously as larger hospitals.

ED transfer rates by cohorts (type of facility) are reflected in Figure 2. Transfer rates prior to 2011 were about 1.6 percent, and they have now doubled to 3.2 percent.