6th Annual National Rural Health ED Study

September 5, 2013
iVantage Health

6th Rural Health ED StudySome Highlights

Often considered the “front door’ to a hospital, the Emergency Department (ED) is a major center of operations, and it may be the most important service offered by Critical Access Hospitals (CAH) in their largely rural communities. (“Critical Access Hospital’ is a federal designation with distinct Medicare reimbursement rules). Rural EDs disproportionately account for patient volumes, expenses, revenues, risk, quality and patient satisfaction when compared to larger urban and suburban hospitals. This 6th Annual National Rural Emergency Department Study quantifies performance indicators from the ED to define rural relevant benchmarks and to establish a baseline for comparison with national industry statistics.

iVantage Health Analytics works with hospitals and hospital networks to provide benchmarking and best practices for performance metrics such as:

  • Total Time in the ED – The total time spent in the Emergency Department from arrival to discharge
  • Time to Medical Screening Exam (MSE) – The total time it takes from arrival for a patient to be evaluated in the Emergency Department by a qualified provider
  • Patient Satisfaction in the Emergency Department – Patient willingness to “recommend this Emergency Department to friends and family”
  • Admissions to Acute/Inpatient – Percentage of Emergency Department visits admitted to a hospital’s general acute/inpatient unit
  • Admissions to Observation – Percentage of Emergency Department visits admitted to a hospital’s observation unit
  • Transfers – Percentage of Emergency Department visits that are transferred to another facility for care
  • Patient Severity – Percent of patients categorized into each severity as codified by the Agency for Research and Healthcare Quality (ARHQ) Patient Severity Index[i]

About the Study

iVantage Health AnalyticsTM® maintains the largest proprietary repository of rural patient encounter data in the industry. Collected from a participating research base representing over 10% of all U.S. rural hospitals, the data is submitted voluntarily by users of the company’s ED information products. One of the company’s core products is EDManageTM, a Web-based application that collects, reports and benchmarks data for individual Emergency Department visits. For the past six years, patient encounter-level data for over 3.2 million Emergency Department visits have been warehoused, aggregated and indexed. For this portion of the study, iVantage analyzed its proprietary EDManageTM database for visits during the 2012 calendar year.

Summary Statistics

Rural ED Indicators






All U.S. Hospitals

Inpatient Admission Rate







Observation Admission Rate







Total Admission Rate







Transfer Rate







Mean Time to Medical Screening Exam

31 (min)

31 (min)

28 (min)

30 (min)

29 (min)

56 (min)[iii]

Mean Total ED Time

120 (min)

123 (min)

119 (min)

122 (min)

123 (min

247 (min)3

Median Total ED Time

99 (min)

109 (min)

98 (min)

100 (min)

101 (min)

156 (min)[iv]

n = 3.2 million patient encounters



ED utilization in rural hospitals doubled in the six-year period between 2007 and 2012. The average increase for All US Hospitals was 24% in the decade between 1998-2008[v].  Results from a recent ED survey conducted by HealthLeaders Media indicate that “almost nine in 10 healthcare leaders (86%) expect their ED volumes to increase within the next three years.” Sixty-one percent of respondents to the same survey described their ED as being overcrowded, a sharp increase from 46% of respondents a year ago[vi].

Patient Severity

In 2012, iVantage found that 54% of all Emergency Department visits to CAHs were categorized as low severity cases (semi/less-urgent and non-urgent) as coded by the Agency for Healthcare Research and Quality (AHRQ) Patient Severity Index1.  Research shows that a national baseline of 29% of ED visits are low severity cases2. The lower severity found in rural hospitals poses the question as to the utilization of the rural Emergency Department as a primary care “safety net” location.


More than 50% of rural ED visits were classified as less urgent/non-urgent. More than 50% of these low severity visits to the rural ED take place during daytime business hours (9am-5pm). This finding is in contrast to other research that reports a national baseline of 29% of patients’ access the ED for lower severity visits, and only one third of all ED visits occur during business hours5. These data reveal new findings about rural practices and variation that is inconsistent with other generalized research addressing all US hospitals. These findings have policy implications regarding access to care in the rural setting and should be understood as incentives and reimbursement models are considered for the rural setting.

ED Wait Times

Rural hospitals have an ED total throughput time of 123 minutes. This is 124 minutes (more than two hours) faster than mean times reported in national research (247 minutes)4.It takes approximately half the time for a patient to see a physician in a rural location than in a larger urban hospital (29 vs. 56 minutes)3

Emergency Department Admissions

Inpatient: Rural Emergency Departments have seen a 29% decrease in the average number of inpatient admissions from 2008-2012. In 2012, rural Emergency Departments admitted, on average, 4.2% of their visits to their hospital’s general acute/inpatient unit, down from 5.9% in 2008. The CDC cites a national baseline average of 12.5% of all Emergency Department visits are admitted to their inpatient units2.

Inpatient revenue accounts for 31 percent of national healthcare spending with nearly all of the growth in admissions due to a 17% increase in unscheduled admissions from the ED . “ED physicians are serving as the primary decision makers for up to half of allTM hospital admissions.”[vii]TM  An analysis of iVantage’s proprietary database reveals that ED physicians may play an even greater role in rural hospitals where more than 70% of inpatient admissions in 2012 came from the ED.

Observations: Admissions to observation units from the ED increased by 35% from 2008-2012 as regulatory pressures to reduce unnecessary hospitalizations increased. If observations and inpatient admissions from the rural ED were to be combined it would result in 7.0% of all rural ED visits being admitted to the hospital. This is compared to a 14.6% rate of admission reported in a 2007 CDC ED study (12.5% inpatient admission rate, plus a 2.1% observation admission rate for all U.S. hospitals2).

Transfers: The average transfer rate of 4.0% for rural emergency departments is more than double the 1.8% transfer rate reported in the 2007 CDC study2. Transfers and “Transfer Communication Measures” reflect a critical rural ED function. Rural hospitals, many times, conclude that the safest, most appropriate care can be delivered at another facility.

Patient Satisfaction

There is a negative correlation between ED wait times and patient satisfaction in the rural ED, thus as wait times increase, patients’ willingness to recommend the facility decrease. Hospitals performing at or above the 90th percentile in Time to MSE or in Total Time in the ED scored significantly higher “Willingness to recommend” scores than those performing in the 10th percentile or lower in ED wait times.


Rural Hospitals performed on par with national published data on publicly reported Outpatient Process of Care Measures such as time to ECG (9 minutes vs. 8 minutes). However, rural hospitals underperform on other Outpatient Measures such as time to transfer (108 minutes vs. 60 minutes). This study includes proprietary data we may compare to the newest Outpatient Measures regarding time in the emergency department (Mean Time to MSE and Total Time in the ED) and demonstrates the efficiency of the rural emergency department.

Rural Hospital Administrators were not well aware of Outpatient Core Measures according to preliminary results from the iVantage Emergency Department Companion Study. They reported mixed intention to voluntarily participate in the future. (CAHs voluntarily participate in many public-reporting initiatives.) In 2010, 17% of CAHs reported Outpatient Process of Care Measures. In 2011, 20% of CAHs reported Outpatient Process of Care Measures despite these being a more relevant candidate measure set for the delivery of disproportionately outpatient-focused healthcare services in the rural hospital setting. In 2012, 23% of CAHs reported Outpatient Process of Care Measures.

DOWNLOAD: 6th Annual National Rural Health ED Study

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