First Look: Emergency Department Operations in the Pandemic Year 2021

There is no disguising it. 2021 was perhaps the most challenging year ever for American emergency department (ED). The combination of staff losses and hospital system failures caused unprecedented operational problems and patient and ED staff dissatisfaction.

The number of patients seen in American EDs has increased steadily since World War II. The early days of the pandemic from March 2020 to September 2020 saw a dramatic and uncharacteristic ED volume loss. While it takes a while for official government figures to be released, preliminary data found ED volume loss in 2020 that was approximately 14 percent compared to 2019. ED volumes increased from 2020 to 2021 and again from 2021 to 2022. Most EDs are now reporting volumes that are approximately the same as those in 2019, but acuity that is higher. The trend of EDs seeing older, sicker patients, combined with continued diversion of patients to retail clinics, telehealth, and other sources of care, has resulted in a net increase in patient severity/complexity for full-service EDs.

The Emergency Department Benchmarking Alliance (EDBA) has just released its 2021 Performance Measures Data Guide. Summary of the findings are as follows:

  • The pandemic resulted in a significantly lower percentage of children presenting to EDs that are not designated as pediatric EDs.
  • Multiple indicators confirm that patient acuity has increased.
  • Patient arrival by EMS increased in 2020 and again in 2021. About 37 percent of those patients were admitted, a relatively constant percentage.
  • The percentage of patients transferred out of the ED to another hospital in 2020 and 2021 was higher than historical numbers.
  • The use of CT scans and EKGs increased across all groups of EDs.
  • There was no significant increase in the time that ED staff needed to greet patients and have those patients seen by an emergency physician despite all other measures of performance getting slower.
  • Unprecedented high ED boarding times (about 39 percent greater than prior years) crushed most ED operations, negatively impacting all other areas of ED performance.
  • The overall length of stay for all ED patients increased to 194 minutes in 2021, up from 186 minutes in 2018, 184 minutes in 2020, and 182 minutes in 2019.
  • Patient walkaway rates (e.g., Left Before Treatment Complete) almost doubled compared to 2019, most likely a victim of increased boarding.

Secondary to lengthy ED boarding times, the median patient processing times (measured as length of stay (LOS)) increased dramatically.