Distribution of Emergency Departments According to Annual Visit Volume and Urban-Rural Status: Implications for Access and Staffing

Objectives: Ongoing efforts to improve access to emergency care and emergency department (ED) staffing would benefit from a better understanding of the distribution of EDs in the United States by size and location. This article describes the distribution of U.S. ED visit volumes according to ED urban versus rural status. Methods: The authors used the 2007 National Emergency Department Inventories (NEDI)-USA database to identify all nonfederal U.S. hospitals with EDs and their annual ED visit volumes. One of twelve 2003 Urban Influence Codes was applied to each ED location based on its county. These categories were collapsed into urban counties and three types of rural counties: adjacent to urban, large nonadjacent, and small nonadjacent. The number of emergency physicians (EPs) needed to staff the higher-volume rural EDs was estimated. Results: Of the 4,874 U.S. EDs in 2007, 58% were in urban counties and 42% in rural counties. Among the 2,038 rural EDs, 56% were adjacent to urban, 15% were large nonadjacent, and 29% were small nonadjacent. Of the 1,503 lower-volume (< 10,000 visit) EDs, 21% were in urban counties. Of the 3,371 higher-volume (>= 10,000 visit) EDs, 25% were in rural counties. Of the 857 higher-volume rural EDs, 66% were adjacent to urban, 22% were large nonadjacent, and 12% were small nonadjacent. The authors estimate that approximately 5,600 EPs are needed to staff these higher-volume rural EDs. Conclusions: There are many lower-volume EDs in urban areas and higher-volume EDs in rural areas. Most higher-volume rural EDs are in rural areas adjacent to urban counties. These data challenge popular assumptions regarding ED visit volumes, locations, and staffing needs. ACADEMIC EMERGENCY MEDICINE 2010; 17:1390-1397 (C) 2010 by the Society for Academic Emergency Medicine.