Hospital emergency departments serve as a lifeline for after-hours care, report finds
Ava Dzurenda
Pittsburgh Post-Gazette
When a medical emergency strikes after dark, heading to the emergency room is often the immediate response.
Hospital emergency departments (EDs) are crucial for providing round-the-clock medical care, especially after normal business hours. In rural Pennsylvania — where reaching a hospital often requires a longer trip — select funding set to cease at the end of the year exacerbates an already growing health care crisis.
In 2021, U.S. hospitals treated approximately 136 million ED patients, with nearly half of these visits occurring after regular business hours — between 5 and 8 p.m. — according to a newly released report by the Coalition to Strengthen America’s Healthcare and KNG Health Consulting. Of these after-hours visits, 65% took place after 8 p.m.
"We see our normal trauma, stroke and heart attack patients at all hours, but when urgent care and local physicians’ offices close in the evening, we do tend to see more lower-acuity patients,” said Thomas Marshall, an emergency medicine physician at West Virginia University Medicine’s J.W. Ruby Memorial Hospital in Morgantown. “This period continues to bring in higher-acuity patients, so when lower-acuity patients show up during these busy times, they often have to wait longer.”
The busiest time at the ED is later in the day, Marshall said, coinciding with the end of the workday. He sees patients of all ages, but often more working-age adults, teenagers and college students appear as the day progresses.
EDs are busier after normal business hours, explained Nicholas Kman, an emergency medicine physician at The Ohio State University Wexner Medical Center in Columbus, because patients are presented with a dearth of primary care physicians, need advanced tests and specialists and, often, psychiatric emergencies occur when mental health resources are scarce.
In addition to after-hours visits, the analysis examined rural and pediatric utilization of ED services. In 2021, pediatric patients made up 21% of all ED visits, with over half of these visits occurring after 5 p.m. Additionally, just under half of all injury and trauma visits and two-thirds of overdose- and poisoning-related ED visits occurred after business hours.
"When urgent care and local physicians’ offices close in the evening, we do tend to see more lower-acuity patients,” says Thomas Marshall, an emergency medicine physician at West Virginia University Medicine’s J.W. Ruby Memorial Hospital in Morgantown.(Courtesy of WVU Medicine)
Rural patients face unique barriers to care compared to their urban counterparts, such as lack of transportation and nearby emergency rooms, according to the report. In 2021, 13% — or 17,680,000 of the 136 million — after-hours ED visits occurred in rural regions.
“Most of our WVU Medicine patients are from rural areas, and many face extended drives of up to an hour,” said Marshall. “The distance from the hospital and the resources required to get there are often a lot more challenging in a rural area.”
Because rural emergency departments are smaller and often have fewer staff members, Kman said they may rely more on general practitioners and nurses rather than specialists.
“In a rural area, somebody might have a farming-, an agricultural- or an occupational-related accident to their hand, and the rural hospital might have an orthopedic doctor, but they may not have a hand surgeon on call,” he said.
Kman said that patients being transported from rural hospitals to Wexner Medical Center happens “all day, every day” due to the lack of specialty care in these regions. However, transferring patients from rural facilities to larger hospitals also stretches EMS resources thin, exacerbating pre-existing staffing shortages.
To address community health needs in Pennsylvania, the state Department of Health has rural health clinics that provide primary care — as well as other medically needed services — by physicians, nurse practitioners, certified nurse midwives and physician assistants. The clinics offer services on-site, and refer patients to hospitals.
In January 2019, the Department of Health and Centers for Medicare and Medicaid Services (CMS) established the Pennsylvania Rural Health Model (PARHM) to support rural hospitals financially while also enhancing the quality of the care they provide by addressing specific health needs.
“Under PARHM, rural hospitals receive a hospital global budget from CMS and other payers,” said a CMS spokesperson in an email. “Hospital global budgets are fixed amounts, set in advance — intended to cover all inpatient and hospital-based outpatient items and services.”
While a 2023 report evaluating PARHM’s first three years found the model has been a motivating factor for participating hospitals to engage new community partners, the global budget was not sufficient to fund hospital activities that allow hospitals to work with their communities. The model is set to end in the commonwealth on Dec. 31, underscoring the need for solutions in rural communities.
At the end of the month, CMS will host Rural Health Hackathons at various cities across the country to generate creative and actionable ideas to address rural health challenges in lieu of budget cuts.
In West Virginia, Marshall said WVU Medicine continues to brainstorm ways to provide more accessible care for rural patients, offering e-visits for lower-acuity complaints to reduce the need for travel. Telemedicine hubs allow patients to consult specialists without leaving their local communities, making follow-up care more accessible.
Despite new technology, EDs serve as a lifeline when someone is experiencing a life-threatening medical emergency.
“For patients in rural areas, telemedicine has been a big help, but usually telemedicine is also only available during daytime hours,” said Kman. “You can't get a telehealth visit at 3 a.m., so that would drive patients to an emergency department after hours.”
Marshall said those in rural areas may face barriers pertaining to transportation, but they will be cared for in an emergency room without hesitation as soon as they walk in the door.
“We care for anybody that walks through the door, 24/7, 365 days a year, without checking for insurance,” said Marshall.
“It’s important to have rural hospitals because they have a big access and community impact, but for certain cases, they're just not going to be able to offer the care that a larger hospital would,” said Kman.