A recent survey of the 5,622 nonfederal emergency departments (EDs) in the United States, of which 4,621 (82%) responded to the question “Is at least one attending physician (not resident) on duty in the ED 24 h/d?”, found that 1 in 13 U.S. EDs lack 24/7 attending physician coverage: “The absence of 24/7 attending physician coverage was more common in low-volume EDs and CAHs [critical access hospitals]. These observations highlight important gaps in ED care nationally. Changes in CAH regulations may help address this important workforce issue … In several states, ≥30% of the EDs lacked 24/7 coverage. Among these 344 EDs, 92% had low annual visit volumes, 89% were in critical access hospitals, and 72% were rural.”
An American College of Emergency Physicians poll from 2021 reported that almost 80% of the U.S. public report that they most trust a physician to lead their medical care while in the ED compared with a nurse, physician assistant, or nurse practitioner. This same poll suggested that adults do make assumptions about whether their treating ED clinician is a physician (e.g., a portion assume this based on the color of the clinician’s scrubs or whether they are wearing a stethoscope).
7.4% of all U.S. EDs reported that they lacked 24/7 attending physician coverage: in 15 states, zero responding EDs reported that they lacked 24/7 attending physician coverage; two states that have recently introduced legislation requiring 24/7 in-person physician coverage in EDs, Indiana and Virginia, had no EDs that reported a lack of 24/7 coverage; however, in several states, ≥30% of the state’s EDs lacked 24/7 coverage. The states with the highest percentages were North Dakota (58%), South Dakota (56%), and Montana (46%).
The survey found that among the 344 EDs without 24/7 attending physician coverage, 50% did not have 2-way voice communication 24/7 with any physician within the hospital, and 19% did not have this with any physician outside the hospital. Ten EDs (3%) reported “no” to both subquestions (i.e., they lacked 24/7 2-way voice communication with any physician).
The characteristics of EDs without 24/7 coverage are low-visit volume EDs (<10,000 visits/year) located within a CAH (CAH designation is given to eligible rural hospitals by the Centers for Medicare and Medicaid Services with the goal of the CAH program to reduce the financial vulnerability of these designated hospitals and to improve access to health care by keeping these hospitals open) and a rural area. Although 77% of these EDs receive telehealth, 23% do not. In a prior survey of rural EDs, most ED directors without telehealth reported that their ED, hospital, or health system leadership had considered it, but the start-up and maintenance costs were often cited for the lack of telehealth adoption.
Most (89%) EDs without 24/7 attending physician coverage were in a CAH. Although CAH regulations require that each facility operates a 24/7 ED, they do not require that the ED be staffed by an attending physician 24/7: “A revision in CAH policy, including financial support for 24/7 attending physician coverage, may help to reduce the number of EDs operating without this coverage.”
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