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Original Research

Comparison of rates of emergency department procedures and critical diagnoses in metropolitan and rural hospitals

Submitted: 18 September 2014
Revised: 25 February 2015
Accepted: 14 April 2015
Published: 13 October 2015

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Author(s) : Waymack JR, Markwell S, Milbrandt JC, Clark TR.

Citation: Waymack JR, Markwell S, Milbrandt JC, Clark TR.  Comparison of rates of emergency department procedures and critical diagnoses in metropolitan and rural hospitals. Rural and Remote Health (Internet) 2015; 15: 3298. Available: (Accessed 17 October 2017)


Introduction:  Emergency medicine (EM) workforce studies show low rates of board-certified/residency-trained emergency physicians practising in rural emergency departments (EDs) in the USA. Rural ED rotations for EM residents may lead to increased numbers of residency-trained EM providers in rural areas. There is concern that residents trained in rural environments will not get sufficient procedural experience or patient acuity. The current literature contains only one single-residency study that provides procedural experience and patient acuity comparison between metropolitan and rural EDs. The purpose of this study is to utilize the Nationwide Emergency Department Sample (NEDS) to compare the rate of selected procedures and critical diagnoses at rural and metropolitan EDs in the USA.
Methods:  The NEDS database contains ED visit records from 958 hospitals and approximates a 20% stratified sample of US hospital-based EDs. The procedures analyzed were chosen based upon the Emergency Medicine Residency Review Committee’s guidelines for procedural competency and the critical diagnoses were selected based upon the American College of Emergency Physicians Model of the Clinical Practice of Emergency Medicine. Procedures and critical patient diagnoses were identified in the NEDS database by International Classification of Diseases (9th revision) code. The rates of eight procedures and twelve critical diagnoses are compared between two categories: The metropolitan category includes hospitals that are in counties defined as large or small metropolitan; the rural category includes hospitals that are in counties defined as micropolitan or non-metropolitan.
Results:  When comparing 22 766 219 rural ED visits to 97 267 531 metropolitan ED visits there were significant differences between the rates of procedures and critical diagnoses. For all procedures analyzed, the rate at which they were performed in the rural setting versus the metropolitan was significantly lower. The decreased performance rate in rural EDs compared to metropolitan EDs was greatest for ED procedures such as fracture reduction, endotracheal intubation and lumbar puncture. Overall, procedures were performed twice as often in metropolitan EDs as compared to rural EDs. Critical diagnosis rates also tended to be lower for rural EDs when compared to metropolitan EDs. This difference in identification of critical diagnosis rate was greatest for acute myocardial infarction, cardiac dysrhythmia and ischemic cerebrovascular accident.
Conclusions:  The rates of critical diagnoses are similar, but are still lower in rural EDs as a recent single-site study has shown. The lower rates of procedures and critical diagnoses in rural EDs confirm the concern that residents receiving a substantial portion of their training in rural EDs may not get sufficient experience in certain procedures or critical diagnoses. The benefits of a rural ED rotation must be weighed against the risk of lower procedure and critical diagnosis rates. The impact of a 1–3 month rotation in a rural ED on overall procedural competency and clinical experience cannot, however, be extrapolated, and further study is required to quantify this effect.

Key words: ED visits, metropolitan, NEDS, procedures, resident training, USA.

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