Vizient projects an 8% increase in emergent cases, defined as those needing immediate attention, across U.S. emergency departments from 2025 to 2035.
Benjamin Abella, MD, system chair of the emergency medicine department at New York City-based Icahn School of Medicine at Mount Sinai, summed up the issue: “Emergency medicine, in general, across the country is getting busier.”
There are numerous contributing factors, including limited primary care access, more medically complex cases due to care advancements and a swelling population of older adults. Emergent cases also require more resources in EDs, with an average length of stay of 5.3 hours compared to 2.4 hours for urgent cases.
Similar to building a dam to manage a river’s flow, hospitals are renovating EDs and expanding ambulatory services to mitigate the rising tide of patients.
For example, Mount Sinai Health System’s South Nassau hospital in New York City doubled the size of its ED through a $50 million renovation. The football field-size department can now see 75,000 patients annually. Dr. Abella said the expansion increased capacity up to 30%.
In anticipation of rising emergent demand, the system’s flagship hospital added a larger critical care resuscitation area during a similar renovation. The space accommodates patients and hulking lifesaving equipment, including cardiopulmonary bypass machines, expanded modern dialysis and continuous dialysis equipment.
At Novant Health’s Mint Hill (N.C.) Medical Center, the 36-bed facility saw 6,500 patients from its Oct. 1, 2018, opening through Dec. 31, 2018. Joy Greear, president of Mint Hill Medical Center and Thomasville (N.C.) Medical Center, said the patient influx validated the demand for healthcare services, while presenting a forecast for future needs.
“We felt like a very busy ED would be about 18,000 patients a year,” Ms. Greear told Becker’s. “Well, after the first year we were seeing [between 20,000 and 22,000] people. Then the next year, we were seeing 25,000, then 27,000 and 28,000. And now fast-forward, we were seeing 31,000, 32,000.”
Mint Hill invested $45 million to double its ED size. The facility now spans 44,000 square feet as it added 13 treatment rooms, four behavioral health rooms and two trauma rooms.
The predicted growth in emergent cases will not directly affect Mint Hill, Ms. Greear said, as nearby larger hospitals within Winston-Salem, N.C.-based Novant Health can absorb more complex cases.
A landlocked redesign
Northern Arizona Healthcare, which covers about 50,000 square miles and serves more than 700,000 residents, has to take a different approach.
The system’s Flagstaff (Ariz.) Medical Center is the state’s only level 1 trauma center north of Phoenix, according to Northern Arizona Healthcare COO Robert (Bo) Cofield, DrPH. So far this year, the hospital’s ED has recorded nearly 50,000 visits.
Volumes have steadily increased in its emergency, ambulatory, procedural and acute care services, Dr. Cofield said, as Flagstaff’s annual growth hovers between 12% and 14%.
The medical center cannot physically grow, however.
“Because of space limitations at the current hospital site, including structural limits, the inability to reduce the size of other departments, and the need to maintain the limited parking availability, we will not be able to add square footage to the ED during this project,” Northern Arizona Healthcare said in a May 15 statement.
The project, which is rolling out in phases while the ED remains open, will reorganize clinical operations to improve throughput, Dr. Cofield said. Flagstaff Medical Center also nearly doubled its primary care network and launched an urgent care service line to redirect low-acuity cases from EDs.
“Redesigning the patient flow is our only option to improve service,” the system said.
Redirecting low-acuity cases
The percentage of urgent cases in EDs is not expected to grow in the next 10 years, according to Vizient. But that does not mean these cases are going to disappear.
Rachel Levitan, MD, an emergency medicine physician and interim chief medical officer at Flagstaff Medical Center, said the ED launched a model for ambulatory cases. The model moves patients to a testing and treatment area so as not to clog bed space.
“Because we’re not growing our footprint of the emergency department, we’re trying to rationalize the locations of our care: the right patient at the right level in the right setting,” Dr. Cofield said. “As our volumes go in urgent care and primary care, we hope that we’ll be decreasing unnecessary utilization of an emergency department for nonemergent care.”
LifeBridge Health’s Northwest Hospital in Randallstown, Md., introduced a similar initiative in December 2023, according to Craig Carmichael, president and COO of the hospital and senior vice president of Baltimore-based LifeBridge Health.
Northwest’s express treatment has yielded strong results, Mr. Carmichael said. For example, average door-to-provider time has dropped from 62 minutes in 2023 to 28 minutes in early 2025.
Over the same time period, average admit length of stay declined from 713 to 557 minutes. The “left before treatment complete” rate fell from 7.4% to 3.5%, and emergency medical services’ median offloads decreased from 28 to 12 minutes after Northwest Hospital’s renovated ED opened in September.
A behavioral health focus
Each hospital executive told Becker’s their ED projects incorporated new workflows, technologies and space specifically for behavioral health patients.
Flagstaff Medical Center constructed a private and quieter space, Northwest Hospital implemented a new workflow for behavioral health patients, Mint Hill Medical Center added retractable garage-like doors to cover gasses and other medical equipment to enhance safety, and South Nassau invested in a 24/7 telepsychiatry service.
In addition to more beds and space, South Nassau’s ED improved lines of sight and secured cords to reduce self-harm risk.
Historically, behavioral health patients “were considered essentially the same as any other emergency medicine patient who might be having a heart attack or, you know, an infectious problem. But they’re really not,” Dr. Abella said. “These patients have special considerations that will make our care better, safer, more appropriate. We owe it to the families, we owe it to the patients and, quite frankly, we owe it to our staff too to make sure they can practice in a safe environment.”
Workforce shortages, financial turbulence
When asked about preparing staff for more emergent cases, several leaders pointed to ongoing workforce shortages as a considerable hurdle.
Ms. Greear said she is worried about shortages of nurses, paramedics, certified nursing assistants and employees in radiology, respiratory therapy and lab services. Financial pressure is another challenge.
“Given the challenging margins in healthcare these days [and] given that labor costs are high, most health systems staff very judiciously,” Dr. Abella said. “That is necessary for day-to-day operations, but it’s actually a vulnerability for the concept of flexing.”
Upcoming Medicaid cuts will throw another variable into the mix, according to Dr. Cofield. With more than 11 million people projected to lose health insurance by 2034 due to the One Big Beautiful Bill Act, emergency departments could face more strain.
Uninsured individuals are less likely to see a physician and are thus more likely to visit an ED as a last resort. When a rural facility such as Flagstaff Medical Center’s ED is at capacity, there is no other option. If untreated, the ED capacity issue could boil over to the entire industry.
“If every emergency room in the country is full all the time with fully committed resources, we can’t adequately respond to new threats, whatever they might be,” Dr. Abella said.
“One challenge that health system leaders and emergency care leaders have faced is, how do we keep up? And how do we make sure that we maintain surge capacity and that we maintain our ability to flex, because we don’t know what’s on that horizon. And I think one of the big lessons of COVID is that things can change quickly, and we really don’t want to be flat-footed. We want to have a posture of readiness.”
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