1. The 2007 State of Americas Hospitals – Taking the Pulse Findings from the 2007 AHA Survey of Hospital Leaders July 2007

2. Executive Summary Hospitals face workforce shortages that are affecting patient care. Hospitals had an estimated 116,000 registered nurse vacancies as of December 2006. Nearly half of emergency departments (ED) are at or over capacity. A majority of urban hospitals experience time on diversion. The most common reason for diversion is lack of staffed critical care beds. 55% of hospitals experienced gaps in specialty coverage in the ED. Many hospitals are reporting increased difficulty maintaining physician ED call coverage. More than a third of hospitals now pay for some physician specialty ED call coverage. Coverage issues are most prevalent in orthopedics and neurosurgery. Hospitals are taking a variety of actions to bolster disaster readiness including participation in large scale drills, establishing back-up communications plans and developing resource sharing plans with other hospitals.

3. Survey Methodology Survey was sent to approximately 5,000 community hospital CEOs in late February 2007 via fax and Email. Data was collected through March 2007. Unless otherwise specified, data reflects the above mentioned time period. A total of 840 responses were received, a response rate of approximately 17%.

4. Overview Workforce Hospital Capacity, Emergency Department Diversion and Specialty Coverage Disaster Readiness

5. 2007 Survey Results WORKFORCE

6. Vacancy Rates for Selected Hospital Personnel, December 2006 Hospitals face workforce shortages in key care- giving professions… Source: 2007 AHA Survey of Hospital Leaders Note: 116,000 vacancies is a national estimate created by extrapolating the vacancy rate to all 5,000 community hospitals in 2005. ST: Speech Therapist, OT: Occupational Therapist, PT: Physical Therapist. 116,000 RN Vacancies*

7. ..that are perceived to be getting worse… IT Technologists Housekeeping/ Maintenance Nursing Assistants LPNs Billing/Coders Laboratory Technicians Imaging Technicians Pharmacists Registered Nurses Percent of Hospitals Reporting Recruitment More Difficult in 2006 vs. 2005 Source: 2007 AHA Survey of Hospital Leaders. Therapists (Speech, Occupational and Physical)

8. …and are affecting patient care. ED Overcrowding Diverted ED Patients Reduced Number of Staffed Beds Increased Wait Times to Surgery Discontinued Programs/ Reduced Service Hours Delayed Discharge/ Increased Length of Stay Cancelled Surgeries Curtailed Acquisition of New Technology Curtailed Plans for Facility Expansion Type of Impact Source: 2007 AHA Survey of Hospital Leaders Percent of Hospitals Reporting Service Impacts of Workforce Shortage, 2006 Decreased Patient Satisfaction Decreased Staff Satisfaction

9. 17 percent of hospitals reported hiring foreign- educated* nurses in 2006. Percent of Hospitals Reporting that They Hired Foreign- educated* Nurses to Help Fill RN Vacancies in 2006 Source: 2007 AHA Survey of Hospital Leaders *Foreign-educated nurses are individuals who are foreign born and received basic nursing education in a foreign country. In general many of these nurses come to the US on employment visas which allow them to obtain a green card.

10. 42 percent of hospitals reported that they hired more foreign-educated* nurses in 2006 vs 2005. Percent of Hospitals Reporting More, Less or the Same Number of Foreign-educated* Nurses to Fill Vacancies in 2006 vs 2005 Source: 2007 AHA Survey of Hospital Leaders *Foreign-educated nurses are individuals who are foreign born and received basic nursing education in a foreign country. In general many of these nurses come to the US on employment visas which allow them to obtain a green card.

11. 84 percent of those hospitals hiring foreign-educated nurses recruited from the Philippines. Source: 2007 AHA Survey of Hospital Leaders Percent of Hospitals Hiring Foreign-educated Nurses by Country from which They Recruited, 2006

12. 2007 Survey Results HOSPITAL CAPACITY, EMERGENCY DEPARTMENT DIVERSION AND SPECIALTY COVERAGE

13. Nearly half of EDs are at or over capacity… Percent of Hospitals Reporting ED Capacity Issues by Type of Hospital, 2007 Source: AHA 2007 Survey of Hospital Leaders 65% 31% 73% 42% 48%

14. …and a majority of urban and teaching hospitals experience time on ED diversion… Percent of Hospitals Reporting Time on Diversion in Last 12 Months Source: AHA 2007 Survey of Hospital Leaders

15. …most often caused by a lack of staffed critical care beds. Percent of Hospitals Citing Factor as Number One Reason for Ambulance Diversion, January 2007 Source: AHA 2007 Survey of Hospital Leaders Lack of Staffed Critical Care Beds ED Overcrowded Lack of General Acute Care Beds Staff Shortages Lack of Specialty Physician Coverage Lack of Psychiatric Beds

16. Percent of Time on Diversion in January 2007 (Among Urban Hospitals Experiencing Diversion in the Last 12 Months) For urban hospitals reporting diversion, nearly one in eight was on diversion more than 20 percent of the time. Source: AHA 2007 Survey of Hospital Leaders Percent of Urban Hospitals Experiencing Diversion Percent of Time on Diversion

17. 42 percent of hospitals reported an increase in boarding behavioral health patients in the ED. Percent of Hospitals Reporting Increases in Boarding Behavioral Health Patients in the ED by Type of Hospital Source: AHA 2007 Survey of Hospital Leaders Note: Boarding is a term used when patients that are in need of inpatient psychiatric or substance abuse services remain in the emergency department until a suitable placement can be found. 51% 33% 52% 39% 42%

18. Percent of Hospitals Losing Specialty Coverage in the ED for Any Period of Time in Last 24 Months and Reasons Cited 55 percent of community hospitals experienced gaps in specialty coverage in the ED. Source: AHA 2007 Survey of Hospital Leaders. *Respondents could check more than one reason for loss of specialty coverage. Percent of Above Citing Reason as Factor in Loss of Coverage*

19. Maintaining ED coverage is becoming more difficult for many hospitals in key specialty areas. Percent of Hospitals Reporting Increased Difficulty in Maintaining Physician ED Call Coverage by Selected Specialty in 2007 Source: AHA 2007 Survey of Hospital Leaders 44% 43% 40% 25% 36% 34% 32% 36% 23% 21% 18%

20. Gaps in coverage were most often reported for orthopedics and neurosurgery. Percent of Hospitals Reporting Loss of Specialty Coverage for Any Period of Time in 2007 Source: AHA 2007 Survey of Hospital Leaders

21. More than a third of hospitals pay for some physician ED on-call coverage. Percent of Hospitals Reporting Payment for ED On-call Coverage by Specialty, 2007 Source: AHA 2007 Survey of Hospital Leaders 37% 33% 31% 16% 22% 21% 18% 25% 13% 9%

22. 2007 Survey Results DISASTER READINESS

23. The majority of hospitals reported taking part in a large- scale drill with external response agencies. Hospitals Participating in Large-scale Community-wide Drills with External Response Agencies in 2006 Source: AHA 2007 Survey of Hospital Leaders Yes, have already taken action No, but plan to take action in 6-12 months No, but plan to take action when resources permit No action planned

24. 85 percent of hospitals have established back up systems for communication with police, fire etc. Percent of Hospitals with Established Back-up Community-wide Communications Ability, 2006 Source: AHA 2007 Survey of Hospital Leaders Yes, have already taken action No, but plan to take action in 6-12 months No, but plan to take action when resources permit No action planned

25. Chart 1.5: National Expenditures for Health Services and Supplies (1) by Category, 1980 and 2005 (2) Source: AHA 2007 Survey of Hospital Leaders Number of Staffed Beds Hospitals Estimate Could be Available in the Following Time Periods in the Event of a Disaster, 2007 The majority of hospitals have the ability to add more bed capacity in the event of a disaster.