therefore the insurance company may apply utilization management to deny coverage. in 2004, a study found that emergency room visits were the most common reason for appealing disputes over coverage after receiving service. in 2017, anthem expanded this denial coverage more broadly, provoking public policy reactions. united kingdom the emergency department at the royal infirmary of edinburgh a&e sign in the united kingdom uk road sign to a hospital with a&e all accident and emergency (a&e) departments throughout the united kingdom are financed and managed publicly by the national health service (nhs of each constituent country: england, scotland, wales and northern ireland). the term "a&e" is widely recognised and used rather than the full name; it is used on road signs, official documentation, etc. a&e services are provided to all, without charge. other nhs medical care, including hospital treatment following an emergency, is free of charge only to all who are "ordinarily resident" in britain; residency rather than citizenship is the criterion (details on charges vary from country to country). in england departments are divided into three categories: type 1 department – major a&e, providing a consultant-led 24 hour service with full resuscitation facilities type 2 department – single specialty a&e service (e.g. ophthalmology, dentistry) type 3 department – other a&e/minor injury unit/walk-in centre, treating minor injuries and illnesses historically, waits for assessment in a&e were very long in some areas of the uk. in october 2002, the department of health introduced a four-hour target in emergency departments that required departments in england to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary. it was expected that the patients would have physically left the department within the four hours. present policy is that 95% of all patient cases do not "breach" this four-hour wait. the busiest departments in the uk outside london include university hospital of wales in cardiff, the north wales regional hospital in wrexham, the royal infirmary of edinburgh and queen alexandra hospital in portsmouth. in july 2014, the qualitywatch research programme published in-depth analysis which tracked 41 million a&e attendances from 2010 to 2013. this showed that the number of patients in a department at any one time was closely linked to waiting times, and that crowding in a&e had increased as a result of a growing and ageing population, compounded by the freezing or reduction of a&e capacity. between 2010/11 and 2012/13 crowding increased by 8%, despite a rise of just 3% in a&e visits, and this trend looks set to continue. other influential factors identified by the report included temperature (with both hotter and colder weather pushing up a&e visits), staffing and inpatient bed numbers. a&e services in the uk are often the focus of a great deal of media and political interest, and data on a&e performance is published weekly. however, this is only one part of a complex urgent and emergency care system. reducing a&e waiting times therefore requires a comprehensive, coordinated strategy across a range of related services. many a&e departments are crowded and confusing. many of those attending are understandably anxious, and some are mentally ill, and especially at night are under the influence of alcohol or other substances. pearson lloyd's redesign – 'a better a&e' – is claimed to have reduced aggression against hospital staff in the departments by 50 per cent. a system of environmental signage provides location-specific information for patients. screens provide live information about how many cases are being handled and the current status of the a&e department. waiting times for patients to be seen at a&e were rising in the years leading up to 2020, and were hugely worsened during the covid-19 pandemic that started in 2020. in response to the year-on-year increasing pressure on a&e units, followed by the unprecedented effects of the covid-19 pandemic, the nhs in late 2020 proposed a radical change to handling of urgent and emergency care, separating "emergency" and "urgent". emergencies are life-threatening illnesses or accidents which require immediate, intensive treatment. services that should be accessed in an emergency include ambulance (via 999) and emergency departments. urgent requirements are for an illness or injury that requires urgent attention but is not a life-threatening situation. urgent care services include a phone consultation through the nhs111 clinical assessment service, pharmacy advice, out-of-hours gp appointments, and/or referral to an urgent treatment centre (utc). as part of the response, walk-in urgent treatment centres (utc) were created. people potentially needing a&e treatment are recommended to phone the nhs111 line, which will either book an arrival time for a&e, or recommend a more appropriate procedure. (information is for england; details may vary in different countries.) critical conditions handled cardiac arrest cardiac arrest may occur in the ed/a&e or a patient may be transported by ambulance to the emergency department already in this state. treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses. heart attack main article: myocardial infarction patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. they will receive oxygen and monitoring and have an early ecg; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (gtn or ntg) will be given, unless contraindicated by the presence of other drugs. an ecg that reveals st segment elevation suggests complete blockage of one of the main coronary arteries. these patients require immediate reperfusion (re-opening) of the occluded vessel. this can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (ptca). both of these are effective in reducing significantly the mortality of myocardial infarction. many centers are now moving to the use of ptca as it is somewhat more effective than thrombolysis if it can be administered early. this may involve transfer to a nearby facility with facilities for angioplasty. trauma main article: physical trauma major trauma, the term for patients with multiple injuries, often from a motor vehicle crash or a major fall, is initially handled in the emergency department. however, trauma is a separate (surgical) specialty from emergency medicine (which is itself a medical specialty, and has certifications in the united states from the american board of emergency medicine). trauma is treated by a trauma team who have been trained using the principles taught in the internationally recognized advanced trauma life support (atls) course of the american college of surgeons. some other international training bodies have started to run similar courses based on the same principles. the services that are provided in an emergency department can range from x-rays and the setting of broken bones to those of a full-scale trauma centre. a patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). this critical time frame is commonly known as the "golden hour". some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma centre. this inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. in such cases the emergency department can only stabilize the patient for transport. mental illness some patients arrive at an emergency department for a complaint of mental illness. in many jurisdictions (including many u.s. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. the emergency department conducts medical clearance rather than treats acute behavioral disorders. from the emergency department, patients with significant mental illness may be transferred to a psychiatric unit (in many cases involuntarily). in recent years, empath units have been developed to relieve pressure on hospital emergency departments and improve the treatment of psychiatric emergencies. emergency departments are often the first point of contact with healthcare for people who self-harm. as such they are crucial in supporting them and can play a role in preventing suicide. at the same time, according to a study conducted in england, people who self-harm often experience that they don't receive meaningful care at the emergency department. asthma and copd acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (copd), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest x-ray and arterial blood gases and are referred for intensive care if necessary. noninvasive ventilation in the ed has reduced the requirement for tracheal intubation in many cases of severe exacerbations of copd. special facilities, training, and equipment an ed requires different equipment and different approaches than most other hospital divisions. patients frequently arrive with unstable conditions, and so must be treated quickly. they may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ed staff are trained to work quickly and effectively even with minimal information. ed staff must also interact efficiently with pre-hospital care providers such as emts, paramedics, and others who are occasionally based in an ed. the pre-hospital providers may use equipment unfamiliar to the average physician, but ed physicians must be expert in using (and safely removing) specialized equipment, since devices such as military anti-shock trousers ("mast") and traction splints require special procedures. among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and eds employ many such specialists. ed staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. often, joint training and practice drills are organized to improve the coordination of this complex response system. busy eds exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items. cardiac arrest and major trauma are relatively common in eds, so defibrillators, automatic ventilation and cpr machines, and bleeding control dressings are used heavily. survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. the best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars and fire apparatus, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls. because time is such an essential factor in emergency treatment, eds typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. nearly all have radiographic examination rooms staffed by dedicated radiographers, and many now have full radiology facilities including ct scanners and ultrasonography equipment. laboratory services may be handled on a priority basis by the hospital lab, or the ed may have its own "stat lab" for basic labs (blood counts, blood typing, toxicology screens, etc.) that must be returned very rapidly. non-emergency use metrics applicable to the ed can be grouped into three main categories, volume, cycle time, and patient satisfaction. volume metrics including arrivals per hour, percentage of ed beds occupied, and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. patient satisfaction metrics, already commonly collected by nursing groups, physician groups, and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement. health information exchanges can reduce nonurgent ed visits by supplying current data about admissions, discharges, and transfers to health plans and accountable care organizations, allowing them to shift ed use to primary care settings. in all primary care trusts there are out of hours medical consultations provided by general practitioners or nurse practitioners. in the united