This article evaluates the degree of implementation of ten urgent and emergency hospital services comprising the macro and micro-regional referral system in Pernambuco State, Northeast Brazil. The study analyzes criteria related to structure (physical and organizational, and material and human resources) and process (routine and referral/counter-referral activities), classifying the hospitals as satisfactory, acceptable, and deficient. The majority of the hospitals were classified as deficient, including all the micro-regional units and one macro-regional referral unit. Macro-regional units show better performance in the work process, while implementation of the structural dimension is better in the micro-regional hospitals. The results highlight the priority of upgrading these hospitals by strengthening decentralized human resources and technology policies, oriented towards the improvement of work processes in keeping with the State's regional contexts.