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Insight: The Impact of Ambulance Diversion Policies on ED Overcrowding

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Insight: The Impact of Ambulance Diversion Policies on ED Overcrowding

By Richard D. Zane, MD, FAAEM, Brigham and Women's Hospital

Related to: Emergency Medicine

Emergency Department (ED) overcrowding is an increasingly prevalent topic, with much scrutiny in medical literature and the lay press. One consequence of ED overcrowding is ambulance diversion wherein drivers are instructed to bypass a specific ED and to bring the patient to another hospital with theoretically (more) capacity to care for patients. Diversion status is requested by the hospital and may or may not be granted, depending on the current state of the emergency medical system.

For instance, if multiple contiguous hospitals simultaneously request diversion, or there is a weather or traffic emergency, then diversion status may not be granted. In addition, when diversion status is granted, it does not apply to patients who 1) are critically ill, 2) are victims of major trauma, or 3) insist on being transported to a particular hospital despite diversion status. Although the reason to request ambulance diversion is to decrease the number of patients who arrive to an ED during times of high census or overcrowding, we cannot demonstrate that diverting ambulances changes ED volume or patient acuity. In addition, multiple factors lead to ambulance diversion and, despite much scrutiny, the specific causes of diversion are not known. There is, however, a correlation between a high hospital inpatient census and ambulance diversion.

In 1999, in response to growing concern over the escalating use of ambulance diversion, the Massachusetts Department of Public Health (DPH) convened the Ambulance Diversion Task Force. First, the task force issued a series of best practices for ambulance diversion—in attempts to standardize the practice of ambulance diversion—then, in 2002, it issued guidance on unified rules and definitions. Despite such efforts, ambulance diversion hours increased steadily across Massachusetts (e.g., in Boston, from 448 hours in 1997 to 2,855 hours in 2006). In October 2006, Boston’s teaching hospitals agreed to participate in a two week moratorium on diversion. ED data for those two weeks, during which no hospital went on diversion, were compared to historical base-lines. Although the two week period was probably too short to make definitive conclusions, there were no untoward events reported. ED length of stay appeared to be slightly lower, while ambulance turnaround time and the volume of ED visits was largely unchanged.

As the problem of ambulance diversion, ED overcrowding and ED boarding (inpatients remaining in the ED due to a lack of inpatient beds) continues to grow, the DPH has reconvened the Ambulance Diversion Task Force as the Boarding and Diversion Task Force in another attempt to address the issues related to overcrowding. One of its recommendations was to (as of January 1, 2009) ban all ambulance diversions to dispel it as a viable solution or response to overcrowding and boarding. Without that option, hospitals will have to be more creative and substantive in the way in which they combat the problem.


November 10, 2009
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