Diversion!

During my undergraduate education, I worked nights and weekends as an ED tech and frequently I would walk into work with a full waiting room and grease board, eventually leading the ED to go on ‘Diversion’. At the time, my understanding of diversion was something that made the patients stop coming and the nurses start celebrating. To me, it seemed like a good idea; have EMS take patients to other hospitals to give us a chance to decrease our own patient load. Moving into medical school, it seemed to become a point of pride that the ED would rarely—if ever—go on diversion. Now, the culture is starting to shift with many states and regions moving to diversion bans to prevent hospitals from not accepting EMS patients. Massachusetts became the first state to enact a ban in 2009, and a new brief in Health Affairs discusses the most recent research and debate about hospital diversion.

Ambulance diversion was first cited in 1990, when it was viewed as an option to be used rarely, such as during a crisis or disaster when a large number of patients could potentially overwhelm an ER’s ability to function. As the new HA brief states, by the early 2000’s, 45% of EDs had gone on diversion within a year, with 70% of urban hospitals having diverted in the same time frame. EDs have utilized diversion because it works; in the short term, individual EDs are able to process the overflow of patients and return to normal function. The secondary effects, however, are bringing about regional and state bans on the practice. Once diversion is initiated, surrounding hospitals must bear the brunt of these displaced patients, potentially triggering additional diversion statuses, prolonging EMS transport times, and leading to delays in patient care. What was once considered a crisis response tool has become a frequently used means with dubious outcomes.

As a result of diversion bans, systems have seen no increase in length of stay for discharged patients, decreased length of stay for admitted patients, and faster ambulance turn-around times. As a prior ED tech, most surprising to me was that ED clinicians and administrators strongly support the diversion ban.  With diversion seemingly on the way out, other approaches to ED crowding are taking the spotlight. Recently, the Urgent Matters Podcast discussed the Advance Resource Medic (ARM) with Rick Lewis, EMT-P EMS chief for South Metro Fire Rescue. The ARM utilizes an advanced practice paramedic and nurse practitioner to provide on-scene care for non-life threatening calls, and was first piloted in 2013.

Looking toward the future, ED crowding will continue to be an issue as utilization of emergency departments increases, and new policies to increase patient flow and department decompression will be required to treat the higher number of patients.

 

Read the complete Health Policy Brief on ambulance diversion.

Sources:

 "Health Policy Brief: Ambulance Diversion," Health Affairs, June 2, 2016. http://www.healthaffairs.org.proxygw.wrlc.org/healthpolicybriefs/brief.php?brief_id=158

Kincaid, Cynthia. "Use the ARM." JEMS. N.p., 21 Feb. 2014. Web. 7 June 2016. http://www.jems.com/articles/2014/02/use-arm-2013.html

Urgent Matters Podcast. An Urgent Care Clinic on Wheels. Rec. 26 May 2016. N.d. MP3. https://itunes.apple.com/us/podcast/urgent-care-clinic-on-wheels/id92638...

Catherine W. Burt, Linda F. McCaig, and Roberto H. Valverde, "Analysis of Ambulance Transports and Diversions among US Emergency Departments,"Annals of Emergency Medicine 47, no. 4 (2006): 317-26.


Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital