A new health policy brief published in the online version of the journal Health Affairs found that diverting ambulances may provide temporary relief for emergency room and hospital overcrowding.
But the five-page brief concluded that it “is unlikely to resolve the overall problems that diversion is supposed to address,” finding that “approaches to overcrowding that incorporate additional strategies alongside limitations on diversions are more likely to be effective in generating long-term changes.”
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Ambulance diversions — which occur when a hospital announces it is on diversion status and won’t accept new ED patients — typically happen during overcrowding within hospitals or emergency departments. When hospitals invoke diversion status, local ambulances direct emergency patients to other hospitals.
The author, David Tuller, a lecturer at the University of California, Berkeley, School of Public Health, found the first mention of ambulance diversions in a 1990 article. Then, it was considered rare. By 2003, 45 percent of American EDs were reporting diversion status at least once in the previous year, with a rate among urban hospitals approaching 70 percent. That year, more than 500,000 diversions were reported, about one per minute.
Over time, diversion incidents often dominoed into further diversions, as newly clogged hospital EDs become overcrowded and had to refuse emergency patients.
Tuller pointed to hospital and ER overcrowding, increased demand for ED services, reduced numbers of EDs and hospital closures in urban areas as factors driving diversions.
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The American Hospital Association reported that ED visits grew from an average of 359 visits per 1,000 people in 1993 to 423 per 1,000 people in 2013, even as the numbers of hospitals staffing EDs fell from 2,446 in 1990 to 1,779 in 2009, an average annual loss of 89 EDs, according to a Journal of the American Medical Association study. A U.S. Centers for Disease Control and Prevention (CDC) study recorded more than 130 million ED patient annual visits, 20 million arriving by ambulance.
The most immediate impact is longer waiting times for patients and greater stress and lowered morale for ED staff, Tuller found. He said a 2006 study identified patterns in overcrowding and diversion were more likely at times of peak ED volume during the day in mid-afternoon to late evening, on Mondays and during predicted annual periods, such as flu season.
A 2010 New York City study found an association between higher levels of diversions and increased deaths from heart attacks, though he noted the study had limited use. Diversions also disproportionately impacted minorities. Tuller cited articles describing diversion strategies, such as managing ED patient traffic, appointing nurses as patient flow coordinators and creating regional agreements and coordinated policies about when to invoke diversion status, as well as employing technology to monitor and balance available resources with patient needs.
After Massachusetts banned ambulance diversions in 2009, the state and its hospitals took a comprehensive approach to ED overcrowding. Waiting times for patients admitted to the hospital fell by 10.4 percent at nine hospitals in the Boston area. And a study of ED physicians and administrators found widespread support for the diversion ban, higher quality of care and greater patient satisfaction.
Tuller said that “greater regional communication and cooperation can minimize the likelihood of a domino effect that flips one hospital after another into diversion status.”
