Ambulance Diversion

HEALTH REFORM: Stop the Ambulance, I Want to Get Off

Joanne Kenen — Mon, 15 Sep 2008 20:09:00 -0400

We recently published an issue brief and blog posts (here, here, and here) on ambulance diversions. That's when your local emergency room is so crowded that it temporarily shuts its doors to more ambulance traffic and sends patients elsewhere. So we noticed when today's Boston Globe reported that Massachusetts has ordered its hospitals to stop the practice by January 1.

The state's director of healthcare safety and quality Paul Dreyer said ambulance diversions may give ERs momentary breathing room but it doesn't solve the underlying problem of crowded emergency departments with patients backed up in hallways waiting for an open bed in the hospital.

To the contrary, he told the Globe's Liz Kowalczyk, diversion may create more problems than it solves, interfering with patient choice, increasing ambulance travel time (which can be dangerous) and just shifting the crowding to other hospitals. Instead of getting taken to the hospital where their doctor works and their records are kept, patients get taken to other hospitals where no one knows their medical history, prescription regimen etc. (Another argument for Health IT and records that doctors can access from any hospital but we digress).

"Undoubtedly this [ban on diversion] is going to be better for patients," Dr. Alasdair Conn, chief of emergency services at Mass. General told the Globe. "It makes no sense for a patient with 20 years of history at a hospital, where they had their surgery, where their EKG and other test results are, to have to go somewhere else." Last year Mass General was on diversion for the equivalent of almost a full month.

Dr. Conn said his hospital is focusing on ways to discharge patients from the hospital earlier in the day, thereby freeing up beds for patients waiting in the ER. That's one of the steps our colleague Dr. Guy Clifton recommended in the New America diversion paper and in other blog posts.

Dr. Brien Barnewolt, chairman of emergency medicine at Tufts Medical Center in Boston, said Tufts stopped temporarily closing its ER to ambulances in August to prepare for the change. Tufts has made several changes to free up beds to make room for patients who need to be admitted from the emergency department, including performing blood tests on overnight patients at 5:00 or 6:00 a.m. That way doctors can get test results and discharge patients earlier in the day, improving the patient flow.

We know that more efficient discharge procedures is only part of the solution, although one that can make a difference. Solving the overall emergency care crisis is more complicated. We need to cover the uninsured who turn to the ER as a last resort. We need to have better primary care to address more routine problems that don't belong in the ER. And we need to have better management of chronic disease, so that people don't end up having medical crisis that land them in the ER. In other words—we need comprehensive health reform.

QUALITY: Ambulance Diversions Show Need for Reform (Part 3)

Health Policy — Mon, 08 Sep 2008 15:01:00 -0400

Last week we posted (here and here) about our new issue brief on ambulance diversions. Here are a few thoughts about what we can do to fix the problem, which is a threat to all of us, regardless of our wealth or insurance status. Shutting emergency departments, even briefly, to ambulance traffic is a a sign of the strain on our overall health care system.

One part of the solution is to set standard criteria for when a hospital can put itself on diversion. Criteria might include: percentage of hospital beds currently in use, the number of staff on duty, and the number of people in the ED waiting room. Hospital accountability for reporting and abiding by diversion standards could be tied to federal funding. For instance, failure to report diversion rates in a timely manner would jeopardize hospital funding. It would help if we could do a comprehensive national study to assess hospital capacity, and diversions' impact.

The second part is a bigger challenge. We need to cover the uninsured. As we've said, the 46 million uninsured are not the only source of strain on the emergency system, but it's a big factor. Making sure all Americans have quality, affordable health coverage will help keep patients out of the hospital for non-emergency treatment and allow EDs to function at their highest level when patients need them the most.

We'll write more about the emergency care crisis (and the mirror image, the primary care crisis) soon. Stay tuned.

QUALITY: Ambulance Diversions Show Need for Reform (Part 2)

Health Policy — Fri, 05 Sep 2008 15:40:00 -0400

New America's Dr. Guy Clifton and Hannah Graff this week posted a new issue brief on ambulance diversions—when hospital Emergency Departments can't handle more patients and divert ambulances elsewhere. Yesterday we wrote about how common diversions are, and how they can affect anyone, regardless of whether they have good, bad or no health insurance. Today we'd like to talk about three reasons why diversions happen, and what they say about the troubled state of our health care system. If you've been following our earlier posts on emergency room crowding, you'll know that the problem is not just the uninsured.

Emergency Departments have become a major source of primary care. The New England Healthcare Institute has found that one-in-four emergency room visits were non-urgent, and another fourth could have been addressed or prevented by a visit to a doctor's office. Uninsured people are twice as likely to seek care for a chronic condition in an ED, when it could be (and should be) treated in a primary care setting. Misuse of EDs makes it more likely that a hospital will have to divert ambulances.

The number of patients that can be admitted to an ED in a given hospital is dictated by the number of staffed beds, or beds attended to by hospital staff on duty. No available staff means no room for emergency patients. Hospitals will ask that ambulances be diverted if their own staff is occupied and unable to give prompt care for new arrivals. Lack of staffed beds tends to be a problem in urban hospitals with a high volume of patients. (A hospital can have more licensed beds than staffed beds)

Inefficient patient flow. This refers to how hospitals manage their own resources, how and when they discharge patients, how and when they move patients from one setting (such as the ED) to another (a regular floor or an ICU for instance). According to the GAO, half of hospitals reported one reason they go on diversion is when they have ED patients who need to be moved elsewhere in the hospital—but they don't have a suitable bed open. This graph illustrates that "patient flow" is indeed a major problem.

Conditions Hospitals Reported as Contributing to Diversion, FY2001

Source: General Accounting Office, “Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities,” 2003.

On Monday we'll wrap up this series with some thoughts on what we can do to solve the problem.

QUALITY: Ambulance Diversions Show Need for Reform (Part 1)

Health Policy — Thu, 04 Sep 2008 15:01:00 -0400

Whether you are rich or poor, insured or uninsured, a savvy "health care consumer" or a blithely not-so-savvy one doesn't matter if you are lying critically ill or injured on an ambulance gurney and the nearest ER is on "diversion"—meaning temporarily closed to ambulance traffic and sending patients elsewhere. Dr. Guy Clifton and Hannah Graff, two members of our health policy team, have published a new issue brief explaining what ambulance diversions are, why you should care, and what we should do about it. We'll share the highlights in three blog posts from today through Monday.

When an ambulance is diverted from one hospital emergency department and sent to another, critical care can be delayed by precious minutes. A threat to both the insured and uninsured populations, diversions are also a barometer of how badly our struggling health system needs comprehensive reforms. Diversions are not an occasional problem, nor are they restricted to certain regions or types of hospitals. Every minute in the United States, an ambulance is diverted. In 2004, almost half of all hospitals and nearly 70 percent of urban hospitals reported at least some time on diversions. Diversions affect both people being rushed to the nearest hospital at the onset of a medical crisis, as well as those being transferred from one hospital to a larger or more specialized one that can deliver life-saving care.

Ample evidence shows diversions hurt.

A study from New York City boroughs found the death rate from heart attacks increased by 47 percent on days when hospitals were on diversion. Patient care suffers, too, when more than one hospital in a given area is on diversion.

Another comprehensive study found that when more than 60 percent of area hospitals are on diversion, median treatment time for heart attacks increased by almost 10 minutes.

And research in Houston found that the death rate for severely injured patients requiring inter-hospital transfer was about 10 percent higher on "high-diversion" days—25 percent on the high days, versus about 14 percent on low diversion days.

Tomorrow we'll look at the causes of diversion, and Monday we'll talk about what we can do about it.

QUALITY: Ambulance Diversions are Tip of Emergency Care Iceberg

Guy Clifton M.D. — Wed, 26 Mar 2008 18:24:00 -0400

What happens when your local emergency room is full? For a troubling number of Americans, the ambulance is put on diversion and forced to seek the nearest hospital with open beds. These diversions were the focus of a recent article in Seattle Times and, more importantly, are a warning of the troubling times ahead for our over-burdened health care system.

The Seattle paper told the story of Sara Nakagawa, who had complications 10 days after gall bladder surgery. She waited in an ER for six or seven hours,without being seen, went home and dialed 911. The ambulance then spent 20 minutes parked near her home trying to find a place that would take her. Later, the same thing happened to her 12-year-old stepson in the midst of an acute diabetic crisis.

Ambulance diversion was rare before 1999, but it has since become increasingly prevalent and dangerous. Every minute, one ambulance is diverted from a U.S. hospital, according to a 2006 study in the Annals of Emergency Medicine. A study of New York City hospitals found that periods of ambulance diversion were associated with a 47 percent increase in the mortality rates for heart attacks.

While the effects of ambulance diversion are increasingly apparent, the origins of our current crisis are systematic and date back to the 1990s with the rise of managed care and the Balanced Budget Act of 1997. The calculus of managed care led many hospitals to cut beds, while the budget law meant that the federal government reduced its payments meant to partly reimburse hospitals for treating the uninsured (care that occurred largely in emergency rooms). This one-two punch left hospitals with too few beds and too little money to face an increased demand for emergency services, resulting in the overcrowding of emergency rooms and the diversion of ambulances seen today.

The U.S. has been in the midst of a hospital building boom, but the evidence is that it has focused on high-margin operations such as back surgery, orthopedic surgery, and heart surgery and not on the kinds of services needed by patients with emergency medical conditions, which are less profitable for hospitals.

The nation's emergency services system in most communities is a patchwork of ambulance services all working in isolation taking patients to a group of hospitals that don't talk to each other.Coordination of services is not only crucial to curbing ambulance diversion, but, more broadly, it is a principle for reforming our health care system as a whole. Electronic medical records, medical homes, and host of other reforms have the potential to ensure that individuals have access to the right care when they need it, making sure their primary care physician manage their heartburn and their the ER can manage heart attack.