Ambulance Diversion

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.

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.

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.

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.

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.