Cities attempt to end ambulance diversion

In many cities, diverting ambulances from overcrowded hospital emergency departments (EDs) has strained emergency medical services (EMS), keeping ambulances out of service and slowing response times. Therefore, some cities are implementing plans to reduce the need for ambulance diversion or, in some cases, eliminate it completely.

In June, the Baltimore City Task Force on Emergency Department Overcrowding, comprised of members of the city’s fire department and hospital representatives, released a report outlining recommendations to get patients into, through and out of EDs as quickly as possible. Between 2002 and 2005, the average time ambulances waited at hospitals in the city increased 45 percent, according to the task force report. Also, the number of hours during which hospitals were unable to accept new ED patients increased 165 percent.

The report suggests establishing a center for treating mental health and substance abuse patients, installing electronic bed tracking systems and other technology to quickly move patients into the hospital and to increase patient discharge efficiency. The task force also recommends that the Maryland Institute of Emergency Medical Services Systems (MIEMSS) become more involved in directing ambulances to hospitals with open beds.

In September, the Baltimore City Fire Department (BCFD) began its centralized routing effort, stationing an officer at MIEMSS to monitor the status of the city’s hospitals and ambulances, says BCFD Communications Director Rick Binetti. “We are hoping that the officer can reroute the majority of our priority III [stable] patients to hospitals better suited to accept them at that time,” he says. The ultimate goal of the recommendations, Binetti says, is to eliminate ambulance diversion as much as possible.

Boston, where ED overcrowding has been a problem for several years, is working toward that goal as well, says EMS Chief Richard Serino. “Sometimes we have ambulances waiting for an hour to get the patient triaged,” Serino says. That can contribute indirectly to overtime costs, he says, as the delay can affect the department’s response time, requiring it to assign extra units.

Serino says that, currently, the EMS staff are only allowing each hospital to close for two hours at a time, and only two hospitals are allowed to close at the same time. “If a third one goes on diversion, we open all of them,” he says.

Although Austin, Texas, instituted a no-diversion policy in July 2005, a year passed before the policy went into full effect, says Ed Racht, medical director for Austin-Travis County EMS. “It’s not something where you can just throw a switch [and end diversion],” he says.

Diversion, while it was intended to solve the problem of overcrowded EDs, only created more problems, Racht says. Patients were not taken to the hospital of their choice, doctors sometimes did not have privileges at the hospitals where their patients were taken and city ambulances became unavailable while transferring diverted patients. Also, friction grew between hospital nursing staff and paramedics when the staff had to divert an ambulance. “I think as a concept, diversion has been a failure,” Racht says.

Austin has maintained its no-diversion policy because of EMS and hospital collaboration, flexible planning and the inclusion of an “emergency pop-off valve,” which allows a hospital to close its ED doors if needed.

For the hospitals, eliminating diversion was mostly a matter of reorganizing their procedures, says Pat Crocker, chief of emergency medicine at Austin’s Breckenridge and Children’s Hospital. Crocker says the city hospitals started discharge rounds earlier to clear more beds, expanded the hospitals’ intensive care units and established codes that define steps to take if an ED reaches maximum capacity. “I think most hospitals can do the same,” Crocker says.