Issue 2 : Ambulance Diversion
1. Define in 10-20 words.
“Ambulance Diversion” refers to the problem of ambulances being asked to go to other hospitals due to lack of space or staff in a particular hospital.
2. Research: What information were you able to find on the web or from readings?
According to an article by Guy Clifton & Hannah Graff, New America Foundation, ambulance diversions can pose a health risk to those who need immediate medical attention. They are also an indication that hospitals have inadequate bed capacities, and/or are being poorly managed.
- A study from New York City boroughs found the mortality rate from heart attacks increased by 47 percent on days when hospitals were on diversion.
- In Houston, the mortality rate of patients with severe injuries requiring inter-hospital transfer was more than 10 percent higher on “high-diversion” days—14 percent on low diversion days, and 25 percent on high diversion days.
The article suggests two measures to overcome this problem: standardize ambulance diversion criteria and cover the uninsured.
Another article by the same author shows that ambulance diversions were rare before 1999, but have become increasingly prevalent and dangerous since then. They indicate that every minute, one ambulance is diverted from a U.S. hospital (according to a 2006 study in the Annals of Emergency Medicine).
A study by the ‘American College of Emergency Physicians’ (ACEP) indicates that even one hour of ambulance diversion can result in significant revenue losses for emergency departments. The study suggests increasing the ICU bed capacity to solve this problem.
There are also some local initiatives (example: MARCER initiative in the Greater Kansas City area, another initiative in Florida as indicated by one of our coaches) where people have tried to develop systems to manage diversions better but nothing exists on a nation-wide scale.
3. How can the problem be measured?
The metric that can be used to solve this problem is the number of beds in each hospital. This is also closely tied to the discharge procedure as the availability of beds is dependent on this. The other metrics are patient flow and average wait time to be seen by a physician.
- Prepared for Rep. Henry A. Waxman (U.S. House of Representatives) 2001, National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms. http://reform.democrats.house.gov/Documents/20040827154156-04955.pdf
- Clifton, Guy & Graff, Hannah 2008, New America Foundation - AMBULANCE DIVERSIONS: WHAT THEY ARE, WHY WE CARE, & WHAT TO DO. http://www.newamerica.net/files/Ambulance%20Diversions.pdf
- Clifton, Guy 2008, New America Foundation - Ambulance Diversions are Tip of Emergency Care Iceberg. http://www.newamerica.net/blog/new-health-dialogue/2008/quality-ambulance-diversions-are-tip-emergency-care-iceberg-3006
- ACEP (American College of Emergency Physicians) - Annals of EM Press Releases 2006, Increasing ICU Bed Capacity Decreases Ambulance Diversion and Increases Hospital Revenues. http://www.acep.org/pressroom.aspx?id=25862
- MARCER (Mid-America Regional Council Emergency Rescue) - Community Plan for Ambulance Diversion for the Greater Kansas City Metropolitan Area 2002. http://www.marc.org/emergency/pdfs/diversionplan.pdf
COMMENTS: Ackerman "ambulance diversion" is not intrinsically a problem. Hospitals go on diversion status when they no longer have resources to care for patients or (soemtimes) a specific group of patients. If everyone is on diversion the effect is actually the same as no one being on diversion. Diversion in an ideal world with sufficent overal capacity would be very helpful as it would increase transport time marginally inorder to reduce wait time and availability of resources. In the real world when there is generally a lack of available resources transport times get increased substantially, often without decreasing ED waiting times. Diversion unfortunately is used a way of trying to avoid seeing uninsured patients who will require very high levels of care. While availability of ICUs is frequently part of the reason to go on diversion - sick patients can arrive by other means and they still must be cared for. Revenue loss while on diversion is important because hospitals are trying to make money. Opening hospital beds takes time and money and often hospitals are built planning for 80-90% utilization at all tines. That leaves very little room for surge capacity and the hospitals will tend to saturate before reaching 95% of capacity.
"Diversion is bad" is not a solvable problem. "Diversion creates prolonged transportation of critically ill patients resulting in increased morbidity and mortality" or "diversion worsens the economic impact of uninsured patients" "diversion makes the hospital loose money" - thesean outcome can be measured