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Despite fears, ambulance diversion ban does no harm

By Kathryn Doyle

NEW YORK (Reuters Health) - Ending a practice that was intended to reduce emergency room crowding did not make things worse, and may have prompted improvements at nine Boston hospitals, according to a new study.

U.S. emergency departments have been diverting patients since the late 1990s, sending ambulances to other hospitals when conditions are crowded - despite evidence that sending seriously ill or injured patients away delays their treatment.

Massachusetts put an end to the practice in 2009, instituting the first statewide ban on ambulance diversion after years of urging from the state public health department.

"People were afraid, we've been using diversion for so long, they were afraid that once they no longer had this tool they could have worse crowding problems," lead author Dr. Laura Burke, an emergency room physician at Beth Israel Deaconess Medical Center in Boston, told Reuters Health.

To test that theory, she and her colleagues analyzed data from nine Boston area hospitals before and after the ban.

They found that after the ban, admitted patients stayed in the ER for an average of three hours, nine minutes, down from three hours and 25 minutes pre-ban.

Ambulances also got in and out of the hospital two minutes quicker, in an average of 24 minutes instead of 26, according to the results published in Annals of Emergency Medicine.

The length of time the average patient stays in the ER is considered a reliable measure of hospital crowding. The researchers speculate that wait times for patients and ambulances probably improved under the diversion ban because hospitals made other efficiency changes in anticipation of the change.

A similar study in western Massachusetts also found no negative effect from the diversion ban in a more rural area of the state.

"For people who think about diversion as a solution, this debunks that myth," Dr. Jesse Pines, director of the Center for Health Care Quality at George Washington University in Washington, D.C., told Reuters Health.

According to Burke, doctors and nurses who work in the ER have known for some time that hospitals rely too heavily on diversion, which produces little benefit, instead of focusing on other measures like flexible ER staffing to combat overcrowding.

Diversion can actually be harmful to patients in critical condition or those who are taken to a hospital that doesn't have their medical records, according to Pines. Previous studies have linked ambulance diversion to more heart attack deaths, for example.

"When you're having a heart attack, you don't want to wait," Pines said.

A quarter of the emergency rooms open 20 years ago are now closed, and people who visit the ER are sicker, older and tend to stay longer than they did two decades ago - making crowding a growing problem, Pines pointed out.

Crowded ERs mean long wait times for patients who may be critically ill, and that more people leave before being treated out of frustration.

As the Patient Protection and Affordable Care Act takes effect, a surge in the number of insured people will likely mean a spike in ER visits, making crowding even worse, Pines said.

"It's not good care for patients to be sitting in an emergency department for hours to days instead of being taken to the inpatient units," Burke said.

This study and others suggest the solution is not to let fewer patients into the hospital by controlling when and where ambulances can go, but to get patients released or moved to other areas of the hospital more quickly, she said.

"The way to do it is to have a better-run emergency department," Pines said.

That can include using space in emergency room hallways, moving patients to the inpatient wards to free up more beds and reorganizing emergency staff to accommodate busier times, as the Boston hospitals did in anticipation of the ban.

Each hospital approached the ban differently. One installed real time updating electronic dashboards showing which beds were occupied, another elected a "bed czar" to oversee expediting admitted and discharged patients and a third hospital established a "surge pod" of 10 extra beds in the inpatient ward to take overflow patients from the ER.

Pines and Burke agreed that organizational measures like these within hospitals are the key to solving overcrowding.

"You shouldn't just ban diversion and do nothing else," Burke said.

SOURCE: http://bit.ly/11ghavR Annals of Emergency Medicine, online January 25, 2013.

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