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Ambulance Diversion: Solution or Problem?
By Timothy A. Litzenburg, Esq., and N. Beth Dorsey, Esq.; Hancock, Daniel, Johnson & Nagle, P.C., Richmond, VA
As ED overcrowding becomes more widespread, the companion problem of ambulance diversion becomes increasingly acute at EDs across the nation.
Reasons for Ambulance Diversion
a.bulance diversion is the phrase commonly used to describe the practice of turning away patients from an ED when it is overcrowded and sending the emergency vehicle to an alternate hospital. The practice originally was intended to provide quick relief to a full ED, and served to protect current patients when the arrival of another patient would jeopardize the quality of care.1 Federal regulation defines "diversionary status" as a hospital that "does not have the staff or facilities to accept any additional emergency patients."2 This practice, unfortunately, has become all but standard operating procedure at some institutions.1
Initially, the health care community welcomed ambulance diversion as an effective solution to ED overcrowding.3 Diversion was one way to ease the burden on EDs created by the inappropriate use of emergency medical care by patients without urgent medical conditions.3 Moreover, in the late 1980s and early 1990s, the United States experienced a dramatic downsizing of hospital capacity. In 1981, America had 1.36 million hospital beds; that number dropped to 829,000 by 1999. During this same period, ED visits increased (14% between 1992 and 1999).3 This led inevitably to overcrowding, including the practice of "boarding," or retaining admitted patients in the ED as they waited for a hospital bed. In turn, ED patients experienced longer wait times, and some left the hospital without being seen.1
In response to this chronic problem, and sometimes in response to temporary emergencies such as mass-casualty events, the emergency medicine system adapted to redistribute and transport patients. Most commonly, an institution diverts incoming ambulances when its ED has exceeded its capacity to care for patients. A hospital might also divert patients to higher-level facilities when medically indicated; for example, to another hospital that has better radiology equipment or on-call specialists. Diversion can happen simply as a result of patient preference as well.4
a. recently as 2000, the U.S. Surgeon General and Joint Commission made statements to the effect that diversion was a cyclical problem that would resolve itself, and that it did not need a specific policy response.5 Contrary to these expectations, however, diversion has not resolved itself. In fact, diversion has become standard practice in many communities. One 2006 study found that 45% of hospitals practiced ambulance diversion, and that they spent an average of 3% of their operating time in diversion mode.6 As use of ambulance diversion has become more widespread, hospitals and policymakers have realized that the practice is not without its own risks.
Pitfalls of Ambulance Diversion
a.though the diversion of patients with urgent conditions to other hospitals can serve to lighten the burden on the diverting institution's ED, it also can pose dangers to patient care and safety. The most obvious and critical of these dangers is the delay in treatment that the diverted patient experiences if the distance between the alternate hospital and the diverting hospital is significant.
a.review of civil lawsuits involving EDs indicates that diversion of patients to other hospitals can result in critical delays in treatment, and can even contribute to patient deaths. In one high-profile case in Ontario in 2000, an 18-year-old man experienced severe respiratory distress and his family called 911. An ambulance arrived 9 minutes later, just as the man collapsed and experienced convulsions. The nearest ED was on "critical care bypass," diverting would-be ED patients to other hospitals. The patient was asystolic by the time he reached an available ED. Normal rhythm was established in the ED, but the man had irreversible brain damage. He died two days later.7
a.bulance diversion also can lead to the misallocation of EMS resources. As emergency vehicles are forced to travel longer distances, there are fewer vehicles available to the community at a given time.4 Furthermore, while the practice may alleviate overcrowding at the diverting hospital, it is likely to contribute to overcrowding at the receiving hospital, negatively impacting patient care there.6
Finally, ambulance diversion can have a negative impact on a hospital's revenues. One study found that the net revenue from patients arriving at the ED by ambulance was nearly three times higher than that of patients arriving by other means.8 When a hospital takes measures to reduce diversion, one study concluded that it gains an average of $1,100 per hour for each hour of diversion avoided. Another study found that a suburban teaching hospital lost as much as $5,845 per hour of ambulance diversion.9
Pertinent Law and Federal Case Studies
The Emergency Medical Treatment and Active Labor Act (EMTALA) governs any situation where a patient "comes to the emergency department" seeking "examination or treatment for a medical condition."10 Federal regulations state that a patient is not considered to have come to the ED if he is in a non-hospital-owned ambulance and is not on hospital property. The hospital may direct the ambulance elsewhere if it is in "diversionary status."2 If an ambulance is diverted to another hospital prior to arriving at the diverting hospital, it would seem that EMTALA would not apply to that patient. However, two federal courts have ruled that, if done improperly, ambulance diversion can be a violation of EMTALA.
In 2001, the Ninth Circuit Court of Appeals ruled that a defendant hospital violated EMTALA by diverting a patient when the hospital was not in "diversionary status" at the time. The plaintiff experienced shortness of breath at his workplace, and his coworkers called for an ambulance. The ambulance picked up the patient and departed for the nearest ED. En route, ambulance personnel contacted the ED by radio. They relayed that the patient was in severe respiratory distress. One of the EPs directed that the ambulance take the patient to a government hospital, rather than proceeding to his ED. The ambulance driver complied, and the patient's condition deteriorated en route to the government hospital, which was further than the originally planned ED. He died less than an hour after arrival. His family sued the hospital and the EP group. The court overturned a lower court's ruling of summary judgment for the defendants, finding that where the hospital was not in "diversionary status," it could not divert the patient as it had done, which violated EMTALA.11 The court held that a hospital may divert ambulances "only when the diverting hospital has a valid, treatment-related reason for doing so," such as an ED that could not safely accept additional patients.
More recently, in 2008, the First Circuit Court of Appeals ruled that when an ED turned away a patient in an ambulance based on financial considerations, that patient had "come to the emergency department" for EMTALA purposes.12 The patient, who was carrying an ectopic pregnancy, experienced severe abdominal pain and vomiting. Her coworkers called for an ambulance, which collected her and departed for the hospital where her obstetrician practiced. Ambulance workers called the hospital en route, and spoke to the ED director, who inquired whether the patient had perhaps induced an abortion and further inquired as to her medical insurance coverage. Receiving no assurances from the physician that the hospital would accept her, the ambulance crew took the patient to another hospital. The patient sued the hospital that turned her away. The court ruled that EMTALA applied because the patient was en route to the hospital and the hospital had been notified.
State Law and Case Studies
State laws require physicians to comply with the standard of care, which is generally defined as what a reasonably prudent physician would do in the same or similar circumstances. EPs must carefully consider their duties to existing patients as well as prospective patients when making decisions regarding possible diversion. State courts, for example, have imposed liability in cases where patients were diverted for improper purposes.
For example, in a 1988 Georgia case, a man was injured in an automobile accident and EMTs responded. The EMTs requested a medivac helicopter to transport the patient to a burn center in a nearby city. The local hospital authority, which did not own the burn center, instead directed the helicopter to its own nearby hospital, which did not have the capability to treat severe burns. Once the patient arrived, hospital personnel realized that he required the care of a burn center, but encountered some difficulty in transporting him, including a helicopter crash (with no injuries). The man died as a result of his burns, and his estate sued the hospital authority for wrongful diversion. A jury awarded the estate $1.31 million.13 The hospital authority could have avoided liability by allowing the helicopter to transport the patient to a burn center directly from the automobile accident scene.
To avoid liability at both the state and federal level, physicians and EDs must make careful choices when deciding whether to divert incoming emergency vehicles. Patients should be directed to other nearby hospitals only when the diverting facility is on diversionary status because it does not have the staff or facilities to accept any additional emergency patients. Preferential routing of certain patients to an ED for financial reasons, or diversion due to lack of insurance, must never occur.14
Ideas for Improvement
There is no silver bullet to fix the problems of overcrowding and ambulance diversion, but studies have found that common-sense approaches are most effective. Measures that improve hospital efficiency or patient flow are also helpful, such as improving patient triage through physical space modifications of the ED area itself.1 Critical decision units, or "23-hour observation units," have been shown to help reduce diversion. Such units, under the control of the ED but not physically part of its space, allow physicians to monitor patients without keeping them in the ED or admitting them to the hospital floor, thereby freeing up ED beds.15 Observation units have been linked to a 40% reduction in ambulance diversion.16 Diversion is strongly connected to boarding patients in the ED, and any efforts to decrease the latter will have a positive effect on the former.17
Local EMS agencies can limit the time a hospital can be on diversionary status, or establish a minimum time a hospital must stay off diversionary status. This approach relies heavily on the cooperation of EDs, but some EMS agencies have found it highly effective.1
a.vances in information technology have provided an opportunity for lessening the potential harms of ambulance diversion. Some communities, such as Milwaukee and Syracuse, have begun to use real-time information sharing systems that constantly monitor the status of services in the area, including diversionary status. Using the system, hospitals' diversionary status changes according to guidelines and automated data reporting.18 These systems have the capacity to disseminate urgent data to all area hospitals simultaneously.19 This serves to decrease confusion and instantaneously optimizes the allocation of resources in the community, skipping the step of ambulance diversion. Furthermore, it forces hospitals to take a problem-solving and cooperative tact, rather than simply turning a patient away.
a. least one state has taken the step of prohibiting diversionary status, with positive results. In 2008, Massachusetts announced the mandatory elimination of routine ambulance diversion. In response to the ban, hospitals changed their procedures to improve efficiency, taking measures such as hiring nurse practitioners, drawing labs earlier, and developing a "surge pod" for ED patients awaiting inpatient beds.20
Finally, increased funding could reduce the burden on EDs and thus decrease diversion. EDs and ED physicians suffer a low reimbursement rate. To maintain the quality of emergency care, state and local governments might provide more reimbursement to hospitals that treat a large portion of uninsured patients.21
ED overcrowding can lead to ambulance diversion, which, while ameliorative, is a problematic policy. Rather than send patients elsewhere in response to crowding, EDs and emergency physicians should work to address the problem of crowding itself through improving patient flow and efficiency. Ambulance diversion is likely to remain in practice for some time, but an ED must never divert a patient for any reason other than patient safety.
1. Castillo E, et al. Collaborative to decrease ambulance diversion: The California Emergency Department Diversion Project. J Emerg Med 2010; Apr 10.
2. 42 C.F.R. 489.24.
3. Olshaker J, Rathlev N. Emergency department overcrowding and ambulance diversion: The impact and potential solutions of extended boarding of admitted patients in the emergency department. J Emerg Med 2006;30:351-356.
4. Pham J, et al. The effects of ambulance diversion: A comprehensive review. Acad Emerg Med 2006;13:1220-1227.
5. Tye L. Officials offer little hope for emergency room diversion. Boston Globe November 19, 2000; A12.
6. Burt C, et al. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med 2006;47:317-326.
7. Walker A. The legal duty of physicians and hospitals to provide emergency care. Can Med Assoc J 2002;166: 465-469.
8. McConnell J, et al. Ambulance diversion and lost hospital revenues. Health Policy Clin Pract 2006;48:702-710.
9. Bukowski K, et al. EMS diversion of ambulances effectively decreases volume and revenue to hospitals. Poster Presentation at the National Association of Emergency Medical Services Physicians Annual Meeting. Panama City Beach, FL; January 16-18, 2003.
10. 42 U.S.C. § 1395dd(1)A.
11. Arrington v. Wong, M.D.D., Hawaii, 1998 Ruling.
12. Morales v. Sociedad Espanola de Auxilio Mutuo y Beneficiencia, 524 F.3d 54 (1st Cir. 2008).
13. Jones v. Hospital Authority of Gwinnett County, No. 87-A-17816-4 (Cobb Cty. Suprt. Ct. 1988).
14. Glushak C, et al. Ambulance diversion (position paper). National Association of EMS Physicians. Available at: www.naemsp.org/pdf/AmbulanceDiversion.pdf. Accessed Feb. 1, 2011.
15. Croskerry P, et al, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams and Wilkins; 2008: 154.
16. Trzeciak S, Rivers E. Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emerg Med J 2003;20:402-405.
17. Schull M, et al. Emergency department contributors to ambulance diversion: A quantitative analysis. Ann Emerg Med 2003;41: 467-476.
18. Patel P, et al. Ambulance diversion reduction: The Sacramento solution. Am J Emerg Med 2006;24:206-213.
19. Froman P. EMSystem and Emergency Department Diversion Overview. Available at: www.emsmdc.com/emsystem_overview.html. Accessed Feb. 1, 2011.
20. Burke L. Ending ambulance diversion in Massachusetts. Virtual Mentor 2010;6:483-486.
21. Institute of Medicine. Committee on the Future of Emergency Care in the U.S. Health System.