Limiting emergency departments to a single hour of diversion every eight hours dramatically reduced the time a facility was closed but increased “drop-off” times for emergency medical services, according to a recent report from researchers at the University of New Mexico in Albuquerque. (Am J Emerg Med 2008;26[6]:670.)
The method has promise for temporarily reducing the strain on an emergency department without overtaxing others, said Robert Derlet, MD, a professor emeritus of emergency medicine at the University of California, Davis. “By doing it this way, the researchers showed that this works, and it doesn't sound like anyone was too upset,” he said.
The study's countywide protocol for emergency medical services limited diversion to one hour of every eight so total diversion time could be kept under 90 hours a month, a number the hospital deemed reasonable. That single hour, however, gave the ED the time it needed to reassess its resources and needs, noted the authors, who were unavailable for comment.
Before the protocol went into effect in March 2005, the researchers wrote, hospitals could go on diversion any time and stay that way unless more than three hospitals were on divert simultaneously. When hospitals on diversion forgot to take themselves off, the result was many more diversion hours than needed. On the other hand, if one hospital went on diversion and put too much pressure on others, the other institutions would force them to go off before they could decompress and improve the throughput in their ED.
Transport Times Up
The study compared diversion hours and emergency medical services drop-off times (time EMS crews required to transport patients) from September 2004 to February 2005 (pre-protocol), March 2005 to August 2005 (interim), and from September 2005 until February 2006 (post-protocol). The number of monthly transports remained basically the same pre- and post-protocol, but the number of monthly diversion hours decreased by 251 hours, from 305 to 81. At the same time, monthly drop-off times by EMS increased by 178 hours.
“This study demonstrates a significant reduction of ambulance diversion in a heterogeneous county composed of urban, suburban, and rural regions,” the authors wrote. “Our study confirms that a strict protocol regulating the duration of time an individual ED can be closed to ambulance traffic yields clear improvement in measurable outcomes. However, successful ambulance diversion is contingent upon collaboration of all EDs in the network and adherence by prehospital providers. This county was successful in decreasing ambulance diversion by 82 percent during the post-trial period.”
“All emergency departments nationwide are crowded,” said Dr. Derlet. “The hallways are filled. The most significant reason is that inpatient beds are filled. What happens in the emergency departments is that you are ready to melt down if one more patient comes in. You just need a breather. An hour is enough to get in order. Then you can take another critical patient.”
The proposal, he cautioned, is simply a stopgap and not a long-term solution for the real problem of crowding in the emergency departments. “The number one problem is the lack of inpatient beds,” he said. “More people are crowding a dwindling number of emergency departments. There are more people with chronic diseases and no primary care.”
Trying to fix diversion is not going to make a major difference in crowding, said David Persse, MD, the medical director of emergency medical services for the Houston Fire Department. “My personal opinion is that diversion is a failed experiment that hospital ED personnel hold onto dearly. When hospitals look at their productivity measures [left without being seen, patients seen per hour, wait times], in general, they do not correlate at all with when the ED is on diversion. Diversion appears to have absolutely no impact, positive or negative, on these productivity measures. Diversion simply makes the staff feel like they did something to make things better. All that has happened is they have passed the problem on to the ambulance crews, which when they then detain ambulances is to have passed the problem on to the community.
“The problems that appear to cause hospital EDs to get overwhelmed have little to do with ambulance traffic. They are generally throughput issues related to prolonged bed turnover times for inpatients, housekeeping delays, lack of incentive for nursing staff in ICU or wards to move patients who can be moved or discharged, and lack of incentive for physicians as well to move patients,” said Dr. Persse.
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