Nearly five years after Massachusetts banned ambulance diversion, two studies have demonstrated that the health care facilities operate well without resorting to the drastic measure of closing their EDs to EMS traffic. The physicians who led the study, in fact, noted that diversion and the lack of it had absolutely no effect on crowding.
One study that evaluated the effect of the diversion ban on nine Boston-area emergency departments showed that none of them had an increase in emergency department length of stay for admitted or discharged patients and that none of them experienced increased ambulance turnaround times, even though several of the EDs saw patient volume escalate. (Ann Emerg Med 2013;61:303.) A prior study by Niels K. Rathlev, MD, the chair of emergency medicine at Baystate Medical Center in Springfield and Tufts University School of Medicine, and colleagues saw similar results when they examined the effect of the diversion ban in their part of the state. (J Emerg Med 2013;44:313.) They found no changes in throughput measures in any of the emergency departments, even those that were previously high-diversion facilities.
The ban came about after an attempt at voluntary limitations, said Laura Burke, MD, MPH, the first author of the Boston study who is an attending emergency physician at Beth Israel Deaconess Medical Center in Boston and a clinical instructor of medicine at Harvard Medical School. “Diversion was common in Boston at one time,” she said. “I was fortunate to work with a number of people who have been advocates for addressing crowding. We know diversion does not work to reduce crowding. It is harmful for patients and creates problems for emergency medical services.”
Efforts to limit diversion voluntarily were largely unsuccessful, she said. Regions worked to do that on their own, but success varied, even creating animosity among institutions in some instances. The state of Massachusetts was also actively encouraging hospitals to address crowding by optimizing patient flow, and those efforts were not working either. “Massachusetts is progressive in that our state has been interested in addressing the issue and had a boarding and diversion task force,” she said.
The state announced the diversion ban in the summer of 2008, and it went into effect the following January, giving hospitals time to adapt. Many people were apprehensive, however, when the new year rolled around. “They feared this would be harmful for patients,” Dr. Burke said. “They worried that the emergency departments would be too crowded to take care of patients and that EMS would be waiting to offload patients. It didn't happen.”
She and her colleagues decided to evaluate the hospitals before and after the ban, collecting data for a full year. “We used the median length of stay because we did not have the granularity to capture it all. It did not go up, and, in some circumstances, we were surprised to find it went down as did ambulance turnaround time in some cases. We knew diversion did not reduce crowding. The most accepted model of crowding is the input-throughput model,” she said. “It's not the input factor that correlates with crowding. It's the boarding of patients that affects it. Diversion took the focus off the real causes of crowding.”
Dr. Burke said the state department of public health services sponsored conference calls before the ban to share ideas, and every hospital was required to have a plan to deal with boarding and crowding. “When boarding became too severe, there needed to be a hospital-wide plan to move all admitted patients out of the emergency department in 30 minutes,” she said, noting that some of the ideas for that came from hospitals that were already not using diversion.
“I think diversion was a psychological crutch,” Dr. Rathlev said. “The emergency departments were saying, ‘We need a break. We are overwhelmed.’” Diversion seemed like the answer; after all, keeping more patients from entering the department made intuitive sense. One problem: it didn't work.
Boston's four trauma centers would go on diversion in succession, each giving it up after two hours. “It would ping-pong back and forth,” he said. “In Springfield, two hospitals that were high-diversion hospitals would alternate every two hours. The biggest problem, I see, is if we were on diversion at Baystate, some of our patients, who might have been postop or quite ill, would end up at a different institution where the doctors had no access to any information about them at all. I've been the recipient of post-op patients, and trying to reconstruct the whole scenario was difficult. It was poor care.”
The hospital eliminated diversion for a two-week trial, and the results were as positive as those published in the Journal of Emergency Medicine. Dr. Rathlev said he believes the effects can be generalized to any facility. “Across emergency departments and physicians, the commonalities are greater than the differences. Geography should not make a difference,” he said. “How do we keep emergency departments from being overwhelmed? Diversion is not the answer to that question. The answer is not immediately forthcoming because across the nation, EDs are getting busier.”
Dr. Burke said the focus is now on how to avoid crowding for medical and surgical patients and those with behavioral health issues. “In Massachusetts, we don't have to think about diversion anymore. We can stop wasting our time on a useless tactic, and focus on things that will really work. I hope other states will reproduce it,” she said.
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