Guidelines for Ambulance Diversion

This Policy Resource and Education Paper is an explication of the Policy Statement Ambulance Diversion.

Emergency Medical Services Committee of the American College of Emergency Physicians

October 1999

John A. Brennan, MD, FAAP, FACEP
Chair, EMS Committee

Ambulance Diversion Workgroup
Dennis M. Allin, MD, FACEP
Anne Calkins, MD
Enrique Enguidanos, MD
Leah Heimbach, JD, RN, EMT-P
James N. Pruden, MD, FACEP
David G. Stilley, MD


The American College of Emergency Physicians (ACEP) believes that access to quality emergency care, including emergency medical services (EMS), is a critical component of the American health care system. Access to EMS requires maintaining a timely response, providing properly trained personnel, transporting to appropriate health care facilities, and ensuring medical oversight.

Hospital resources, including emergency services may occasionally be overwhelmed and may not be able to provide optimal patient care. Factors contributing to this problem include a shortage of qualified health care providers, lack of hospital-based resources and ongoing hospital and ED closures.

ACEP believes that each EMS system, including all of its component agencies, must develop a cooperative diversion policy designed to:

  • Identify situations in which a hospital's resources are not available and temporary ambulance diversion is required.

  • Notify EMS system and hospital personnel of such occurrences. This notification must occur through the EMS lead agency or a designated communications coordination center.

  • Regularly review and update the hospital's diversion status.

  • Provide for the safe, appropriate, and timely care of patients who continue to enter the EMS system during periods of diversion.

  • Notify EMS system personnel and affected hospitals promptly when the situation that caused diversion has been resolved.

  • Explore solutions that address the causes of diversion and implement policies that minimize the need for diversions.

  • Continuously review policies and guidelines governing diversion.


To ensure access to emergency care, the College has developed the following guidelines for the development of a diversion policy:

  • All hospitals and EMS agencies in the EMS system must have working agreements among themselves.

  • Diversion criteria must be based on the defined capacities or services of the hospital.

  • When the entire health care system is overloaded, all hospitals must open. A system must be in place to properly rotate patients to all facilities.

  • Diversion criteria must be defined prospectively. Diversion categories may include critical care divert, routine admission divert, and selective divert.

  • Ambulance diversion should occur only after the hospital has exhausted all internal mechanisms to avert a diversion, which includes calling in overtime staff.

  • Hospital diversions should not be based on financial decisions. Hospitals should not go on diversion to save beds for either elective admissions or potential deterioration of hospitalized patients.

  • The decision for diversion should be made by the emergency physician in the emergency department in coordination with nursing and/or administrative staff. Appropriate hospital representatives should be notified as soon as possible of the diversion status. All personnel with diversion decision power must be identified and titles prospectively communicated to the EMS system's lead agency.

  • When on diversion, hospitals must make every attempt to maximize bedspace, screen elective admissions, and use all available personnel and facility resources to minimize the length of time on diversion.

  • A record of the diversion should be maintained by the hospital after each episode which includes a record of appropriate approval, type of diversion and reason for it, time of diversion initiation and completion. All diversions must undergo physician review.

  • Diversion must be temporary. The system must return to normal operation as quickly as possible. Unless otherwise notified, automatic return to normal status in a predetermined time is the preferred mechanism.

  • Consideration should be given to developing a mechanism for denial of a hospital's request for diversion or for overriding a hospital's diversion status when the EMS physician medical director determines a patient's condition may be jeopardized by bypassing a facility.

  • EMS physician medical directors must be an integral part of the development of policies governing diversions.




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