No Ill Effects From Halt To Ambulance Diversion

ACEP News 
July 2009

By Bruce Jancin
Elsevier Global Medical News

ambulance diversionNEW ORLEANS -- A bold Boston experiment has demonstrated that ambulance diversion can temporarily be eliminated in a major city without adverse impact on the efficiency of hospital and emergency medical services.

On the basis of the Boston success, coupled with strong pressure from community groups, the Massachusetts Department of Public Health ended ambulance diversion statewide as of Jan. 1, 2009, Dr. Franklin D. Friedman noted at the annual meeting of the Society for Academic Emergency Medicine.

He presented the results of a 2-week citywide moratorium on ambulance diversion conducted in October 2006 by a consortium of Boston's 10 teaching hospitals, including all of the city's trauma centers. The control period consisted of the 2 weeks beforehand.

The study hypothesis was that halting ambulance diversion would not have any significant impact on measures of hospital and emergency medical services (EMS) efficiency; in other words, diversion--an increasingly common response to the pervasive problem of overcrowding in emergency departments and hospitals--is without benefit.

This did prove to be the case, explained Dr. Friedman, an emergency physician at Tufts Medical Center, Boston.

The median daily admission rate increased by 1.5 patients per hospital during the no-diversion period, and the median ED length of stay for patients admitted to hospital decreased by 18 minutes. Those modest differences were the only statistically significant changes.

The average 9-minute reduction in ED length of stay for discharged patients wasn't significant, nor was the average 30-second-greater EMS time spent at the hospital.

The study was undertaken in response to the growing use of ambulance diversion, which increased in Boston from a total of 448 hours in 1997 to 2,855 hours in 2006 despite a series of interventions by the Massachusetts Department of Public Health aimed at curbing the practice.

Several audience members said they'd love to see ambulance diversion eliminated in their own cities now that the Boston group has shown that diversion doesn't help the problem of ED overcrowding. There is concern that patients' status can worsen while they're being diverted to a more distant open ED.

Dr. Friedman said his anecdotal observation was that ED staff and hospital administrators were "extremely nervous" going into the no-diversion experiment. But their fears weren't realized.

"I remember turning to a nurse on a very busy day and saying, 'I'm glad there's no diversion today,' because the ambulances were actually coming in regularly rather than in big boluses, which is what happens when the next hospital goes on diversion and you get a domino effect," he recalled.

The study was done without outside funding. Although the investigation did not include any formal assessment of the psychological impact of eliminating diversion on ED nurses and physicians, Boston EMS surveyed the reactions of its personnel.

"The [emergency medical technicians] were dramatically pleased during this intervention. They didn't have to argue with patients, [who] could go where they wanted. They were much happier," according to Dr. Friedman.

The Massachusetts Department of Public Health has been collecting ED and hospital efficiency data since the elimination of ambulance diversion. It plans to begin releasing figures in the second half of the year.


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