Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban.

BACKGROUND: The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts' 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED). METHODS: We obtained Medicare Fee for Service claims records (2007-2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients ("reference ED"). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients ("safety-net ED"). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states. RESULTS: Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (- 2.7 percentage point; 95% CI, - 4.5 to - 1.0) and Black (- 4.1 percentage point; 95% CI, - 6.2 to - 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, - 2.3 to - 0.2). CONCLUSION: Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination.

Effects of Real-time EMS Direction on Optimizing EMS Turnaround and Load-balancing Between Neighboring Hospital Campuses.

Background: Implemented in September 2017, the "nurse navigator program" identified the preferred emergency department (ED) destination within a single healthcare system using real-time assessment of hospital and ED capacity and crowding metrics. Objective: The primary objective of the navigator program was to improve load-balancing between two closely situated emergency departments, both of which feed into the same inpatient facilities of a single healthcare system. A registered nurse in the hospital command center made real-time recommendations to emergency medical services (EMS) providers via radio, identifying the preferred destination for each transported patient based on such factors as chief complaint, ED volume, and waiting room census. The destination decision was made via the utilization of various real-time measures of health system capacity in conjunction with existing protocols dictating campus-specific clinical service availability. The objective of this study was to evaluate the efficacy of this real-time ambulance destination direction program as reflected in changes to emergency medical services (EMS) turnaround time and the incidence of intercampus transports. Methods: A before-and-after time series was performed to determine if program implementation resulted in a change in EMS turnaround time or incidence of intercampus transfers. Results: Implementation of the nurse navigator program was associated with a statistically significant decrease in EMS turnaround times for all levels of dispatch and transport at both hospital campuses. Intercampus transfers also showed significant improvement following implementation of the intervention, although this effect lagged behind implementation by several months. Conclusion: A proactive approach to EMS destination control using a nurse navigator with access to real-time hospital and ED capacity metrics appears to be an effective method of decreasing EMS turnaround time.

A review on ambulance offload delay literature.

Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

A Full-Capacity Protocol Allows for Increased Emergency Patient Volume and Hospital Admissions.

PROBLEM: Our hospital was encountering problems with ED crowding. We sought to determine the impact of implementing a full-capacity protocol to respond to anticipated or actual crowding conditions. Our full-capacity protocol is based on collaboration among multiple hospital units. METHODS: We completed a quality improvement initiative using a pre/post analysis of all ED patient encounters after implementing a full-capacity protocol with a corresponding period from the prior year. The principal outcomes measured were patient volume, admission rate, patient left without being seen (LWBS) rate, length of stay, and ambulance diversion hours. RESULTS: In the post-full-capacity protocol period, a 7.4% increase in emergency patient encounters (P < .001) and an 11.9% increase in admissions (P < .001) were noted compared with the corresponding period in 2013. Also noted in the study period were a 10.2% decrease in LWBS rate (P = .29), an increase in length of stay of 34 minutes (P < .001), and a 92% decrease in ambulance diversion hours (111 fewer hours, P < .001). IMPLICATIONS FOR PRACTICE: The collaborative full-capacity protocol was effective in reducing LWBS and ambulance diversion, while accommodating a significant increase in ED volume and increased hospital admission rates at our institution.

Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care.

BACKGROUND: Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. OBJECTIVES: To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED. METHODS: This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis. RESULTS: In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU. CONCLUSIONS: Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.

Cleveland hospitals increase capacity, hire additional staff to help end ambulance diversion.

With pressure from EMS to curb ambulance diversion, the four hospital systems serving metropolitan Cleveland have made a pact to bring diversion to an end. The agreement is voluntary, but all sides were determined to make the ban on diversion stick as of mid-February 2016. To get there, the health systems are increasing capacity, adding staff, and taking steps to tackle deeper hospital throughput issues. In 2015, reports noted that University Hospitals logged more than 550 hours on diversion, and MetroHealth closed its doors to new ambulance traffic for more than 400 hours. The Cleveland Clinic went on diversion for only 10 hours last year. To prepare for the ban on diversions, MetroHealth is adding more inpatient and ED beds, and it is also hiring additional staff. University Hospitals is taking similar steps while also building on the success of its medical access clinic, a lower-cost setting where patients can be screened, stabilized, and connected with primary care for future low-acuity needs. Hanging over the effort in Cleveland: Voluntary efforts to ban ambulance diversion in Boston failed repeatedly. However, once regulators mandated a ban on diversion statewide in 2009, the hospitals all fell into line with few signs of any adverse consequences. The city has now operated diversion-free for seven years.

Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research.

BACKGROUND AND PURPOSE: Emergency medical services routing of patients with acute stroke to designated centers may increase the proportion of patients receiving care at facilities meeting national standards and augment recruitment for prehospital stroke research. METHODS: We analyzed consecutive patients enrolled within 2 hours of symptom onset in a prehospital stroke trial, before and after regional Los Angeles County Emergency Medical Services implementation of preferentially routing patients with acute stroke to approved stroke centers (ASCs). From January 2005 to mid-November 2009, patients were transported to the nearest emergency department, whereas from mid-November 2009 to December 2012, patients were preferentially transported to first 9, and eventually 29, ASCs. RESULTS: There were 863 subjects enrolled before and 764 after emergency medical service preferential routing, with implementation leading to an increase in the proportion cared for at an ASC from 10% to 91% (P<0.0001), with a slight decrease in paramedic on-scene to emergency department arrival time (34.5 [SD, 9.1] minutes versus 33.5 [SD, 10.3] minutes; P=0.045). The effects of routing were immediate and included an increase in proportion of receiving ASC care (from 17% to 88%; P<0.001) and a greater number of enrollments (18.6% increase) when comparing 12 months before and after regional stroke system implementation. CONCLUSIONS: The establishment of a regionalized emergency medical services system of acute stroke care dramatically increased the proportion of patients with acute stroke cared for at ASCs, from 1 in 10 to >9 in 10, with no clinically significant increase in prehospital care times and enhanced recruitment of patients into a prehospital treatment trial. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.

Ambulance Diversion: Ethical Dilema and Necessary Evil.

Ambulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational inefficiencies within our health systems that lead to conditions such as patient boarding, high waiting room congestion, and ambulance diversion. Addressing these inefficiencies has a greater potential impact on ambulance diversion than simply banning or restricting the practice for practical or ethical considerations.

Ethics of ambulance diversion.

Ambulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy, ambulances bound for one hospital are redirected to another, usually under policies established by regional emergency medical services systems. Other responses to this mismatch include maladaptive behaviors (such as "boarding" in "hallway beds") and the development of terminology intended to normalize these practices, all of which are reviewed in this article. We examine the history and causes of diversion as well as the ethical foundations and practical consequences of it. We contend that (1) from a moral viewpoint, the most important stakeholder is the individual patient because diversion decisions are usually relative rather than absolute; (2) decisions regarding ambulance diversion should be made with careful consideration of individual patient preferences, local and state emergency medical services laws, and institutional surge capacity; and (3) authorities should consider the potential positive effects of a regional or statewide ban on diversion.

Managing emergency department overcrowding via ambulance diversion: a discrete event simulation model.

BACKGROUND/PURPOSE: Ambulance diversion (AD) is considered one of the possible solutions to relieve emergency department (ED) overcrowding. Study of the effectiveness of various AD strategies is prerequisite for policy-making. Our aim is to develop a tool that quantitatively evaluates the effectiveness of various AD strategies. METHODS: A simulation model and a computer simulation program were developed. Three sets of simulations were executed to evaluate AD initiating criteria, patient-blocking rules, and AD intervals, respectively. The crowdedness index, the patient waiting time for service, and the percentage of adverse patients were assessed to determine the effect of various AD policies. RESULTS: Simulation results suggest that, in a certain setting, the best timing for implementing AD is when the crowdedness index reaches the critical value, 1.0 - an indicator that ED is operating at its maximal capacity. The strategy to divert all patients transported by ambulance is more effective than to divert either high-acuity patients only or low-acuity patients only. Given a total allowable AD duration, implementing AD multiple times with short intervals generally has better effect than having a single AD with maximal allowable duration. CONCLUSION: An input-throughput-output simulation model is proposed for simulating ED operation. Effectiveness of several AD strategies on relieving ED overcrowding was assessed via computer simulations based on this model. By appropriate parameter settings, the model can represent medical resource providers of different scales. It is also feasible to expand the simulations to evaluate the effect of AD strategies on a community basis. The results may offer insights for making effective AD policies.

Secondary triage in prehospital emergency ambulance services: a systematic review.

OBJECTIVE: Secondary telephone triage to divert low-acuity patients to alternative non-ambulance services before ambulance arrival has been trialled in the UK and USA as a management strategy to cope with the increase in ambulance demand. The objective of this systematic review was to examine the literature on the structure, safety and success of secondary triage systems. METHODS: For inclusion in the study, the telephone triage system had to be a secondary process, receiving referred patients who had already been categorised as low priority by a primary triage process. Two independent reviewers conducted the search to identify relevant studies. Six articles and one report were identified. RESULTS: The major theme of the papers was the safety and accuracy of secondary telephone triage in identifying low-acuity patients. Two studies also discussed patient satisfaction. There was a low incidence of adverse events, as expected as these patients had already been subjected to primary telephone triage. In the studies identifying ambulance dispatch as a potential final disposition, at least half of the patients were diverted away from ambulance dispatch. In the studies that identified self/home care as a final disposition, a maximum of 31% of patients were categorised to this outcome. Otherwise all patients were recommended for assessment by a healthcare professional other than ambulance clinicians. Patients appeared to be satisfied with secondary telephone triage on follow-up. CONCLUSIONS: These results suggest that, while secondary triage of these patients is safe, further research is required to determine its most appropriate structure and its effect on ambulance demand.

"No diversion": a qualitative study of emergency medicine leaders in Boston, MA, and the effects of a statewide diversion ban policy.

STUDY OBJECTIVE: We examine the attitudes of emergency department (ED) key informants about the perceived effects of a statewide ban on ambulance diversion on patients, providers, and working relationships in a large urban emergency medical system. METHODS: We performed a qualitative study to examine the effects of a diversion ban on Boston area hospitals. Key informants at each site completed semistructured interviews that explored relevant domains pre- and postban. Interviews were deidentified, transcribed, coded, and analyzed with grounded theory for emerging themes. We identified important themes focused on patient safety, quality of care, and relationships before and after implementation of the diversion ban. RESULTS: Nine of 9 eligible sites participated. Eighteen interviews were completed: 7 MD ED directors, 2 MD designees, and 9 registered nurse leaders. Although most participants had negative opinions about diversion, some had considered diversion a useful procedure. Key themes associated with diversion were adverse effects on patient care quality, patient satisfaction, and a source of conflict among ED staff and with emergency medical services (EMS). All key informants described some positive effect of the ban, including those who reported that the ban had no direct effect on their individual hospital. Although the period preceding the ban was reported to be a source of apprehension about its effects, most key informants believed the ban had improved quality of care and relationships between hospital staff and EMS. CONCLUSION: Key informants considered the diversion ban to have had a favorable effect on emergency medical care in Boston. These results may inform the discussion in other states considering a diversion ban.

Enhancing capacity management.

It is essential for organizations to be able to accept patients requiring care. Capacity planning and management are necessary to ensure an organization has an accepting physician/service, an available bed, and staff to care for the patient and family. This organization implemented strategies including communication plans, staffing guidelines, morning rounds, proactive planning, and an escalation process to reverse the trend of not being able to accept all patients.

Does an ED flow coordinator improve patient throughput?

INTRODUCTION: At our urban academic medical center, efforts to alleviate ED overcrowding have included the implementation of a "fast track" area, increasing the ED size, using hallway beds, and ambulance diversion. In October 2012, we began the first steps of a process that created a system in which the admission process involves equal amounts of pushing and pulling to achieve the balance necessary to accomplish optimal outcomes. The foundation of the initiative was based on the use of a BSN-educated emergency nurse as a flow coordinator; a position specifically empowered to affect patient throughput in the emergency department. METHODS: A determination of quality improvement was obtained by the local institutional review board for a retrospective analysis of all ED patient encounters 1 year before and 1 year after the implementation of the ED flow coordinator position. All patient encounters were included for consideration and calculation; no encounters were excluded. RESULTS: The flow coordinator program decreased length of stay by 87.6 minutes (P=.001) and lowered LWBS rate by 1.5% (P=.002). Monthly hospital diversion decreased from 93 hours to 43.3 hours (P=.008). DISCUSSION: Investing in a flow coordinator program can generate improvements to patient flow and can yield significant financial returns for the hospital. A decrease in diversion by an average of 49.8 hours per month translates to an annual decrease of nearly $20 million in lost potential charges. A decrease in the LWBS rate by 1.5% (31% relative decrease) per month translates to an annual decrease in lost potential charges of more than $5 million. Our research shows that an ED flow coordinator, when supported by departmental and hospital leadership, can yield significant results in a large academic medical center and that the program is able to produce an effective return on investment.

Is emergency department crowding associated with increased "bounceback" admissions?

OBJECTIVE: Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions. METHODS: We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission. RESULTS: We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00). CONCLUSIONS: Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.