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Alan Woodward, retired emergency physician
Woodward

Ambulance-diversion ban seen as success


By Ashok Selvam
Posted: December 24, 2012 - 12:01 am ET
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(This story has been updated with a correction.)

A Massachusetts ban on ambulance diversion did little to increase emergency department overcrowding, research from an Annals of Emergency Medicine study (PDF) concluded.

“Ambulance diversion is an unsafe and inefficient policy at dealing with emergency department overcrowding,” said Dr. Alan Woodward, a retired emergency physician and head of a Massachusetts state task force that studied ambulance diversion.

Researchers believe ED boarding poses a larger threat, as their data show that diversions—where ambulances are rerouted to deliver patients to other hospitals—do little to impact the length of a patient's stay in the ED and ease the burden of overcrowding. Boarding is the practice of moving patients out of hospital beds and into ED beds after the hospital reaches capacity. Critics say it places an unfair burden on ED resources and adversely affects ED care.

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The paper, “The Effect of an Ambulance Diversion Ban on Emergency Department Length of Stay and Ambulance Turnaround Time,” was published last week and studied nine Boston-area EDs after Massachusetts enacted a 2009 ban on diversions. Massachusetts is the only state with such a ban, though other communities, mostly on the county level, have instituted their own diversion prohibitions, Woodward said. King County in Seattle doesn't have a formal ban, but after a year-and-a-half of discussions, its 18 EDs decided to halt diversions in March 2011.

The study in Boston showed overall ED volume rose by 3.6%, while length of stay fell by 10.4 minutes for admitted patients. These results supported observations from emergency physicians, said Dr. Laura Burke, the study's lead author from Beth Israel Deaconess Medical Center in Boston.

“We've had this in place for three years now—going on four—and it's gone well,” she said. “I haven't heard any talk about bringing back diversions.”

The American College of Emergency Physicians has identified reducing ED overcrowding as a priority to improve patient care. Research released earlier in December showed patients at over-burdened EDs are 5% more likely to die versus those treated at less-crowded EDs. Meanwhile the ACEP has tied higher mortality rates to diverted patients, according to a study last year.

Burke noted that the facilities involved in the study were warned six months before the ban to take steps to improve patient flow so their EDs wouldn't suffer gridlock during the ban, and that those improvements are reflected in the study's results. The biggest change was mandating hospitals to have a code help plan in place, which forces facilities to move patients out of the ED within 30 minutes after the department has reached capacity.

The work done to improve patient flow should give hospital administrators a blueprint to reducing ED overcrowding and an alternative to ambulance diversion or boarding, Woodward said. Healthcare administrators need to understand that the issue affects the entire hospital, not just the ED, he said.

“I want hospital leadership to take this issue on,” Woodward said. “Once you do that, you can have significant positive impact on patient care and the stress level of staff, as well as patient satisfaction.”

Patient satisfaction is what drove King County to take action, said Clark Hartley, a former paramedic and hospital administrator the county hired to study diversion. Hartley said patients were complaining about diversions, saying that when driven to a new hospital, staff there didn't have their health records, which led to poor care. Hartley helped establish compliance standards for EDs, and that gave officials achievement goals, which measured success and convinced them that doing away with ambulance diversions was the right move. He's worked with officials from San Francisco and Clark County in Las Vegas, which have also considered diversion restrictions.

“Hospital administrators felt initially that they didn't have time to change their culture,” Hartley said. “It takes a long time to change culture.”

It took the support of all hospitals in the area to make the cessation of diversions a success, Hartley said. They decided against a ban to avoid negative backlash from forcing a mandate.

“Do you really want to wait until somebody dies before you consider a policy like this, or do you want to acknowledge that this is a risk?” Hartley said.


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