Although the primary focus of an advanced EMS system is typically the patient care rendered in the field and during transport, the act of delivering the patient to the most appropriate facility, performing a safe transfer of care, and returning to service to await the next emergency call is an important and sometimes overlooked by EMS physicians as part of the “operational component.” Diversion and bypass may increase transport distance and delays in offload of patients in crowded emergency departments can cause EMS crews to be out of service for longer periods, reducing system efficiency. Clearly this component has a direct impact on patient care, both current and for those who have not yet dialed 9-1-1. Defining and understanding the different components and facets of this part of the medical operation is critical to medical directors seeking to ensure patient high-quality care.
Define terms ambulance diversion, hospital bypass, patient demand, ambulance offload delay, alternative destination, and emergency department crowding.
Discuss the historical and contemporary effects of ambulance diversion.
Describe the practice of hospital bypass and specialty hospital designations (eg, trauma, ACS/PCI, stroke).
Describe the NEDOCS scoring system and its potential use in EMS resource management.
Discuss state regulations, as well as legal, financial, and ethical implications of patient demand.
Discuss the use of alternative destinations, such as urgent care centers, psychiatric facilities, and doctors’ offices.
Discuss the concept of “treatment, no transport” as an alternative to transport to the emergency department.
Emergency departments and EMS personal serve as the country’s so-called medical safety net. As such, both are expected to be able to handle any and all patients at all times. The population within the United States continues to increase and as such, so do its medical need and the demands it places on the EMS system. Emergency department crowding and extended wait times have both become the norm and the focus of the press, legislature, and public.1,2 Several strategies have been implemented in an effort to decrease ED wait times and crowding. Prominent and controversial among these is ED diversion. Depending on the communities in which you serve, ED diversion may play a significant role in day-to-day EMS operations and present particular challenges to the prehospital provider.
Emergency medical personnel face many unique and challenging situations in the prehospital environment aside from that of direct patient care. Ideal patient management often requires careful consideration of the final destination for the patient and selection of a facility optimally equipped to deal with their particular emergency. For example, it may be appropriate to bypass the local community hospital in favor of the closest trauma center, focused pediatric emergency department, or high-risk labor and delivery hospital depending on the situation and the patient. Other decisions such as to potentially transport a patient by air as opposed to ground must also be considered and must factor in variables such as patient acuity, weather, and availability of aircrews. Selection of the most appropriate facility for the patient is significantly influenced by real-time variables such as time of transport (traffic delays during peak travel periods, etc), distance of transport, and patient acuity, among others. As a general rule, getting the patient to the closest most appropriate facility is always the goal. This is not always as straightforward as it may sound. If there is a question as to the most appropriate disposition for the patient, it may be necessary to get medical control involved in the decision-making process. If there is significant concern about the stability of a patient, they should be transported to the closest emergency department for further stabilization, assessment, and subsequent transfer. A relatively newer facet of emergency care referred to as ED diversion is further complicating these already complex decisions as well as affecting prehospital providers in a number of other ways.
Ambulance diversion (AD) is the practice of redirecting or limiting destination of an ambulance carrying a patient to a hospital as its destination. Typically AD occurs as part of the EMS system, where it is an excepted practice for hospitals to signal the system that their ED is crowded and there is likely to be a significant delay, or lack of patient care services if additional patients were to arrive by ambulance during that time.
Hospital bypass (HB) is the practice of directing prehospital providers to transport patients needing specialty care to a specialty center instead of the nearest hospital. This sometimes means significant increases in travel time and is usually in cases where time to definitive care is believed to be the primary clinical factor affecting patient outcome (eg, major trauma, ST-elevation MI, acute stroke).
Patient demand (PD) refers to the right of the patient to choose their hospital destination, even when the prehospital provider advises a different destination, or in some systems, even when the chosen hospital is on diversion.
Ambulance offload delay (AOD) is the time between arrival of an ambulance, and the time that the patient is both (1) off the stretcher and (2) EMS report has been given. AOD is a relatively new quality measure in the United States, but has been evaluated in Canada for some time due to the fact that it represents a delay in patient care that is sometimes significant.
Transport to alternative destinations in response to 9-1-1 calls is not a new concept, but is not yet widely accepted. In many systems, ambulances on 9-1-1 calls may only transport patients to an emergency department. In some systems, prehospital providers are allowed to use clinical judgment and/or specific criteria to determine the appropriateness of transporting to an urgent care center, doctor’s office, or psychiatric facility. In some cases, the providers may also be able to determine the appropriateness of treating the patient and leaving them at their home or initial call location. If the patient requires no emergency care and it is determined that the patient should seek primary care services (rather than emergency care) some systems allow providers to decline treatment and transport and provide the patient with a list of resources and clinics instead.
Emergency department crowding (EDC) is a significant problem in many systems across the country. Hospital throughput issues and limited primary care access are thought to be significant contributing factors. Expanding ED facility size has not been found to be a particularly successful solution to this problem.
It is important for the EMS physician to have a general understanding of the background basis for ED diversion as well as the evidence-based results of its implementation as it can significantly affect the field provider in real time as well as the administrator looking to optimize unit hour utilization (UHU). First described by Lagoe and Jastremski in 1990 as a novel approach to alleviating EDC in an urban environment, AD has swept across the nation and is increasingly utilized in one form or another by most busy medical systems.3–6 While there are variations on its definition, essentially an ED which is placed on diversion is closed to all incoming ALS and BLS traffic. Exceptions to this rule can include PD and specialty services (trauma, burn, etc). Proposed benefits of incorporating some type of diversion system include a decrease in mortality and morbidity by avoiding crowded (overwhelmed) EDs, a decrease in waiting times and crowding, and increased efficiency in utilizing resources. Proposed detriments to the system include complex patients being transported to facilities both unfamiliar with their history and lacking the patient’s primary physicians, increased turnaround times for EMS personal traveling outside of normal service areas, and public perception of an institution turning away individuals requiring emergency care. This public perception can also be transferred to the prehospital provider. While ideal in concept, actual implementation and experience with diversion status have yielded conflicting research and brought the practice into question. Not only is the process being scrutinized by many different researchers and medical systems, the growing problem of EDC has clearly been shown to be much more complex than simply numbers of patients presenting to the Emergency Department via ALS and BLS ambulance.7,8
A first glance at the research and data surrounding diversion yields seemingly conflicting results. A number of researchers have demonstrated some association between AD and increased patient mortality and morbidity.9–11 However, a recent systematic review of the literature relating to AD has suggested no such association exists.12 This same review also concluded that based on the summary of the literature AD is common and increasing in frequency, is associated with EDC, is reducible through redesign or addition of resources, is associated with a small increase in patient transport and treatment times, slightly decreases ambulance flow, and appears to be associated with estimated losses to hospital revenue. Based on initial studies and this review, one could conclude diversion either has no demonstrable effect on mortality and morbidity or may slightly increase it.
As stated above, a theoretical benefit of diversion is greater utilization of available resources, and this is where the role of the prehospital provider is introduced as they are one of the obvious key available resources. Somewhat surprisingly studies have shown diversion results in only slightly increased turnaround times or has no significant negative effect on EMS resources.12,13 Carter and Grierson sought to determine how diversion impacts ambulance resources. They evaluated 1563 instances of response times during an hour of diversion and 30 minutes before and after for 2002. These were compared with 1403 calls in 2001 when hospitals were not on diversion. They concluded their findings did not support a significant negative effect on EMS resources when one hospital in their study city was on diversion. They additionally state no difference was noted in transport, hospital turnaround, or total out-of-service times. The review by Pham and colleagues identified six articles evaluating AD and transport and treatment times. These articles demonstrated a 1.7 to 5 minute delay in transport times associated with AD. Delays in treatment times have been associated with increased patient mortality and morbidity.14,15
Several studies have shown institution of protocols and plans to both EMS systems and hospitals to decrease diversion hours have been effective. Based on the aforementioned articles demonstrating either no delay or minimal delay in treatment of patients when hospitals are on diversion, it would seem evident a reduction or elimination of diversion hours would benefit patients. Early intervention has been shown to be an important predictor in patient outcomes.16,17 Asamoah, Weiss, and colleagues implemented a novel diversion protocol among a county of 600,000 people and 10 hospitals over a period of 6 months.18 The protocol utilized limited diversion hours to one out of every eight (a total of 90 hours/month). The protocol was successful in reducing diversion hours during the trial (305 hours/month pretrial to 54 hours/month posttrial). The authors do note, however, they did see a small but statistically significant increase in turnaround times for EMS providers as they waited longer to off load patients in busy emergency departments.
Vilke et al also examined a community intervention to decrease diversion hours.19 They looked at a community of 2.8 million people and implemented a policy where hospitals could be on diversion for 1 hour only, could not go back on diversion until they had received at least one ambulance patient, and lastly, while on diversion, the hospital would take patient requests unless a significant patient safety issue existed. The trial took place over a 3-month period during which 235,766 patients were transported to emergency departments in the county. During the study, AD was decreased by 73% and the number of patients who could not be transported to their hospital of choice was decreased by 75%. In a review of the literature, Pham et al identified nine studies where individuals sought to limit diversion time through similar methods as those listed above (putting limitations on diversion status only).12 An additional seven studies looked at emergency department and hospital-wide interventions to decrease diversion time (mainly through increasing throughput and admissions). They concluded that diversion rates can be reduced by adding resources to decrease EDC or closely monitoring diversion. No definite conclusions could be drawn with regard to EDC or patient outcome simply based on changing or limiting diversion.
After reviewing the relevant literature, it is difficult to endorse uniform use of AD. Diversion appears to have either no effect on mortality and morbidity or results in a slight increase. Therefore, based on mortality and morbidity data, the practice cannot be supported. The majority of studies indicate diversion can result in increased turnaround and therefore response times for EMS personal as they are unable to access the closest appropriate hospital during times of diversion. This must also take into account the complex issues the prehospital provider is faced with when attempting to deliver optimal patient care as stated at the beginning of the chapter. Practices to decrease diversion times have proven to be successful and have allowed patients’ greater access to primary hospitals where their medical records and primary providers are located. Some important references on AD are listed in Table 11-1.
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