# Presentation: 486879

## Emergency Department Overcrowding and Ambulance Diversion

**Brad Prenney, M.S., M.P.A.**
- Deputy Director
- Bureau of Health Quality Management
- Massachusetts Department of Public Health

## Statement of the Problem

- Ambulances are diverted away from the closest appropriate hospital because that hospital can not provide timely care.
- Diversion results in a delay in definitive care.
- Diversion is a public health problem that has worsened over the last several years.
- A related problem is the “boarding” of patients in the ED for extended periods of time while waiting for an inpatient bed.

## Region IV Hospital Diversion Hours 2000-2002

**Region IV Hospital Diversion Hours 2000-2002**

## Selected Highlights of Massachusetts Initiatives to Address Ambulance Diversion

- May 1999	First meeting of Ambulance Diversion Task Force
- December 1999	Issuance of Best Practice Guidelines to Hospitals
- December 2000 	Issuance of Recommended Measures to Hospitals
- February 2001 	DPH Diversion Survey of Hospitals
- June 2001	Publication of Issue Brief/Brandeis Forum
- February 2002	Diversion Uniform Rules/Definitions Distributed
- October 2002	Disaster/Gridlock Plan Developed
- November 2002	Completion of Hospital Patient Flow Study

## Focus of Initiatives to Address Ambulance Diversion and ED Overcrowding 

- Providing guidance to hospital and pre-hospital providers
- Management of the problem
- Understanding the factors contributing to the problem

## Diversion Measures within the Hospital (12/2000)

- Integrate written diversion policies within hospital disaster plans.
- Fast-track non-emergency patients.
- Staff all licensed beds during peak demand periods.
- Establish admissions plans for periods of ED overcrowding that:
- give priority to emergency patients
- schedule surgeries in a way to maximize bed capacity
- allow for rescheduling of elective surgeries to care for higher acuity patients.

## Uniform Definitions/Rules Governing Ambulance Diversion 

- Definitions for boarder, ED saturation, diversion
- Honoring diversion requests
- Exceptions to diversion
- Immediate life-threatening situations
- Patient preference/ insistence/ refusal
- When contiguous hospitals request diversion
- Selective diverting of ambulances

## Demand Factors 

- Increase in volume of patients presenting to the ED (hospital closures, demographics — aging population, decreased access and/or satisfaction with community-based care)
- Increase in acuity
- Increased diagnostic and treatment capability in the ED
- Seasonal variation in communicable disease (i.e. flu)

## Supply Side Factors 

- Lack of staffed inpatient beds (financial constraints faced by hospitals, conversion to other uses, no longer staffing for the peaks)
- Shortage of staff (especially nursing, difficulty recruiting and retaining)
- Hospital closures (Massachusetts has lost about 1/3 of its hospitals over the last 20 years)

## Internal Hospital Operations 

- Factors that impede a hospital’s ability to move patients efficiently through the system
- 	a)  Variability in scheduling OR/beds for elective and emergency surgery
- 	b)  Variability in admission and discharge processing
-    c)  Variability between discharge and next admission to a bed
- Lack of sufficient coordination and communication between services

## “While increasing use of the ED, especially for non-urgent needs, causes significant problems in patient flow, staff burn-out, and ED operations, we do not think that it is those who seek care for non-urgent issues who are responsible for the recent crisis of ambulance diversions. It is really the acutely ill patient who is waiting in the ED for a hospital bed who creates the bottleneck that leads to overcrowding, diversions, and essentially a breakdown in the entire system.”- Brent Asplin, M.D., M.P.H., Director of Research,Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota  

## Current Initiatives To Address Ambulance Diversion and ED Overcrowding 

- Quarterly meetings of Ambulance Diversion Task Force
- Completion of patient flow study and dissemination of simulation model to hospitals
- Development of disaster/gridlock plan
- Continued Promotion of Best Practices

## DPH Gridlock PreparednessSaturation/Gridlock Disaster Response Plan

## Influenza and Pneumonia* Hospital Admissions from Sept 1999 – Sept 2000

- ICD-9-CM 480-487

## Massachusetts Acute Care Hospital DischargesFFY 2000

- 				_ER Charges_                       	_No ER Charges_
- 				  _Number of_              		   _Number of_
- _Payer Type_     			_Discharges (%_)    		_Discharges (%)_
- Medicare/Medicare 			203,171      (58)       		117,031      (27)
- Managed Care
- HMO				47,390         (13)		118,383       (27)
- Medicaid/Medicaid 			34,065         (10)		64,944          (15)
- Managed Care
- Blue Cross/Blue Cross			25,481           (7) 		65,957          (15)
- Managed Care
- Self Pay/Free Care                  		15,423           (4)		12,545            (3)
- All Other				26,566           (8)		55,786          (13)
- TOTAL				352,096       (100)		434,646      (100)