Editorial: Ambulance Diversion: the Con Perspective.

American Journal of Emergency Medicine xxx (2015) xxx–xxx Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Controversies Editorial: Ambulance Diversion: the Con Perspective Yuko Nakajima, MD ⁎ , Gary M. Vilke, MD Department of Emergency Medicine, UC San Diego Health System, 200 West Arbor Dr #8676 San Diego, 92103 As the ultimate safety net, emergency departments (EDs) are expected to care for any patient, at any time, under any circumstances. When EDs are overwhelmed in periods of surge, one solution is to redistribute pa- tients. A commonly used method for redistributing patients is ambulance diversion. Ambulance diversion is not a new phenomenon and, over time, has become commonly used by EDs to address the growing problem of ED overcrowding and saturation [1]. As ED visits have increased through the years, ambulance diversion has evolved into standard practice in many health systems. Along with this, ambulance diversion has always involved controversy over whether,overall, it is beneﬁcial or detrimental to the pa- tient, emergency medical services (EMS) systems, and hospitals. In some circumstances, EDs and hospitals may occasionally be overwhelmed and may not be able to provide optimal patient care. Di- version may be viewed as a necessary mechanism to avoid the substan- dard situations in the ED represented by crowding, boarding, and hallway beds. It is used as a way to direct patients away from one’s hos- pital when waiting rooms are crowded and ED beds are full. However, in many circumstances, the patient is being directed to another facility that is just as busy and impacted but now further away, keeping pa- tients in the back of ambulances longer and thus keeping ambulances out of service for longer periods of time. Ambulances being out of ser- vice have been associated with delays in response to the next emergen- cy because there are fewer units in service and the available ambulances have to travel further to reach patients. These delays have also attribut- ed to adverse medical outcomes. Recent data support that ambulance diversion does not work to ease ED overcrowding and may result in the worsening of patient care. Stud- ies have shown that ambulance diversion can lead to delays for patients in obtaining deﬁnitive medical care given the increased ﬁeld time and transport time and distances [2,3] leading to adverse outcomes includ- ing death. Diversion increases trafﬁc accident risks and may malposition EMS resources. In addition, some patients may require specialty re- sources only available at the requested hospital and may not be able to receive them at an alternate destination. There is a possible association between ED diversion and increased mortality in certain populations of patients, such as trauma and acute myocardial infarction patients [4,5]. Studies like these led to American College of Emergency Physicians forming an EMS taskforce to review the topic of ambulance diversion. The taskforce penned a position paper that stated, “Ambulance diversion should occur only after the hospital has exhausted all internal mechanisms to avert a diversion, which includes calling in overtime staff” [6]. The National Association of EMS Physicians also states that “… ambulance diversion has not been shown to improve ED patient throughput” [7]. It has been demonstrated that if one hospital goes into ED diversion status, an oscillatory phenomenon may occur, where the one hospital going on bypass causes a neighboring hospital to receive a dispropor- tionate share of patients and is then forced to go onto bypass itself. This can create a domino effect impacting other hospitals nearby or, if there are no other hospitals to receive the patients, forcing the original hospital to accept more patients until it again gets impacted and goes back onto bypass. The cycle continues ad inﬁnitum [8]. During this time of diversion, the hospital is receiving its own patients as well as pa- tients who originally had requested another hospital as a destination. These patients will arrive to a hospital that does not have immediate ac- cess to medical records, study results, private physicians, and some- times not even an inpatient bed being held for that patient for admission. Countless times, patients arrive to the “wrong” hospital be- cause of diversion and have to be transferred back to the original re- quested destination for admission. And this transfer occurs after possibly an unnecessary workup and evaluation, as well as taking up valuable ED bed time to complete the evaluation, transfer call process, and wait-time for a transport team to remove the patient from the bed and transfer said patient to the hospital that they should have gone in the ﬁrst place. Hours of physician, nursing, and administrative time are wasted. This does not even quantify the inconvenience and frustration to the patient and families. In the end, the patients ultimately end up at the originally requested hospital, but not until after time and health care dollars are wasted. While this is happening at the receiving hospital, patients requesting said facility end up at the “wrong” hospital, thus creating the same inefﬁcien- cies there. And so the oscillating cycle continues, even leading to defensive ambulance diversion, where the second hospital, though not at saturation status, would go on diversion when hearing that the ﬁrst hospital just went on diversion. After observing the oscillatory phenomenon, two hos- pitals that collaborated and committed to staying off ambulance diversion for a week were able to demonstrate that this oscillating effect goes away, patients get to the “right” hospital the ﬁrst time, and still all of the patients get seen without any detriment to patient care [8]. Follow-up work quantiﬁed at a more regional level involving multi- ple hospitals working together to collectively stay off ambulance diver- sion demonstrated that this can be done safely with no reported adverse effects to patient care. All of the patients still get seen in the collective group of EDs, but the patients get to the correct hospital the ﬁrst time [9]. This eliminates the ineffectiveness as described above for patients not being delivered to their requested medical home. San Diego County took the success of these two regional short-trial successes to the next level in 2002. After ambulance diversion was http://dx.doi.org/10.1016/j.ajem.2015.03.005 0735-6757/© 2015 Elsevier Inc. All rights reserved. Please cite this article as: Nakajima Y, Vilke GM, Editorial: ambulance diversion: the con perspective, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.03.005