Emergency Department Overcrowding and Ambulance Diversion

1
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

2
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.

3
Region IV Hospital Diversion Hours 2000-2002
4
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

5
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

6
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.

7
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

8
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)

9
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)

10
Internal Hospital Operations

• Factors that impede a hospitals 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

11
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
12
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

13
DPH Gridlock PreparednessSaturation/Gridlock
Disaster Response Plan
14
Influenza and Pneumonia Hospital Admissions from
Sept 1999 Sept 2000
ICD-9-CM 480-487
15
Massachusetts Acute Care Hospital DischargesFFY
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)