ED diversion rates high throughout the calendar

If you are experiencing all-time high diversion rates, you’re not alone. A new study shows that ED diversions are now a year-round problem. The Washington, DC-based Center for Studying Health System Change conducted site visits at 12 EDs in Boston; Cleveland; Greenville, SC; Indianapolis; Lansing, MI; Little Rock, AR; Miami; northern New Jersey; Orange City, CA; Phoenix; Seattle; and Syracuse, NY. (See "Resources" at the end of this article for how to obtain the complete report.)

The key finding was that diversion isn’t just a seasonal problem for EDs anymore. "In fact, it has become a year-round problem in many communities," reports Cara S. Lesser, director of site visits. "The problem stems from changes in both supply and demand."

According to the study, high diversion rates are a result of more patients and fewer inpatient hospital beds. On the supply side, the number of EDs has decreased, and hospitals have downsized, which has led to delays in admitting patients, Lesser explains. "Closures of many skilled nursing facilities and home health services have compounded the problem because there are fewer discharge options," she adds.

The nursing shortage, which has become severe in many communities, has complicated hospitals’ capacity problems by limiting the ability to staff existing beds, says Lesser. Meanwhile, there has been increased demand for ED services due to a more strict enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) and a growing number of uninsured patients who rely on the ED as their usual source of care, according to Lesser. "The implications for ED managers is that there is a real problem that deserves the attention of hospital executives and community leaders," she stresses. "You need to ensure that there is adequate capacity to meet the emergency needs of the community."

She adds that at the time of the site visits (June 2000-March 2001), EDs were in the early stages of grappling with the diversion problem. "Many have since developed coordinated diversion programs to ensure that patients maintain reasonable access to care," she says.

Here are some of the strategies that are being tried:

• improving recruiting and retention of nurses;

• hiring additional nurses (Lesser points to Massachusetts General Hospital’s recent addition of 22 nursing positions and two attending physician positions to increase ED capacity);

• reassigning nurses from outpatient clinics to inpatient units;

• bolstering nursing rosters with temporary staff;

• freeing beds by discharging patients earlier in the day;

• decreasing lengths of stay by moving patients to extended care settings;

• accelerating patient discharge with more reliance on clinical guidelines to standardize the treatment process;

• postponing elective admissions; and

• increasing inpatient capacity by reopening licensed beds that had been "mothballed" in previous years. "For example, Massachusetts General and Brigham and Women’s Hospitals reopened about 300 beds," Lesser says. "This includes most of the beds closed in the mid-1990s to reduce operating costs."


For more information about the study, contact: Cara S. Lesser, Center for Studying Health System Change, 600 Maryland Ave. S.W., Suite 550, Washington, DC 20024. Telephone: (202) 484-4220. Fax: (202) 484-9258. E-mail: clesser@hschange.org.


A complete copy of Emergency Room Diversions: A Symptom of Hospitals Under Stress (Issue Brief No. 38) is available free of charge on the Center for Studying Health System Change web site (www.hschange.org). Click on "Publications," "Issue Briefs," and scroll down to "Emergency Room Diversions: A Symptom of Hospitals Under Stress." Or to obtain a paper copy contact: Center for Studying Health System Change, 600 Maryland Ave. S.W., Suite 550, Washington, DC 20024. Telephone: (202) 484-5261. Fax: (202) 484-9258. E-mail: orderpub@hschange.org.