Diversion crisis eases, but strategies still critical

Fast-track systems and 23-hour observation units are helping EDs across the country reduce ambulance diversions, but more effort is needed, one analyst says. A hospitalwide focus on more efficient use of beds also is helping ease the problem, she adds.

A wide range of strategies are responsible for a decrease in diversions in the past year, the analyst says. Weekend radiology and lab services also can improve the flow of patients through the ED and reduce the need for diversions, says Linda R. Brewster, MBA, a consulting researcher with the Center for Studying Health System Change (HSC), a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation in Princeton, NJ.

"It was a great surprise to me to see that more than half of the sites we surveyed are starting to pay specialists to ensure that they are there to cover the ED," Brewster says. "That’s a big change, but it can have a significant effect on avoiding diversions."

Some hospitals, especially on the West Coast, are using clinical pathways more in the ED so patients can be followed up in the community after discharge instead of them showing up in the ED again.

"Here’s one that really astounded me: A few hospitals that were being overburdened by patients of a particular type actually were paying for them to be cared for in another setting, to keep them from using up beds in the ED," Brewster says. "One hospital found that alcoholics were taking up an inordinate number of beds and time in the ED, so they paid to have them cared for in another facility, just to free up the beds. They were willing to do it to have beds free for more profitable patients."

Because the HSC survey assured participants confidentiality, Brewster cannot reveal the hospitals using those strategies.

The efforts are paying off, according to a study released recently by HSC. (For information on how to access the study, see resources at the end of this article.) Brewster was the lead researcher. The study shows that the nationwide surge in ED ambulance diversions has eased as hospitals improved capacity management to free up beds and communities increased coordination to prevent diversions.

Although ED diversions still occur with regularity, HSC’s 2002-2003 site visits to 12 nationally representative communities found ambulance diversions are no longer as frequent or as unmanageable. A decrease in inpatient use likely accounts for some of the drop in diversions, but hospitals also have worked to improve staffing, bed availability, and patient flow within and out of hospitals, Brewster says.

He notes ED diversions primarily stem from a lack of critical care beds and other inpatient beds, which creates bottlenecks in the ED and forces hospitals to delay emergency admissions or divert ambulances to other hospitals. While many hospitals are expanding ED capacity to reduce crowding at the point of intake, improved inpatient capacity management has been critical in easing diversions, she says.

ED volume increased dramatically four years ago, leading to a surge in ED diversions, Brewster says. Much of that volume increase was tied to a breakdown of managed care systems that led to patients visiting EDs more easily, without getting prior approval from insurers.

More than 110 million visits were made to the nation’s emergency departments in 2002, an increase of more than 3 million over the previous year, according to a new report from the Centers for Disease Control and Prevention (CDC) in Atlanta. (For information on how to access the report, see resources at the end of this article.)

J. Brian Hancock, MD, president of the Irving, TX-based American College of Emergency Physicians (ACEP), notes that patients were spending more time in EDs and says these trends are likely to continue, especially as the population ages.

"Emergency department overcrowding is a growing and severe problem in the United States, and we all should be concerned," Hancock says. "As dedicated as emergency physicians and nurses are to caring for our patients, we may not have the resources or the surge capacity to respond effectively."

Some solutions will require a national commitment and recognition of emergency medicine as an essential community service — more than ED managers can do on their own, he says. But Hancock says any efforts to improve flow through and efficiency in the ED will help ease overcrowding and diversions.

The CDC found two-thirds of emergency patients spent one to six hours in the ED, with the average duration of a visit lasting 3.2 hours. It also found an increase in visits for patients older than 44 years old.

The CDC report also shows emergency patients are increasingly sicker, with a greater percentage of patients being classified as emergent, defined as needing treatment within 15 minutes (22.3%, up from 19.2% in 2001), Hancock notes. The percentage of patients classified as urgent, meaning they need treatment in 15-60 minutes, also increased (34.2%, up from 31.2% in 2001). Nonurgent patients also were up slightly, to 10.2% from 9.1% in 2001.

"Some hospitals have been successful in alleviating the overcrowding problem by moving patients to the floors in which they will be admitted, instead of boarding them in the emergency department," Hancock says. "This shifts the burden throughout a hospital and allows an emergency department to continue to receive ambulance patients, as well as new patients from the waiting room."

The CDC reports that from 1992 to 2002, the number of emergency visits increased on average about 2 million visits: from 89.8 million to 110.2 million annually (up 23%). At the same time, the number of hospital EDs decreased about 15%.

Hancock says emergency patients are increasingly sicker, with a greater percentage of patients being classified as emergent (22.3%, up from 19.2% in 2001), defined as needing treatment in fewer than 15 minutes, and urgent (34.2%, up from 31.2% in 2001), defined as needing treatment in 15-60 minutes. The percentage of patients classified as nonurgent rose slightly to 10.2% (from 9.1% in 2001), defined as needing treatment in 2-24 hours.

"The numbers are overwhelming sometimes, so hospitals are really employing a wide range of strategies," Brewster says. "Throughput is the critical issue with avoiding diversions, so that’s what most of them are focusing on."

Sources and Resources

For more information on diversions, contact:

  • Linda R. Brewster, MBA, Consulting Researcher, Center for Studying Health System Change, 600 Maryland Ave. S.W., No. 550, Washington, DC 20024. Phone: (202) 484-5261.
  • J. Brian Hancock, MD, President, American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038-2522. Phone: (800) 798-1822.
  • The Center for Studying Health System Change (HSC) study’s findings are detailed in Emergency Department Diversions: Hospital and Community Strategies Alleviate the Crisis, available free on the HSC web site at www.hschange.com. Choose "issue briefs" on the left side of the page, and then select the diversion study.
  • The Centers for Disease Control and Prevention report is available free on the web site at www.cdc.gov. Enter "Advance Data Number 340" in the search box.