Original Contributions
Ambulance diversion reduction: the Sacramento solution

Presented in part at the Research Forum, American College of Emergency Physicians, San Francisco, Calif, October 17 to 18, 2004.
https://doi.org/10.1016/j.ajem.2005.09.005Get rights and content

Abstract

Purpose

The diversion of ambulances away from their intended emergency departments (EDs) in the United States has become commonplace and may compromise patient care. Although ambulance diversion resulting from ED overcrowding has been well described in the literature, little is known about how to reduce the incidence of ambulance diversion on a regional level. We describe the development, implementation, and impact of a region-wide program to reduce ambulance diversion.

Basic Procedures

This study was undertaken in the greater Sacramento, California region from January 2001 to December 2003. This comprehensive ambulance diversion reduction program was implemented May 15, 2002, with analysis of data for this 3-year time frame. The data for this study were obtained from 17 hospitals with ambulance diversion hours being the main outcome measure for this study.

Findings

The greater Sacramento region had 23 785 hours of ambulance diversion in 2001. In 2003, there were 7143 ambulance diversion hours. Comparing the 17-month period before implementation of this program with the 19-month period after implementation, the difference in the means of these two groups was −1428 hours per month (95% confidence interval, −1252 to −1597), a 74% decrease in ambulance diversion hours. Notably, this reduction occurred despite overall increases in ED census (6.5%), hospital admissions from the ED (8.8%), EMS arrivals to the ED (17.1%), inpatient hospital census (7.4%), and overall Sacramento population (5.7%).

Conclusions

Our results demonstrate a sizeable reduction of ambulance diversion in a large urban region after the successful implementation of a comprehensive ambulance diversion reduction program. The description of this effort may serve as a model for other regions across the country that do not have an organized approach in place for ambulance diversion, although boarding of admitted patients will still be a major hurdle to effective reduction of ambulance diversion.

Introduction

Over the past 10 years, the capacity of emergency departments (EDs) has not kept pace with the demand for emergency care in the United States [1], [2], [3], [4]. Overcrowded EDs have resulted in delays in evaluation and treatment of patients who have serious medical problems. Analyses of ED overcrowding have identified many contributing factors: (1) boarding of admitted inpatients in the ED; (2) increase in acuity of illness; (3) increasing demands because of the uninsured; (4) inadequate physical plant space in EDs; (5) nursing shortages; (6) delays in arrival of specialty consultants; and (7) an aging population [5].

One strategy adapted by some overcrowded EDs to relieve “front end pressure” is to divert ambulances away from their departments during times of high census [6], [7]. The rationale behind this approach is to relieve the crowded ED of further incoming ambulance patients to maximize attention to critically ill patients already under its care. Ambulance diversion (AD) also is thought to avoid delay in care for those patients arriving by ambulance into an ED already at maximal capacity.

When AD episodes were rare, the impact on a community would be minimal and surrounding EDs would be able to temporarily absorb those patients who had been diverted from the one ED that was experiencing capacity problems. This is no longer the case. Over the past several years, as ED overcrowding has become commonplace, it is not unusual for several hospitals in one region to go on AD simultaneously [8], [9]. Those EDs remaining open to ambulance traffic may become overwhelmed with a high volume of incoming ambulance traffic. When metropolitan areas experience simultaneous AD at multiple hospitals, paramedics are forced to divert to find an ED that remains “open.” If every ED in a region is closed at the same time, ambulances are rerouted to each of the closed facilities in sequential order, a condition in many cities called “round robin.” Other EMS districts have placed limits on diversion times. Diversion of ambulances because of ED closure has resulted in multiple problems. These include delay in arriving at the hospital because of bypassing a closer hospital, complex patients arriving at distant limited capacity hospitals, and repatriation of patients to their own physicians' hospital resulting in a second ambulance transport.

In the metropolitan area of Sacramento, Calif, the problem of AD developed in the late 1990s and reached crisis proportions by January 2002. At that time, 17 EDs in the Sacramento metropolitan area collectively diverted ambulances for greater than 2000 hours each month. The resulting chaos of ambulances navigating hospital gridlock to deliver their patients to an open ED resulted in headlines and multiple stories in the local media.

This study details the action plan that was implemented in Sacramento beginning in January 2002 to reduce AD. We will describe the specific steps taken, the monitoring process established, and the successful results achieved during the 2 years of implementation. Unlike previous articles that have described the problems and causes of AD, we believe our study will serve as a specific method to reduce AD for other regions across the country.

Section snippets

Theoretical model of the problem

Sacramento hospitals have monitored region-wide AD rates for the past 2 decades. Ambulance diversion occurs when a hospital informs the EMS system that it is unable to accept any more ambulances (except those that require immediate attention such as for cardiopulmonary resuscitation). It was evident by late 2001 that AD and round robin (defined previously) had been steadily increasing over the previous 2 years, requiring an effort to reverse this trend.

Setting and selection of participants

Emergency department physician chiefs, ED

Main results

Ambulance diversion hours had increased dramatically in the 2 years before project implementation. In 1999, Sacramento area hospitals were on AD for 4131 hours. Ambulance diversion increased to 11 098 hours in 2000 and increased to 23 785 hours in 2001. After program implementation in May 2002, AD hours fell significantly and the total number of hours on AD was 7143 in 2003. The monthly AD hours for the 17 months before (1934 hours per month) and the 19 months after implementation of the program

Discussion

This study demonstrates the successful reduction of AD in the Sacramento, California region as a direct result of a collaborative process that was established by the Hospital Council of Northern and Central California. Our study provides specific methodology as well as measurable outcomes. We believe that this process can serve as a model for other systems that have no organized approach in place for AD. For those regions across the country that do have an organized approach, boarding of

Acknowledgments

We thank the many stakeholders in this process improvement effort to reduce AD (includes hospital leadership, EMS and Fire Service, Sacramento–El Dorado County Medical Society, and the various ED physician chiefs and managers). We thank the Hospital Council of Northern and Central California for their support and Bob David (Vice President of the Hospital Council) for his guidance and support. We also thank Scott W. Gordinier, PhD (Senior Analyst, Operations Information Management, Kaiser

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Partial funding for this project was received through the Hospital Council of Northern and Central California. None of the authors have a financial interest in the program studied.

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