Keith Mack
Ambulance diversion is a controversial practice that is nevertheless legal in most states. It occurs when a hospital declares itself on diversion status, indicating that it cannot safely accommodate additional patients and redirecting ambulances to other facilities. While this can have severe consequences, including death, there is no federal policy prohibiting hospitals from diverting ambulances to other hospitals. Diversion is typically implemented when emergency departments are overcrowded and facilities are limited, often due to staff shortages and a surge in cases requiring immediate attention. To avoid diversion, hospitals must identify and address bottlenecks, improve efficiency, and match staffing with patient demand.
| Characteristics | Values |
|---|---|
| Ambulance diversion legality | Legal in most states |
| Federal law requirement for hospitals | Stabilize patients who walk in and request emergency care |
| Ambulance diversion consequences | Loss of prior medical records, malpositioned ambulances, family transportation barriers, duplication of efforts, unnecessary expenses |
| ER diversion causes | Staff shortages, surge in cases requiring immediate care, bottlenecks |
| ER diversion solutions | Hiring additional staff, reworking schedules, expanding emergency waiting rooms and triage areas, improving hospital throughput and efficiency, utilizing computer technology to test proposed policy changes |
| ER diversion status duration | Can vary from one hour to several hours or even days |
| ER diversion status declaration | Made when a hospital and its emergency room are overloaded and can no longer safely accommodate another patient |
| ER diversion impact | Ripple effect on "downstream facilities," resulting in further diversions |
| ER diversion alternatives | Collaboration between hospitals and alternative receiving facilities to ensure appropriate care for diverted patients |
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What You'll Learn
Ambulance diversion legality
Ambulance diversion is a controversial yet common strategy used by hospitals to manage overcrowding in their emergency departments (EDs). When a hospital declares diversion status, it means that its emergency room is overloaded and cannot safely accommodate additional patients. As a result, incoming ambulances are directed to other facilities. While ambulance diversion provides temporary relief to congested EDs, it can also lead to delays in medical care for patients and create a domino effect, causing nearby hospitals to become overwhelmed and triggering them to go on diversion status as well.
The legality of ambulance diversion varies depending on the state and local regulations in the United States. In most states, ambulance diversion is legal, as there is no nationwide policy prohibiting hospitals from instructing ambulances to take patients elsewhere. Federal law mandates that if an individual walks into a hospital and requests emergency care, the hospital is required to stabilize them. However, there is no corresponding policy that penalizes hospitals for diverting ambulances to other facilities.
The frequency of ambulance diversion incidents varies across different cities and states. A 2006 study in the Annals of Emergency Medicine found that 45% of emergency departments in the US had gone on diversion status at least once in the previous year, with urban hospitals reporting a rate of almost 70%. In 2019, an investigation by the Milwaukee Journal Sentinel revealed that 16 out of the 25 largest cities in the country allowed some form of ambulance diversion.
While ambulance diversion can provide temporary relief to overcrowded EDs, it is not a sustainable solution. Hospitals should focus on identifying and addressing the root causes of congestion, such as staff shortages and increased patient volume. By hiring additional staff, expanding facilities, and improving patient flow, hospitals can reduce the need for diversion status and ensure timely and effective care for all patients.
To mitigate the impact of ambulance diversion, hospitals must communicate effectively and collaborate with nearby facilities. They should also explore alternative approaches, such as transferring stable patients to other departments or hospitals and utilizing available resources efficiently. By working together and implementing comprehensive strategies, hospitals can alleviate ED congestion and improve patient outcomes.
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Patient distribution
Emergency Room (ER) diversion occurs when a hospital declares itself on "diversion" status, indicating that its emergency department is overloaded and cannot safely accommodate additional patients. This often results in ambulances being redirected to other hospitals, which can cause a "'ripple effect'," with downstream facilities also reaching capacity and initiating their diversion protocols.
In some cases, patients themselves engage in self-distribution, opting to travel to other emergency departments in the region with shorter wait times. This can lead to longer travel times and transportation barriers, particularly for patients' families. Additionally, it can result in the loss of prior medical records, necessitating back-transfers to the preferred facility and causing delays and unnecessary expenses.
To address the challenges of patient distribution during ER diversion, hospitals employ various strategies. These include expanding their emergency waiting rooms and triage areas, hiring additional staff, and adjusting schedules to align with patient demand. Effective communication is also crucial, as sharing information about patient volumes and capacity issues with other departments and hospitals can help manage patient distribution more efficiently.
In certain regions, collaborative arrangements between hospitals have proven effective. These arrangements require hospitals initiating diversion to contact alternative receiving facilities and ensure appropriate care for diverted patients. Such collaborations are supported by organizations like the American College of Emergency Physicians (ACEP), which advocates for diversion decisions to be made by EMS medical directors, emphasizing that diversion is a "request" rather than a legal mandate.
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ER overload
Emergency Room (ER) diversion happens when a hospital and its emergency room are overloaded to the point that they can no longer safely accommodate another patient. The hospital will declare itself on a "diversion" status, meaning that they cannot accept new ambulance arrivals until they can recover to what they deem is a safer time. This can last from just an hour to several days.
ER diversion is undesirable, yet it remains a common and controversial issue, and it is perfectly legal in most states. There is no federal or nationwide policy that penalizes hospitals for asking ambulances to take patients elsewhere. This can cause ambulances to be malpositioned, create family transportation barriers, and result in the loss of prior medical records. In some cases, it can have grave consequences. For example, in 2017, a Las Vegas resident died after having a stroke; the ambulance that arrived was diverted from the nearest hospital to a facility 70 miles away.
In addition, hospitals can implement strategies to manage patient flow and improve throughput and efficiency. For example, Lawrence General Hospital in Massachusetts addressed ER overload by improving communication between departments, utilizing extra beds, changing standard discharge times, and focusing on getting patients to the right places as quickly as possible.
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Staffing issues
When hospitals face staff shortages, they may struggle to accommodate additional patients safely, leading to diversion status. This status means they cannot accept new ambulance arrivals until they recover to a safer patient volume. Staffing shortages can result from various factors, including layoffs, attrition, and restructuring. For example, hospitals like MemorialCare's Long Beach Medical Center and Lehigh Valley Health Network have laid off or planned to lay off numerous workers, impacting their staffing capacity.
Hospitals can address staffing shortages by hiring additional staff and reworking schedules to match patient demand. For instance, Lawrence General Hospital addressed diversion issues by hiring more staff and adjusting schedules to match demand. They also improved communication by looping in other departments when the ER was overwhelmed, summoning nurses from other floors to assist in the ER, and utilizing extra beds from other units.
To avoid diversion status altogether, hospitals are advised to take an individualized approach to identify and address their specific bottlenecks. This may include expanding emergency waiting rooms and triage areas or collaborating with community organizations for program delivery.
While hospitals are not legally required to accept all ambulance patients, they must stabilize patients who walk in and request emergency care. The decision to divert ambulances can have grave consequences, and there is no central organization dedicated to tracking diversion policies and their outcomes.
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Alternate facilities
When a hospital emergency department goes on divert, paramedics must bypass that hospital and transport the patient to the closest facility with availability. The alternate hospital is not obliged to accept the patient, but they usually accommodate the request. This is known as ambulance diversion or hospital diversion.
Ambulance diversion is a controversial policy, as it can result in longer patient offloading periods, deplete a community's EMS services, cause malpositioned ambulances, create family transportation barriers, and result in the loss of prior medical records. In some cases, patients must be back-transferred to their preferred facility, leading to delays, duplication, and unnecessary expenses.
In the United States, there is no nationwide policy that penalizes hospitals for instructing ambulances to take patients elsewhere. However, if a patient walks into a hospital and requests emergency care, federal law states that the hospital is required to stabilize them.
Some hospitals have successfully ended diversion by identifying and addressing their weakest links or bottlenecks. This may include hiring additional staff, reworking schedules to match patient demand, expanding emergency waiting rooms and triage areas, and utilizing beds in other departments.
It is recommended that hospitals take an individualized approach to avoid diversion status, as no two hospitals are the same.
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Frequently asked questions
ER diversion happens when a hospital and its emergency room are overloaded to the point that they can no longer safely accommodate another patient. The hospital will declare itself on a "diversion" status, meaning that they cannot accept new ambulance arrivals until they can recover to what they deem is a safer time.
ER diversion is controversial yet legal in most states, given how there's no policy that penalizes hospitals for asking ambulances to take patients elsewhere.
ER diversion is caused by bottlenecks in hospitals, such as staff shortages and a surge in cases needing immediate care.
Hospitals can avoid ER diversion by pinpointing and addressing their bottlenecks, such as by hiring additional staff and reworking schedules to match patient demand better.
