Center for Studying Health System Change

Hospital Emergency Department Diversion Crisis Eases

Costly Expansions Forestalled by Improved Hospital Capacity Management

News Release
March 2, 2004

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ASHINGTON, D.C.—The nationwide surge in emergency department ambulance diversions has eased as hospitals improved capacity management to free up beds and communities increased coordination to prevent diversions, according to a study released today by the Center for Studying Health System Change (HSC).

Although emergency department (ED) diversions—when a hospital lacks capacity to care for emergency patients and redirects ambulances to other hospitals—still occur, HSC’s 2002-03 site visits to 12 nationally representative communities found ambulance diversions are no longer as frequent or as unmanageable. A downtick 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.

Emergency department diversions stem primarily from a lack of critical care beds and other inpatient beds, creating bottlenecks in the ED and forcing 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.

"The sudden onset of the diversion crisis pushed hospitals and communities to respond quickly to prevent serious threats to access and quality of care," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation.

"The success in easing diversion problems offers an important lesson for communities-much can be done to improve management of existing hospital capacity before making potentially costly expansions," Ginsburg said.

The study’s findings are detailed in a new HSC Issue Brief—Emergency Department Diversions: Hospital and Community Strategies Alleviate the Crisis. The study by Linda R. Brewster, an HSC consulting researcher, and HSC Research Analyst Laurie E. Felland is based on HSC’s 2002-03 site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

Other key study findings include:

• The ongoing nursing shortage has played a significant role in diversions, and hospitals have redoubled efforts to fill nursing vacancies by turning to international recruiting and relatively costly agency or traveling nurses. Hospitals also have improved recruitment and retention of nurses by offering financial incentives and flexible work schedules.
• Growing physician unwillingness to provide emergency on-call coverage has contributed to diversions, and hospitals in six of the 12 communities have started to pay certain specialists for on-call coverage and, in some cases, compensate physicians for services provided to uninsured emergency patients to ensure adequate coverage and reduce diversions.
• Many hospitals have appointed "bed czars" to expedite patient flow through the hospital. Other strategies to speed bed turnover include improving housekeeping procedures to make sure newly vacated rooms are prepared quickly for incoming patients and adding new space for discharged patients to wait for transportation, allowing them to leave their rooms.
• Improved community coordination and oversight have helped stem diversions by improving communication across hospitals. Most of the 12 communities have updated or developed guidelines to define how long diversions can last, the types of patients or conditions deemed off limits from diversions and the type of capacity limitations that warrant diversions.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by The Robert Wood Johnson Foundation and affiliated with Mathematica Policy Research, Inc.