No diversion in Western Massachusetts.

BACKGROUND: Massachusetts (MA) instituted a moratorium on ambulance diversion ("No Diversion") on January 1, 2009. STUDY OBJECTIVES: Determine whether No Diversion was associated with changes in Emergency Department (ED) throughput measures. DESIGN: Comparison of three 3-month periods. Period 1: 1 year prior (January-March 2008); Period 2: 3 months prior (October-December 2008); Period 3: 3 months after (January-March 2009). SETTING: Seven EDs in Western MA; two - including the only Level I Trauma Center - were "high" diversion (≥562 h/year) and 5 were "low" diversion (≤260 h/year). For "all," "high" diversion and "low" diversion ED groups, we compared mean monthly throughput measures, including: 1) total volume, 2) number of admissions, 3) number of elopements, 4) length of stay for all, admitted and discharged patients. Mean absolute and percent changes were estimated using mixed-effects regression analysis. Linear mixed models were run for "all," "high" and "low" diversion EDs comparing means of changes between periods. Results are presented as mean change per month in number and percent, and 95% confidence intervals were calculated. We specified that a clinically significant effect of No Diversion had to meet two criteria: 1) there was a consistent difference in the means for both the Period 1 vs. Period 3 comparison and the Period 2 vs. Period 3 comparison, and 2) both comparisons had to achieve statistical significance at p ≤ 0.01. RESULTS: According to pre-determined criteria, no clinically significant changes were found in any ED group in mean monthly volume, admissions, elopements, or length-of-stay for any patient disposition group. CONCLUSION: No Diversion was not associated with significant changes in throughput measures in "all," "high" diversion and "low" diversion EDs.

Emergency department patients who stay more than 6 hours contribute to crowding.

BACKGROUND: Admitted and discharged patients with prolonged emergency department (ED) stays may contribute to crowding by utilizing beds and staff time that would otherwise be used for new patients. OBJECTIVES: To describe patients who stay > 6 h in the ED and determine their association with measures of crowding. METHODS: This was a retrospective, observational study carried out over 1 year at a single, urban, academic ED. RESULTS: Of the 96,562 patients seen, 16,017 (17%) stayed > 6 h (51% admitted). When there was at least one patient staying > 6 h, 60% of the time there was at least one additional patient in the waiting room who could not be placed in an ED bed because none was open. The walk-out rate was 0.34 patients/hour when there were no patients staying in the ED > 6 h, vs. 0.77 patients/hour walking out when there were patients staying > 6 h in the ED (p < 0.001). When the ED contained more than 3 patients staying > 6 h, a trend was noted between increasing numbers of patients staying in the ED > 6 h and the percentage of time the ED was on ambulance diversion (p = 0.011). CONCLUSION: In our ED, having both admitted and discharged patients staying > 6 h is associated with crowding.