Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban.

BACKGROUND: The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts' 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED). METHODS: We obtained Medicare Fee for Service claims records (2007-2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients ("reference ED"). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients ("safety-net ED"). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states. RESULTS: Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (- 2.7 percentage point; 95% CI, - 4.5 to - 1.0) and Black (- 4.1 percentage point; 95% CI, - 6.2 to - 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, - 2.3 to - 0.2). CONCLUSION: Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination.

The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: A retrospective cohort study.

OBJECTIVE: Ambulance-based secondary telephone triage systems have been established in ambulance services to divert low-acuity cases away from emergency ambulance dispatch. However, some low-acuity cases still receive an emergency ambulance dispatch following secondary triage. To date, no evidence exists identifying whether these cases required an emergency ambulance. The aim of this study was to investigate whether cases were appropriately referred for emergency ambulance dispatch following secondary telephone triage. METHODS: A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch in Melbourne, Australia following secondary telephone triage between September 2009 and June 2012. Appropriateness was measured by assessing the frequency of advanced life support (ALS) treatment by paramedics, and paramedic transport to hospital. RESULTS: There were 23,696 cases included in this study. Overall, 54% of cases received paramedic treatment, which was similar to the state-wide rate for emergency ambulance cases (55.5%). All secondary telephone triage cases referred for emergency ambulance dispatch had transportation rates higher than all metropolitan emergency ambulance cases (82.2% versus 71.1%). Two-thirds of the cases that were transported were also treated by paramedics (66.5%), and 17.7% of cases were not transported to hospital by ambulance following paramedic assessment. CONCLUSIONS: Overall, the cases returned for emergency ambulance dispatch following secondary telephone triage were appropriate. Nevertheless, the paramedic treatment rates in particular indicate a considerable rate of overtriage requiring further investigation to optimize the efficacy of secondary telephone triage.

Ambulance diversions following public hospital emergency department closures.

OBJECTIVE: To examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs private. DATA SOURCES/STUDY SETTING: Ambulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California's Office of Statewide Health Planning and Development and the American Hospital Association (2007). STUDY DESIGN: We match public and private (nonprofit or for-profit) hospitals by distance and size. We use random-effects models examining diversion probability and timing of private hospitals following diversions by neighboring public vs matched private hospitals. DATA COLLECTION/EXTRACTION METHODS: N/A. PRINCIPAL FINDINGS: Hospitals are 3.6 percent more likely to declare diversions if neighboring diverting hospitals are public vs private (P < 0.001). Hospitals declaring diversions have lower ED occupancy (P < 0.001) after neighboring public (vs private) hospitals divert. Hospitals have 4.2 percent shorter diversions if neighboring diverting hospitals are public vs private (P < 0.001). When the neighboring hospital ends its diversion first, hospitals terminate diversions 4.2 percent sooner if the neighboring hospital is public vs private (P = 0.022). CONCLUSIONS: Sample hospitals respond differently to diversions by neighboring public (vs private) hospitals, suggesting that these hospitals might be strategically declaring ambulance diversions to avoid treating low-paying patients served by public hospitals.

Effects of Real-time EMS Direction on Optimizing EMS Turnaround and Load-balancing Between Neighboring Hospital Campuses.

Background: Implemented in September 2017, the "nurse navigator program" identified the preferred emergency department (ED) destination within a single healthcare system using real-time assessment of hospital and ED capacity and crowding metrics. Objective: The primary objective of the navigator program was to improve load-balancing between two closely situated emergency departments, both of which feed into the same inpatient facilities of a single healthcare system. A registered nurse in the hospital command center made real-time recommendations to emergency medical services (EMS) providers via radio, identifying the preferred destination for each transported patient based on such factors as chief complaint, ED volume, and waiting room census. The destination decision was made via the utilization of various real-time measures of health system capacity in conjunction with existing protocols dictating campus-specific clinical service availability. The objective of this study was to evaluate the efficacy of this real-time ambulance destination direction program as reflected in changes to emergency medical services (EMS) turnaround time and the incidence of intercampus transports. Methods: A before-and-after time series was performed to determine if program implementation resulted in a change in EMS turnaround time or incidence of intercampus transfers. Results: Implementation of the nurse navigator program was associated with a statistically significant decrease in EMS turnaround times for all levels of dispatch and transport at both hospital campuses. Intercampus transfers also showed significant improvement following implementation of the intervention, although this effect lagged behind implementation by several months. Conclusion: A proactive approach to EMS destination control using a nurse navigator with access to real-time hospital and ED capacity metrics appears to be an effective method of decreasing EMS turnaround time.

A review on ambulance offload delay literature.

Ambulance offload delay (AOD) occurs when care of incoming ambulance patients cannot be transferred immediately from paramedics to staff in a hospital emergency department (ED). This is typically due to emergency department congestion. This problem has become a significant concern for many health care providers and has attracted the attention of many researchers and practitioners. This article reviews literature which addresses the ambulance offload delay problem. The review is organized by the following topics: improved understanding and assessment of the problem, analysis of the root causes and impacts of the problem, and development and evaluation of interventions. The review found that many researchers have investigated areas of emergency department crowding and ambulance diversion; however, research focused solely on the ambulance offload delay problem is limited. Of the 137 articles reviewed, 28 articles were identified which studied the causes of ambulance offload delay, 14 articles studied its effects, and 89 articles studied proposed solutions (of which, 58 articles studied ambulance diversion and 31 articles studied other interventions). A common theme found throughout the reviewed articles was that this problem includes clinical, operational, and administrative perspectives, and therefore must be addressed in a system-wide manner to be mitigated. The most common intervention type was ambulance diversion. Yet, it yields controversial results. A number of recommendations are made with respect to future research in this area. These include conducting system-wide mitigation intervention, addressing root causes of ED crowding and access block, and providing more operations research models to evaluate AOD mitigation interventions prior implementations. In addition, measurements of AOD should be improved to assess the size and magnitude of this problem more accurately.

Is Inpatient Volume Or Emergency Department Crowding A Greater Driver Of Ambulance Diversion?

Inpatient volume has long been believed to be a contributing factor to ambulance diversion, which can lead to delayed treatment and poorer outcomes. We examined the extent to which both daily inpatient and emergency department (ED) volumes at specified hospitals, and diversion levels (that is, the number of hours ambulances were diverted on a given day) at their nearest neighboring hospitals, were associated with diversion levels in the period 2005-12. We found that a 10 percent increase in patient volume was associated with a sevenfold greater increase in diversion hours when the volume increase occurred among inpatients (5 percent) versus ED visitors (0.7 percent). When the next-closest ED experienced mild, moderate, or severe diversion, the study hospital's diversion hours increased by 8 percent, 23 percent, and 44 percent, respectively. These findings suggest that efforts focused on managing inpatient volume and flow might reduce diversion more effectively than interventions focused only on ED dynamics.

Closure simulation for reduction of emergency patient diversion: a discrete agent-based simulation approach to minimizing ambulance diversion.

BACKGROUND: The city of Munich uses web-based information system IVENA to promote exchange of information regarding hospital offerings and closures between the integrated dispatch center and hospitals to support coordination of the emergency medical services. Hospital crowding resulting in closures and thus prolonged transportation time poses a major problem. An innovative discrete agent model simulates the effects of novel policies to reduce closure times and avoid crowding. METHODS: For this analysis, between 2013 and 2017, IVENA data consisting of injury/disease, condition, age, estimated arrival time and assigned hospital or hospital-closure statistics as well as underlying reasons were examined. Two simulation experiments with three policy variations are performed to gain insights on the influence of diversion policies onto the outcome variables. RESULTS: A total of 530,000+ patients were assigned via the IVENA system and 200,000+ closures were requested during this time period. Some hospital units request a closure on more than 50% of days. The majority of hospital closures are not triggered by the absolute number of patient arrivals, but by a sudden increase within a short time period. Four of the simulations yielded a specific potential for shortening of overall closure time in comparison to the current status quo. CONCLUSION: Effective solutions against crowding require common policies to limit closure status periods based on quantitative thresholds. A new policy in combination with a quantitative arrival sensor system may reduce closing hours and optimize patient flow.

Impact Of Ambulance Diversion: Black Patients With Acute Myocardial Infarction Had Higher Mortality Than Whites.

This study investigated whether emergency department crowding affects blacks more than their white counterparts and the mechanisms behind which this might occur. Using a nonpublic database of patients in California with acute myocardial infarction between 2001 and 2011 and hospital-level data on ambulance diversion, we found that hospitals treating a high share of black patients with acute myocardial infarction were more likely to experience diversion and that black patients fared worse compared to white patients experiencing the same level of emergency department crowding as measured by ambulance diversion. The ninety-day and one-year mortality rates among blacks exposed to high diversion levels were 2.88 and 3.09 percentage points higher, respectively, relative to whites, representing a relative increase of 19 percent and 14 percent for ninety-day and one-year death, respectively. Interventions that decrease the need for diversion in hospitals serving a high volume of blacks could reduce these disparities.

A Full-Capacity Protocol Allows for Increased Emergency Patient Volume and Hospital Admissions.

PROBLEM: Our hospital was encountering problems with ED crowding. We sought to determine the impact of implementing a full-capacity protocol to respond to anticipated or actual crowding conditions. Our full-capacity protocol is based on collaboration among multiple hospital units. METHODS: We completed a quality improvement initiative using a pre/post analysis of all ED patient encounters after implementing a full-capacity protocol with a corresponding period from the prior year. The principal outcomes measured were patient volume, admission rate, patient left without being seen (LWBS) rate, length of stay, and ambulance diversion hours. RESULTS: In the post-full-capacity protocol period, a 7.4% increase in emergency patient encounters (P < .001) and an 11.9% increase in admissions (P < .001) were noted compared with the corresponding period in 2013. Also noted in the study period were a 10.2% decrease in LWBS rate (P = .29), an increase in length of stay of 34 minutes (P < .001), and a 92% decrease in ambulance diversion hours (111 fewer hours, P < .001). IMPLICATIONS FOR PRACTICE: The collaborative full-capacity protocol was effective in reducing LWBS and ambulance diversion, while accommodating a significant increase in ED volume and increased hospital admission rates at our institution.

Cleveland hospitals increase capacity, hire additional staff to help end ambulance diversion.

With pressure from EMS to curb ambulance diversion, the four hospital systems serving metropolitan Cleveland have made a pact to bring diversion to an end. The agreement is voluntary, but all sides were determined to make the ban on diversion stick as of mid-February 2016. To get there, the health systems are increasing capacity, adding staff, and taking steps to tackle deeper hospital throughput issues. In 2015, reports noted that University Hospitals logged more than 550 hours on diversion, and MetroHealth closed its doors to new ambulance traffic for more than 400 hours. The Cleveland Clinic went on diversion for only 10 hours last year. To prepare for the ban on diversions, MetroHealth is adding more inpatient and ED beds, and it is also hiring additional staff. University Hospitals is taking similar steps while also building on the success of its medical access clinic, a lower-cost setting where patients can be screened, stabilized, and connected with primary care for future low-acuity needs. Hanging over the effort in Cleveland: Voluntary efforts to ban ambulance diversion in Boston failed repeatedly. However, once regulators mandated a ban on diversion statewide in 2009, the hospitals all fell into line with few signs of any adverse consequences. The city has now operated diversion-free for seven years.

Do patients hospitalised in high-minority hospitals experience more diversion and poorer outcomes? A retrospective multivariate analysis of Medicare patients in California.

OBJECTIVE: We investigated the association between crowding as measured by ambulance diversion and differences in access, treatment and outcomes between black and white patients. DESIGN: Retrospective analysis. SETTING: We linked daily ambulance diversion logs from 26 California counties between 2001 and 2011 to Medicare patient records with acute myocardial infarction and categorised patients according to hours in diversion status for their nearest emergency departments on their day of admission: 0, <6, 6 to <12 and ≥ 12 h. We compared the amount of diversion time between hospitals serving high volume of black patients and other hospitals. We then use multivariate models to analyse changes in outcomes when patients faced different levels of diversion, and compared that change between black and white patients. PARTICIPANTS: 29,939 Medicare patients from 26 California counties between 2001 and 2011. MAIN OUTCOME MEASURES: (1) Access to hospitals with cardiac technology; (2) treatment received; and (3) health outcomes (30-day, 90-day, and 1-year death and 30-day readmission). RESULTS: Hospitals serving high volume of black patients spent more hours in diversion status compared with other hospitals. Patients faced with the highest level of diversion had the lowest probability of being admitted to hospitals with cardiac technology compared with those facing no diversion, by 4.4% for cardiac care intensive unit, and 3.4% for catheterisation laboratory and coronary artery bypass graft facilities. Patients experiencing increased diversion also had a 4.3% decreased likelihood of receiving catheterisation and 9.6% higher 1-year mortality. CONCLUSIONS: Hospitals serving high volume of black patients are more likely to be on diversion, and diversion is associated with poorer access to cardiac technology, lower probability of receiving revascularisation and worse long-term mortality outcomes.

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study.

BACKGROUND: Reconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence - with regard to 'early neurosurgery' in this cohort - which we sought to address. METHODS: Pilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). PRIMARY OUTCOMES: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. 'Open-label' secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions. RESULTS: Overall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%; p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury. CONCLUSIONS: Current NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating 'early neurosurgery through bypass' and address the challenge of reliable TBI diagnosis at the scene of injury. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68087745. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care.

BACKGROUND: Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. OBJECTIVES: To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED. METHODS: This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis. RESULTS: In the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU. CONCLUSIONS: Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.

A Successful Model for a Comprehensive Patient Flow Management Center at an Academic Health System.

This article reports on an innovative approach to managing patient flow at a multicampus academic health system, integrating multiple services into a single, centralized Patient Flow Management Center that manages supply and demand for inpatient services across the system. Control of bed management was centralized across 3 campuses and key services were integrated, including bed management, case management, environmental services, patient transport, ambulance and helicopter dispatch, and transfer center. A single technology platform was introduced, as was providing round-the-clock patient placement by critical care nurses, and adding medical directors. Daily bed meetings with nurse managers and charge nurses drive action plans. This article reports immediate improvements in the first year of operations in emergency department walkouts, emergency department boarding, ambulance diversion, growth in transfer volume, reduction in lost transfers, reduction in time to bed assignment, and bed turnover time. The authors believe theirs is the first institution to integrate services and centralize bed management so comprehensively.

The Impact of Ambulance and Patient Diversion on Crowdedness of Multiple Emergency Departments in a Region.

Emergency department (ED) overcrowding threatens healthcare quality. Ambulance diversion (AD) may relieve ED overcrowding; however, diverting patients from an overcrowded ED will load neighboring EDs with more patients and may result in regional overcrowding. The purpose of this study was to evaluate the impact of different diversion strategies on the crowdedness of multiple EDs in a region. The importance of regional coordination was also explored. A queuing model for patient flow was utilized to develop a computer program for simulating AD among EDs in a region. Key parameters, including patient arrival rates, percentages of patients of different acuity levels, percentage of patients transported by ambulance, and total resources of EDs, were assigned based on real data. The crowdedness indices of each ED and the regional crowdedness index were assessed to evaluate the effectiveness of various AD strategies. Diverting patients equally to all other EDs in a region is better than diverting patients only to EDs with more resources. The effect of diverting all ambulance-transported patients is similar to that of diverting only low-acuity patients. To minimize regional crowdedness, ambulatory patients should be sent to proper EDs when AD is initiated. Based on a queuing model with parameters calibrated by real data, patient flows of EDs in a region were simulated by a computer program. From a regional point of view, randomly diverting ambulatory patients provides almost no benefit. With regards to minimizing the crowdedness of the whole region, the most promising strategy is to divert all patients equally to all other EDs that are not already crowded. This result implies that communication and coordination among regional hospitals are crucial to relieve overall crowdedness. A regional coordination center may prioritize AD strategies to optimize ED utility.

Routing Ambulances to Designated Centers Increases Access to Stroke Center Care and Enrollment in Prehospital Research.

BACKGROUND AND PURPOSE: Emergency medical services routing of patients with acute stroke to designated centers may increase the proportion of patients receiving care at facilities meeting national standards and augment recruitment for prehospital stroke research. METHODS: We analyzed consecutive patients enrolled within 2 hours of symptom onset in a prehospital stroke trial, before and after regional Los Angeles County Emergency Medical Services implementation of preferentially routing patients with acute stroke to approved stroke centers (ASCs). From January 2005 to mid-November 2009, patients were transported to the nearest emergency department, whereas from mid-November 2009 to December 2012, patients were preferentially transported to first 9, and eventually 29, ASCs. RESULTS: There were 863 subjects enrolled before and 764 after emergency medical service preferential routing, with implementation leading to an increase in the proportion cared for at an ASC from 10% to 91% (P<0.0001), with a slight decrease in paramedic on-scene to emergency department arrival time (34.5 [SD, 9.1] minutes versus 33.5 [SD, 10.3] minutes; P=0.045). The effects of routing were immediate and included an increase in proportion of receiving ASC care (from 17% to 88%; P<0.001) and a greater number of enrollments (18.6% increase) when comparing 12 months before and after regional stroke system implementation. CONCLUSIONS: The establishment of a regionalized emergency medical services system of acute stroke care dramatically increased the proportion of patients with acute stroke cared for at ASCs, from 1 in 10 to >9 in 10, with no clinically significant increase in prehospital care times and enhanced recruitment of patients into a prehospital treatment trial. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.