The end of ER diversions
Thursday, April 28, 2016
The problem of emergency room overcrowding is not new. It creates a chain of failure, particularly when ambulances with critically ill patients aboard — on the ground or in the air — must divert to a secondary hospital, and therefore delay the onset of care.
Diversion often has another unsavory consequence: dropping off insured patients at out-of-network hospitals, subjecting them to sticker shock bills for any work that needed to be done in the facility, but outside the ER. How to best handle this problem has been debated for more than two decades.
Fortunately, more and more hospitals are solving the problem through an intelligent application of analytics, process flow models and some good old-fashioned common sense. ER diversions have not been completely eliminated, but they are far less common.
The problem, in large measure, came from patients using the ER for the purpose it was not intended — a quick fix for maladies best handled by a scheduled visit to the family doctor, walk-in clinic or at worst an urgent care clinic. According to the Centers for Disease Control and Prevention (CDC), in 2010 only 1 in 8 patients who went to an ER actually needed immediate care.
The other problem is an ER must by law treat all comers, including the undocumented and the uninsured, regardless of ability to pay. That makes emergency rooms the first choice for a large part of the impoverished population seeking healthcare.
As early as 1999, the American College of Emergency Physicians (ACEP) established guidelines for ambulance diversion. At that time, ACEP recommended, among other things:
- all hospitals and EMS agencies in the EMS system must have working agreements among themselves
- diversion should occur only after a hospital has exhausted all internal resources, including calling in overtime staff
- when on diversion, hospitals must make every attempt to maximize bedspace, screen elective admissions, and use all available personnel and resources to minimize the length of time on diversion
"Consideration should be given to developing a mechanism for denial of a hospital's request for diversion or for overriding a hospital's diversion status when the EMS physician medical director determines a patient's condition may be jeopardized by bypassing a facility," ACEP also recommended.
As well-meaning as these guidelines are, the contemporary consensus is that the best diversion policy is no diversions at all — particularly with critically ill patients. And the number of diversions has gone down dramatically thanks to these four developments:
- Beefing up emergency departments with more beds and personnel
- Setting up better screening for those 7 in 8 patients who really don't need to be there and referring them to primary care
- Better process flow for triage, lab and X-rays
- More modern IT in the ER
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