EMS on the Outside Looking In

The running joke in Las Vegas over the last few years, as a pair of new hospitals were being built, was wondering how long it would take the ambulance diversions to begin once they opened. The punch line, when it came, didn't make anyone laugh.

     "It wasn't days or weeks," says Rory Chetelat, EMS Manager for the Southern Nevada Health District, the public-health body governing the Sin City region. "It was hours."

     Perhaps you can feel Chetelat's pain. ED overcrowding and ambulance diversions are phenomena that have afflicted hospitals and EMS systems across the U.S. In 2003 alone, more than half a million ambulances were diverted nationally--roughly one every minute. Around 45% of EDs have utilized the tactic.

     The problem is worst in large departments that absorb more than 50,000 visits a year. Representing 12% of all EDs, these account for 18% of those that went on diversion, 47% of all hours spent on diversion and 70% of the total ambulances diverted. The patient-flow crunch is felt most acutely in big cities. That's certainly true of Las Vegas, a city in the midst of a rapid-fire population explosion. But almost every major metropolitan area has its own horror stories to tell.

     Increasingly, though, there are other kinds of stories being written--success stories. Using a combination of techniques, a number of metro areas have confronted their diversion problems and reduced, if not eliminated, them. Some have acted with EMS in mind; some have incorporated EMS into their solutions.

     This article looks at the steps taken by five such cities.

Las Vegas: Just Say No
     The most facile answer to stopping ambulance diversions is to simply ban them. Don't give hospitals the option, the thinking goes, and they'll make whatever changes they have to make to keep taking patients.

     A number of U.S. cities have done this, and in some it's worked well. It was a strategy that Las Vegas leaders turned to when previous steps like diversion limits and hospital zones proved insufficient.

     "What we'd had was a one-hour diversion limit per hospital per zone," explains Chetelat. "We had city hospitals divided up into three zones, and no more than one hospital could go down for more than an hour at a time per zone. That basically just became a rotation. Hospital A would go on diversion for their hour, then B would go on for their hour, then C, then we'd be back to A. This had gone on for years, and it was really just passing the buck around."

     With patients losing patience and offload delays at open EDs soaring, Vegas officials proposed a ban on diversion. The hospitals weathered the change, and while the offload times didn't improve, life at least got a bit less aggravating for EMS crews.

     "Did it make things better on the EMS side? Not really," says Chetelat. "The offloads didn't improve substantially. But we had an easier system, because we simply went to the nearest facility or the patient's hospital of choice. People were getting where they needed to be. It was easier on EMS and created a more satisfied customer."

     The diversion/offload balance can be a tricky one. If hospitals don't fix their internal flow problems, banning diversion may simply shift the ED overflow burden to EMS.

     "In some communities that try to ban diversion altogether, it explodes on them," says Mike Williams, president of The Abaris Group, a California-based consulting firm specializing in emergency and outpatient services. "Without mitigating the flow and process side of it, chances are you're just moving the problem to EMS. That's what we're seeing now, in very significant degrees, where offload times have significantly increased."