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Policy Innovation Profile

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital


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Snapshot

Summary

In 2009, the Massachusetts Department of Public Health became the first State to ban ambulance diversions—a practice in which a crowded emergency department temporarily stops accepting patients who are transported by ambulance, instead sending them to other nearby emergency departments. To make implementation of the ban as smooth as possible, the Department of Public Health gave hospitals 6 months advance notice, provided general guidance on how hospitals could improve overall patient flow (thereby reducing crowding), and offered administrators frequent opportunities to ask questions and seek guidance on implementation. Despite fears that the ban would lead to increased emergency department crowding and ambulance delays, the steps hospitals took to improve patient flow in the wake of the ban prevented such problems. At nine Boston-area hospitals, emergency department length of stay for patients subsequently admitted to the hospital fell, as did ambulance turnaround time (i.e., how long the ambulance spends at the hospital before returning to service). Emergency department leaders strongly support the ban, believing it has improved patient care, strengthened relationships among health care staff, and increased patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of length of stay for patients in the emergency department and ambulance turnaround times, along with post-implementation feedback from emergency department leaders about their impressions of the impact of the ban.
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Developing Organizations

Massachusetts Department of Public Health
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Use By Other Organizations

In King County, WA, 18 emergency departments voluntarily agreed to halt diversions in 2011.

Date First Implemented

2009

Problem Addressed

Although many hospitals use ambulance diversion on a regular basis, experts believe the practice does little to reduce crowding, and research suggests it has negative consequences. Consequences include increased risk of delayed care and poor patient outcomes.
  • A common practice: Roughly 45 percent of hospitals and almost 70 percent of urban hospitals used ambulance diversion in 2003.1 An estimated 501,000 ambulances were diverted that year, equivalent to one ambulance being diverted every minute of every day.1 Prior to implementation of the Massachusetts ban, ambulance diversion was common throughout the State. For example, in 2007, Boston-area emergency departments (EDs) collectively spent 2,855 hours on diversion, a sixfold increase from a decade earlier.2 
  • An ineffective tool: Many emergency medicine experts believe that diversion is a short-sighted way to reduce hospital and ED crowding. They argue that such crowding typically results from a lack of inpatient capacity (to handle ED patients who need to be admitted), which in turn is driven by hospital-wide operational inefficiencies. As a result, patients end up being "boarded" in the ED until an inpatient bed becomes available.3 In other words, ambulance diversion is only a temporary solution and does nothing to address the underlying causes of ED and hospital crowding.
  • Negative consequences: Diversion has been associated with a number of negative consequences, including delays in patients receiving needed care,4 poor outcomes for trauma5 and heart attack patients,6 and reduced morale among ED staff who do not like turning away patients.7

What They Did

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Description of the Innovative Activity

In 2009, the Massachusetts Department of Public Health (hereafter referred to as "the Department") banned ambulance diversions, making it the first State to do so. To facilitate implementation of the ban, the Department gave hospitals 6 months advance notice, provided general guidance on how to improve overall patient flow, and offered administrators frequent opportunities to ask questions and seek advice. A detailed description of the diversion ban and related implementation support follows:
  • Announcement and description of ban: The Department announced the ban in a July 3, 2008, letter from its commissioner to the chief executive officers of the 78 hospitals in the State with EDs. The start date for the ban (January 1, 2009) was chosen to give hospitals 6 months to prepare for its implementation. The letter stated that exceptions to the ban would be granted only when a hospital's ED status is "code black," meaning it is closed to all patients due to an internal emergency such as a fire, chemical or other environmental contamination, or flooding. (A code black is rare, occurring roughly 10 to 15 times per year in the entire State and usually lasting only several hours, depending on the reason.) The letter also explained that hospitals could continue to issue capacity-related advisories to emergency medical service (EMS) systems to allow them to make decisions in the best interest of patient care. For example, a hospital could inform an EMS system that a computed tomography scan is not available due to a sudden staffing problem, which might lead EMS personnel to transport a patient in need of such a scan to a different ED. The letter also provided background on the rationale behind the ban and a list of resources to help in implementing the policy, including a previously distributed description of best practices for reducing ED and hospital crowding (as described in more detail in the Context of the Innovation section below). 
  • Advice and guidance focused on improving patient flow: The Department advised hospitals to view the problem of boarding patients as a hospital-wide rather than an ED-specific problem. Accordingly, the Department suggested that hospitals thoroughly review all internal operations to identify ways to move patients out of the ED faster, including new policies, strategies, and other system changes to improve patient flow. The Department asked hospitals to document improvements whenever possible. The Department also recommended that hospitals move ED patients who require inpatient admission out of the ED within 30 minutes whenever the ED reaches or exceeds its licensed capacity. Rather than requiring specific changes to achieve this goal, the Department chose to let each hospital devise the best solutions for its unique circumstances. The Department then reviewed each hospital's improvement plan, either approving it or requiring modification. Examples of innovative changes hospitals made in response to this directive follow:
    • Establishing a 10-bed "surge pod" on the inpatient unit to care for boarded ED patients and an associated protocol for activating use of this pod
    • Using nontraditional spaces to board ED patients, such as a postanesthesia care unit and a postprocedure unit used during off hours (i.e., when procedures are not being performed)
    • Increasing the frequency of inpatient bed rounding from once to twice a day
    • Drawing blood for laboratory testing earlier in the morning so results are available earlier in the day, allowing physicians to make more timely treatment decisions
    • Creating "floating pools" of backup physicians and nurses who can be called in during staffing shortages
    • Hiring nurse practitioners to assist with inpatient discharges
    • Using a real-time electronic inpatient bed capacity dashboard to increase awareness of potential crowding
    • Creating a "priority alert" that expedites the movement of admitted patients to an inpatient bed
    • Implementing an admission/discharge/transfer center run by a senior nurse with the help of the admitting office and a physician who serves as "bed czar"
  • Conference calls and one-on-one communication to support implementation: In the weeks leading up to the ban's implementation, the Department's Boarding and Patient Flow Task Force held a series of weekly conference calls in which hospital administrators could discuss concerns with Department leaders and peers. These calls continued for several weeks after implementation. In addition, administrators could contact a task force member via an 800 number to discuss implementation issues one on one. Administrators found these conference calls and one-on-one conversations to be effective ways to learn about innovative steps other hospitals were taking that could be adapted for their own use.

Context of the Innovation

The Massachusetts Department of Public Health oversees public health in the State, including issues such as emergency preparedness and health care quality at hospitals. The impetus for the ban on diversions came from a longstanding concern about the potential negative effects of ambulance diversions in Massachusetts. In 1999, the Department established the Boarding and Diversion Task Force. Consisting of physicians, nurses, administrators, and EMS personnel, this task force studied the topic and developed and distributed best practices to help hospitals improve patient flow and develop alternatives to diversion. As a result, some Massachusetts hospitals voluntarily implemented measures to improve patient flow and conducted tests of diversion bans, including a 6-month trial in six towns in southeastern Massachusetts in 2005 and a 2-week trial by a consortium of Boston teaching hospitals in October 2006.8 However, ambulance diversion remained common at most hospitals in the State. In 2007, a new Department commissioner expressed interest in exploring new approaches to the issue. He reactivated the task force, which began meeting with a broad coalition that included Department officials, leaders of professional organizations, hospital administrators, and ED physicians, with the goal of finding a permanent statewide solution. In 2009, the task force was renamed the Boarding and Patient Flow Task Force in 2009 to reflect its emphasis on patient flow.

Did It Work?

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Results

Despite fears that the ban would lead to increased ED crowding and ambulance delays, the steps hospitals took to improve patient flow in the wake of the ban prevented such problems. At nine Boston-area hospitals, ED length of stay (LOS) for patients admitted to the hospital fell, as did ambulance turnaround time. ED leaders strongly support the ban, believing it has improved patient care, strengthened relationships among health care staff, and increased patient satisfaction.
  • Shorter ED LOS for admitted patients: Median monthly LOS in the ED for patients subsequently admitted to the hospital at nine Boston-area EDs fell by 10.4 minutes (from 323.2 to 312.8) in the first year after implementation of the ban. For these patients, median monthly ED LOS includes time spent in the waiting room, being treated, and waiting to be admitted to a hospital bed. The decline occurred in spite of an increase in ED volume, which was driven by factors unrelated to the ban. During the same time period, median monthly ED LOS for patients discharged from the ED (i.e., not admitted to the hospital) remained essentially the same. This measure includes time spent in the waiting room and being treated in the ED.9
  • Faster ambulance turnaround time: Average ambulance turnaround time fell by 2.2 minutes (from 27.2 to 25 minutes).9 This improvement is particularly noteworthy given that some EMS leaders feared ambulances would be forced to spend more time outside crowded EDs waiting for patients to be transferred from an ambulance to a stretcher, which in turn would delay their ability to return to service and respond to the next emergency.
  • Strong support from ED leaders: Interviews with 18 ED leaders (7 directors, 2 physicians, and 9 registered nurse leaders) at nine hospitals (six of which were the same as those used in the quantitative study described above) found strong support for the diversion ban.7 All respondents described some positive effects from the ban, including several who previously supported diversion and feared that its removal would increase ED crowding. Many respondents said the ban had improved quality of care, strengthened relationships between and among health care staff (e.g., ED and hospital staff, hospital administrators, EMS workers), and increased patient satisfaction.7 Representative comments follow:
    • "Decisions on whether to go on diversion used to take up a significant amount of provider time that is now dedicated to patient care."        
    • "The diversion ban has helped to build stronger partnerships [with EMS]. I think we're all working better as a community."
    • "The biggest impact has probably been on collegial relationships among the staff. ... the fact that it [diversion] wasn't there was almost a relief; it was kind of like, great, they can do their work and not be at each other's throats."
    • "Hospitals recognized that ambulance diversion was not only about volume in the ED and took a more proactive role in improving flow throughout the hospital."
    • "It's made a difference for those patients who were circling, looking for a place to land, or landing in the place that wasn't the best for them."

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of length of stay for patients in the emergency department and ambulance turnaround times, along with post-implementation feedback from emergency department leaders about their impressions of the impact of the ban.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Reassessing problem: The task force reviewed recent research on ambulance diversion, finding its use to be on the rise in Boston (as described earlier) and increasingly associated with detrimental patient outcomes.  
  • Deciding to enact ban: In 2007 and 2008, ongoing discussions with task force members convinced Department leaders that banning ambulance diversions was the only way to gain statewide compliance. In June 2008, the task force formally voted to enact the ban in Massachusetts.
  • Extending "grace period" until ban took effect: As noted, the Department announced the ban in July 2008. The ban was originally scheduled to take effect 3 months later, but Department leaders decided to push the start date back 3 additional months after hospital administrators asked for additional time to prepare.

Resources Used and Skills Needed

  • Staffing: Although no formal data are available, some hospitals hired additional staff to help implement measures to improve patient flow, including nurse practitioners, social workers, and physicians, or increased overtime for existing staff.
  • Costs: Expenses associated with improving patient flow include the staffing costs described above, expansion/remodeling of building facilities, purchase and implementation of new technology, and staff time spent developing and implementing new protocols. However, task force leaders believe such costs have been more than offset by the cost savings and additional revenues associated with the ban. For example, hospitals that improve patient flow can now generate additional revenues by handling more patients.

Tools and Other Resources

The National Quality Forum's 2009 National Voluntary Consensus Standards for Emergency Care: A Consensus Report is available at: http://www.qualityforum.org/Publications/2009/09
/National_Voluntary_Consensus_Standards_for_Emergency_Care.aspx
. See Chapter 3: "Phase II: Hospital-Based Emergency Department Care."

Emergency Department Performance Measures and Benchmarking Summit Consensus Statement is available at: http://www.qualityindicators.ahrq.gov/Downloads/Resources/Publications/2006
/EDPerformanceMeasures-ConsensusStatement.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Make change mandatory: Massachusetts' experience with ambulance diversions suggests that voluntary bans are unlikely to lead to permanent or widespread change. By contrast, a mandate from the State health department ensures that all hospitals will stop using diversion and increases the likelihood that they will make needed changes to improve patient flow.
  • Give hospitals leeway: Providing hospitals with detailed instructions on how to improve patient flow may create resentment among staff who perceive that an outside entity unfamiliar with their day-to-day operations is dictating how they should do their jobs. Instead, hospitals should be encouraged and supported in devising their own solutions, making it more likely that staff will both come up with strategies tailored to the specific problems facing the hospital and work diligently to make them succeed.
  • Emphasize preparation and communication: Because eliminating ambulance diversion is a major policy change, hospitals need sufficient time and support in preparing for the ban, including access to resources that can help. Hospital administrators and ED leaders should be given frequent opportunities to discuss any concerns or problems with health department officials and their peers through conference calls and one-on-one conversations.

Sustaining This Innovation

  • Maintain focus on patient flow: Hospitals should keep a close eye on metrics related to patient flow, such as ED LOS for discharged and admitted patients. This information will help them identify and address issues in a timely manner. For example, an increase in the number of ED patients over the age of 65 might prompt a review of hospital discharge processes for patients going to nursing homes, while an increase in ED patients with mental health issues might lead to an examination of how the hospital works with psychiatric facilities.
  • Continue to share information: Although the ban on ambulance diversion has been in place for several years, the task force continues to meet quarterly and to disseminate information to hospital administrators to help them improve patient flow throughout the hospital.

Use By Other Organizations

In King County, WA, 18 emergency departments voluntarily agreed to halt diversions in 2011.

More Information

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Contact the Innovator

Laura G. Burke, MD, MPH
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
One Deaconess Road, W/CC-2
One Deaconess Road, W/CC-2
Boston, MA 02215-5321
(617) 754-2323
E-mail: lgburke@bidmc.harvard.edu

Innovator Disclosures

Dr. Burke reported that she completed an unpaid internship with the Massachusetts Department of Public Health, assisted with review of hospitals' improvement plans, has served on the Department Boarding and Patient Flow Task Force, and has accepted a consulting position for the Department on addressing emergency department crowding.

References/Related Articles

Burke LG, Joyce N, Baker WE, et al. The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time. Ann Emerg Med. 2013;61(3):303-11. [PubMed]

Burke L. Ending ambulance diversion in Massachusetts. Virtual Mentor. 2010;12(6):483-6. [PubMed]

O'Keefe SD, Bibi S, Rubin-Smith JE, et al. "No diversion": a qualitative study of emergency medicine leaders in Boston, MA, and the effects of a statewide diversion ban policy. Ann Emerg Med. 2013 Oct 10 [Epub ahead of print]. Available at: http://www.annemergmed.com/articleS0196-0644%2813%2901348-6/abstract.

The July 2008 letter from the Department of Public Health announcing the ambulance diversion ban is available at: http://www.mass.gov/eohhs/docs/dph/quality/hcq-circular-letters/hospital-general-0807494.pdf.

Footnotes

1 Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47(4):317-26. [PubMed]
2 Massachusetts Department of Public Health. Monthly diversion statistics. Total hours on diversion in Massachusetts hospitals—EMS region by month (July 1, 2002 to November 30, 2008). Available at: http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/healthcare-quality/health-care-facilities/hospitals/ambulance-diversion
/monthly-diversion-statistics.html
.
3 Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-36. [PubMed]
4 Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006;355(13):1300-03. [PubMed]
5 Begley CE, Chang Y, Wood RC, et al. Emergency department diversion and trauma mortality: evidence from Houston, Texas. J Trauma. 2004;57(6):1260-5. [PubMed]
6 Shen YC, Hsia RY. Association between ambulance diversion and survival among patients with acute myocardial infarction. JAMA. 2011;305(23):2440-7. [PubMed]
7 O'Keefe SD, Bibi S, Rubin-Smith JE, et al. "No diversion": a qualitative study of emergency medicine leaders in Boston, MA, and the effects of a statewide diversion ban policy. Ann Emerg Med. 2013 Oct 10 [Epub ahead of print]. Available at: http://www.annemergmed.com/articleS0196-0644%2813%2901348-6/abstract.
8 Friedman FD, Rathlev NK, White L, et al. Trial to end ambulance diversion in Boston: report from the conference of the Boston teaching hospitals consortium. Prehosp Disaster Med. 2011;26(2):122–6. [PubMed]
9 Burke LG, Joyce N, Baker WE, et al. The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time. Ann Emerg Med. 2013;61(3):303-11. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 04, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Laura G. Burke, MD, MPH
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