Marin independent journal
March 13, 2007

Guest Editorial

Why hospital diversions occur

Drs. Jeffrey Dietz and William Teufel

An  IJ article described the increasing amount of "ambulance diversion" that has been occurring in Marin in the past two years (Jan. 14). We are writing to help residents understand what ambulance diversion means and the factors that cause "ambulance diversion."

As background information, emergency medical services field personnel, under normal circumstances use protocols developed by the Marin County EMS office, in conjunction with emergency medical services provider agencies and hospitals, to take patients to hospitals that are appropriate for the patient's medical condition.

In Marin, all three acute-care hospitals can provide definitive care for most conditions. In most cases, that means hospital destination is determined by geographic considerations or by patient choice. When particular patient problems would benefit by treatment at a facility with special resources, county policy directs patients to such hospitals. The following examples apply: trauma patients and patients who are in labor.

Ambulance diversion, also established by written county emergency medical services policy, occurs when a hospital temporarily does not have the capability to care for particular patients. We can all understand the following analogous situation: if weather conditions become adverse, airports will redirect arriving planes to alternative destinations. The safety of the passengers and crews is paramount. Similarly, when a specific hospital temporarily has limited resources, it is in the patient's interest to be taken to a hospital that has the appropriate resources.

Often, the cause for ambulance diversion is equipment failure. For instance, when a patient in the field exhibits stroke symptoms, that patient ordinarily can be taken to any of Marin's hospitals. However, should a hospital's CT scanner (the key diagnostic test needed for such patients) be inoperable, the patient is diverted to a facility with an operable CT scanner. Patients felt not to need immediate CT scanning are not diverted.

The condition that raises the greatest concern is ambulance diversion based on "emergency department saturation." Saturation is the term used in our county's EMS policy. The rest of the country is using a more graphic term, "ED crowding." This is relatively new in Marin, but is a growing national concern.

The rationale for this type of diversion is the same: if an emergency department is so impacted, then it is in the patient's best interest to be taken elsewhere. We are fortunate that such alternate destinations are in close proximity in our county.

It is important to know that even when on "ambulance saturation diversion," the emergency department continues to function, caring for patients who already are there and those who arrive by private auto, and that even while on saturation diversion, an emergency department must continue to accept certain ambulance patients, as defined by Marin County policy.

In a landmark report in July 2006, the Institute of Medicine, a federally sponsored think tank, discussed the issue of emergency department overcrowding and ambulance diversion.

The institute reported that a large percentage of hospitals go on diversion, and those diversions are a symptom of emergency department crowding. The causes of emergency department crowding are complex and the situation is symptomatic of inadequacies endemic to our entire health-care delivery system. Nationally, while ED visits have gone up significantly in the past 10 years, the number of emergency departments has decreased. The emergency department is the only access for care for an increasing number of both insured and uninsured patients, who often are unable to find an available primary care provider.

On the other side of the spectrum, as our population ages, patients arrive with ever more complex medical problems and with an increased number of emergency department visits. While our hospitals strive to operate more efficiently, our health-care system will need significant modification in order to fully address the challenging issues that cause emergency department saturation, and thus to reduce the number of ambulance of diversions, which are only a partial solution to this problem.

Until that occurs, emergency medical services and hospital personnel will work together to ensure that diversions are occurring in an appropriate fashion and serve to improve the care of patients during periods of limited resources at any of Marin's acute-care hospitals.

Jeffrey Dietz, M.D., is chief of Emergency Medicine at Marin General Hospital. William Teufel, M.D., is medical director of Emergency Medical Services for Marin County.