a b s t r a c t

Ambulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational ineffi- ciencies within our health systems that lead to conditions such as Patient boarding, high waiting room conges- tion, and ambulance diversion. Addressing these inefficiencies has a greater potential impact on ambulance diversion than simply banning or restricting the practice for practical or ethical considerations.

(C) 2015

1. Ambulance Diversion-PRO

In this issue, Geiderman et al [1] have described an ethical construct for evaluation of ambulance diversion by emergency departments (EDs). These authors essentially conclude that ambulance diversion should be avoided under the assumption that the policy violates the eth- ical principles of patient autonomy and beneficence. Although we agree that the best interest of any Patient transported by emergency medical services (EMS) is an important consideration, thoughtful diversion poli- cies can be established that respect both individual autonomy and benef- icence while also honoring the notions of justice and nonmaleficence. In short, any decision to consider ambulance diversion must be undertaken only when the benefits for all ED patients are best served.

Simple Supply and demand dictates the need to consider diversion, typically during periods of high patient volume and high patient acuity. During periods of high ED patient volume when the supply of treatment spaces and inpatient beds are limited, ambulance diversion represents a potential moment to be able to limit the demand on staff and resources. Similarly, during periods of high patient acuity, demands on staff may be significant enough to temporarily limit available ED resources, there- by necessitating diversion. Although it is clear that diversion has a limited role in improving throughput metrics [2,3], the guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the ED as well as those waiting to be seen.

In our experience, diversion is often an undesirable necessity. We believe, however, that a thoughtful diversion policy is possible. In establishing a reasonable diversion policy, it must abide by several important principles.

* Corresponding author at: Department of Emergency Medicine, The Ohio State Univer- sity, 758 Prior Health Sciences Library, 370 West 10th Avenue, Columbus, Ohio 43210. Tel.: +1 614 293 8305.

E-mail address: [email protected] (H.A. Werman).

http://dx.doi.org/10.1016/j.ajem.2015.03.007

0735-6757/(C) 2015

1. The criteria for going on ED diversion must be objective and clearly defined. Although each hospital must establish its own criteria and develop policies and procedures for initiating diversion, these must be transparent to others within the system. Ideally, an objective scoring system such as NEDOCS, EDWIN, or Work Score can be used to drive these decisions [4].
2. Diversion must be time limited and should involve frequent sta- tus reassessment. Several successful systems have established agreed-upon limits while not completely banning ambulance diversion [5].
3. Emergency medical services should be directed to preferentially de- liver patients to other health care institutions within the same health system, if applicable. It has been shown that more coordinated inte- gration of patient flow within a health system reduces ambulance di- version [6].
4. A prospectively agreed-upon policy must exist for situations when multiple institutions must go on to ED diversion. In these situations, the emergency care system should establish appropriate triggers for a system-wide diversion plan that includes appropriate notification of EDs and EMS and have a preestablished plan for equitably distrib- uting patients.
5. The diversion plan must address institutions with unique capabilities for special patient populations such as patients with trauma, patients who had stroke, patients with ST-elevation myocardial infarction, or others. As noted anecdotally in Houston, trauma mortality doubled when trauma centers went on diversion [7].
6. There can be no diversion of patients who are critically unsta- ble. Patients in cardiac arrest, those with a critical airway, or those with Active hemorrhage must be stabilized at the closest available hospital.
7. Finally, a continuous quality improvement process must be in place to review overall system performance as well as address individual patient concerns.

E.J. Adkins, H.A. Werman / American Journal of Emergency Medicine 33 (2015) 820-821 821

Such a system is in place in our region and has been described by other regions as well [8-11]. The successful diversion policy in central Ohio has been coordinated by the Central Ohio Trauma system. Individual hospi- tals are required to develop their own policies and procedures for going on diversion. When multiple hospitals request diversion, city-wide diver- sion is initiated. During this time, EMS traffic is routed to local EDs to en- sure that each institution shares proportionally their Hospital resources.

Although it is important to ponder the ethical implications of diver- sion, we would also argue that such discussion draws attention away from the operational inefficiencies that lead to ED overcrowding and ambulance diversion. Ambulance diversion is simply a surrogate marker for other operational inefficiencies within a health system [12]. Numer- ous factors have led to this problem of ED overcrowding including in- creased demand for emergency services, nursing shortages, limited access of patients to primary care, and decrease in the total number of EDs [13,14]. In addition to ambulance diversion, ED overcrowding has had other important consequences such as increased inpatient mortali- ty, length of stay, and hospital costs [15]. Most significant is the issue of boarding as highlighted in a 2003 General Accounting Office report [16]. Boarding limits the available treatment spaces in an ED and, thus, pro- hibits effective bed use for those waiting to be evaluated [17,18].

Many solutions with a positive impact on ambulance diversion have been proposed such as smoothing of elective surgical cases to include weekends [19], and a short-stay undifferentiated Inpatient unit [20] or ED Observation Units have been tested [21]. Bringing hospital leadership into the discussions is an important facet to effectively reduce opera- tional inefficiencies and reduce diversion [22].

We would argue that improving operational efficiency should be the focus of our discussion on diversion. It has been shown that a 1-hour re- duction of mean Boarding hours in a trauma center would reduce med- ical ambulance diversion by 1.2 hours per day and trauma diversion by

0.7 hours per day day in an urban tertiary care hospital [23]. Another study identified various combinations of ED throughput benchmarks for admitted and discharged patients that would minimize time on am- bulance diversion to less than 3% [24]. Simulations have also shown that additional efficiencies such as fast track, a holding area for admitted pa- tients, an observation unit, and reducing laboratory turnaround time can reduce ambulance diversion up to 24% [25].

Although ambulance diversion is certainly not desired in any EMS environment, a carefully constructed diversion program may be essen- tial to ensure the appropriate care for all patients requiring emergency care. Having such a system in place then allows us to focus on the more pressing issue: operational inefficiencies in the ED.

References

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