The Case Against Diversion

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“It’s like a drug. First, it makes you feel better even though your situation isn’t any different. Second, and worse, it’s addicting.” Chuck Shufflebarger, MD, said this to me about ambulance diversion last summer as I was preparing a talk about concepts in patient flow.

Want to improve patient flow in your ED? Start by killing ambulance diversion.


“It’s like a drug. First, it makes you feel better even though your situation isn’t any different. Second, and worse, it’s addicting.”

Chuck Shufflebarger, MD, said this to me about ambulance diversion last summer as I was preparing a talk about concepts in patient flow. As the Vice Chair for Clinical Affairs at Indiana University and the Medical Director of Methodist Hospital, an 100K+ Level 1 Trauma Center in Indianapolis, Dr. Shufflebarger knows a thing or two about how to run a busy ED.

Ambulance diversion was first reported twenty years ago in New York City to divert patients with minor injuries away1. Fast forward to 2003 when 45% of EDs across the country reported that they had used ambulance diversion at least once during that year2. This same year, Brent Asplin raised the question of “Does ambulance diversion matter?” as a commentary on the underlying causes of ambulance diversion and its concern as a public health problem for patients seeking access to emergency care3.


So, does ambulance diversion matter, and does it make a difference? In Boston, the practice of ambulance diversion in the early part of the last decade led to a domino effect, where the first hospital to go on divert would lead to the next closest one, until all hospitals in the city were closed to ambulances. As a result, they would all open up again, and the same round-robin game would start all over. Realizing the futility in this, a group of EDs in Boston banned the practice of ambulance diversion for two weeks in 2006. The result? It didn’t impact the efficiency of EMS or EDs to deliver care4. Based on these findings, the entire state of Massachusetts banned the practice of ambulance diversion on January 1st, 2009. So far, reports have demonstrated no negative impact from doing so. If Massachusetts can do it, why can’t the rest of the country?

Ambulance diversion is a luxury of EDs in urban settings. For critical access hospitals in rural settings, closing their doors to ambulances would mean additional hours of transport to the next closest hospital. This could be bad for patients and maintaining access to the EMS services that provide for them. Instead of looking to ambulance diversion as a strategy, they make do and adjust to the demands placed on them.

After accepting the concept that diversion is a maladaptive strategy, an ED staff can take the energy away from deciding whether or not to go on diversion and instead focus on how to deal with patients. Looking at trends over time, we can all predict our peaks of patient volume and allocate resources accordingly. Typically, the worst day of the week is Monday. On a daily basis, things tend to start out slow in the morning, pick up during the afternoon and early evening, then die down again after midnight. Instead of closing our doors to the problem, why don’t we embrace the challenge and adapt? Rita Mae Brown said that “Insanity is doing the same thing over and over again, but expecting different results.”

What can we as emergency physicians do within our own EDs to meet the demand? At the front end, a systematic review of the literature has demonstrated having providers up front at triage is a good thing. It leads to shorter lengths of stay (LOS) and door-to-provider times5. Even if you can’t afford to have a provider up front, triage standing orders have been found to reduce LOS for common complaints6. Another option is to adopt a split patient flow model. The EDs of Banner Health in Arizona did this a few years ago. By taking patients with an ESI 3-5 immediately back to an internal waiting room where they are seen by a group of physicians and mid-level providers, patients immediately receive care upon arrival. Because of this, they were able to dramatically reduce their door-to-provider times and elopement rates without having the hospital change a thing on the inpatient side.


Looking to your respective hospitals to solve your ambulance diversion problems is a path leading to despair and perpetual frustration. If hospital administration has to decide between a definitely-insured elective admission and a possibly-insured ED patient, which one do you think they will favor? All calls to serving the public aside, it is not a decision of whether or not they like you, but a sound financial one. Is boarding crippling your capacity to see new patients? Make a compelling financial argument to your hospital that getting these patients upstairs, along with the elective cases, is in their best interests. Peter Viccellio’s Inpatient Full Capacity Protocol7 or Surgical Schedule Smoothing as first implemented in Boston8 are both examples of successful strategies. With these in place, all patients receive better care, not just those in the ED. As the recession proved last year, when elective cases wane, the ED can be counted upon to provide a steady source of admissions. We are the metaphorical bonds in the hospital’s patient investment portfolio. Not always lucrative, but constant through thick and thin.

Therefore, I would like to issue a challenge to EDs across the country. Instead of resorting to our traditional ways of playing the victim, of being persecuted by the rest of the medical community, forced to serve as a safety net for all that is wrong in healthcare, let us embrace the challenge set before us. Let us roll up our sleeves and implement proven strategies and devise creative solutions to meet the growing demand. Who better than an emergency physician can do this? Let us create ways to deliver cost-effective care while the primary care system lags to meet the demand. If healthcare reform progresses to universal coverage, no longer would we be financial albatrosses on the hospital balance sheets. The renaissance of emergency medicine may still lie ahead, and not be a thing of the past.

1. Lagoe RJ, Jastremski MS. Relieving overcrowded emergency departments through ambulance diversion. Hosp Top. 1990;68(3):23-27.
2. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47(4):317-326.
3. Asplin BR. Does ambulance diversion matter? Ann Emerg Med. 2003;41(4):477-480.
4. Friedman F, Rathlev, N., Moyer, P., White, L. A Trial to End Ambulance Diversion In Boston. Acad Emerg Med. 2009;16(4):S151.
5. Rowe BH, Guo X, Villa-Roel C, et al. The Role of Triage Liaison Physicians on Mitigating Overcrowding in Emergency Departments: A Systematic Review. Acad Emerg Med. 2011;18(2):111-120.
6. Retezar R, Bessman E, Ding R, Zeger SL, McCarthy ML. The effect of triage diagnostic standing orders on emergency department treatment time. Annals of Emergency Medicine. 2011;57(2):89-99 e82.
7. Innes G, Grafstein E, Stenstrom, R, Harris D, Hunte G. Impact of an Overcapacity Care Protocol on Emergency Department Overcrowding. Acad Emerg Med. 2007;14(5):S85.
8. McManus ML, Long MC, Cooper A, et al. Variability in surgical caseload and access to intensive care services. Anesthesiology. 2003;98(6):1491-1496.



1 Comment

  1. Unfortunately, I have seen the hospital’s refusal to go on divert literally cost lives.
    Full means FULL. There is no “Rolling up your sleeves” when you literally have no where to put anyone, unless you lay them on the floor. Accepting patients you cannot care for is criminal at best. Often, administrators hide when things go bad and when you can reach them, they tell you “No” to going on divert, while in the comfort of their home.
    There is never a plan for extra help to come in.

    So, how about we fix the problem instead of treating the symptoms ?

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