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Two Studies Expose Emergency Department Problems

Two recently released studies on ambulance diversion provide an alarming glimpse into the ability of the country's emergency departments (ED) to handle the ever-increasing number of patients who are transported via ambulance to the hospital for emergency treatment. The Annals of Emergency Medicine has published two studies that uncover the extent of ambulance diversion as well as insights about the causes and characteristics of this growing problem.

The first study, conducted by researchers at the U.S. Centers for Disease Control and Prevention (CDC) found nationally that about one ambulance is diverted every minute from its originally intended emergency department. The primary reason for diversion was that the intended ED was overcrowded and could not safely care for another sick or injured patient. That translates into a significant number of patients. According to CDC, about 16.2 million patients arrived by ambulance to emergency departments in 2003 (the last year for which data is available).

Nearly 40 percent of the emergency department ambulance visits were made by patients over the age of 65. And not only were many of the emergency ambulance users older, but they were also sicker. CDC found that nearly 70 percent had medical conditions that were classified as either emergent or urgent and more than a third were ultimately admitted to the hospital. For these patients, minutes can be the difference between life and death, so diversion can have devastating consequences.

CDC found that hospital EDs cited a lack of appropriate beds (51 percent), a high number of ED visits (50 percent) and complexity of ED cases (18 percent) as reasons for diverting ambulances.

The second study on ambulance diversion was conducted by researchers at UCLA and was designed to assess the impact hospital closures have had. Looking at data from a seven-year period, the researchers found that diversions at Los Angeles County hospitals more than tripled between 1998 and 2004. In California the number of hospital emergency departments decreased by 12 percent between 1990 and 1999 at the same time that emergency visits increased by 27 percent.

The UCLA researchers also found that county-operated hospitals spent 150 more hours on diversion, compared with other hospitals. They also reported what they call the "network effect" whereby the number of diversion hours tracked at one hospital was similar to the number of diversion hours at nearby hospitals. This suggests when one hospital goes on diversion, area hospitals become overwhelmed by the increase in incoming ambulances.

The research team at UCLA reached several conclusions based on their findings. First, the increasing number of diversion hours, along with an increased network effect, suggests that ED capacity to absorb future closures is declining. Second, emergency department overcrowding is more likely the result of diminished ED and hospital capacity rather than increased patient demand for emergency medical services.

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