Crowding Out Care: Overburdened Emergency Departments Could Hurt Patients by Diverting Ambulance Traffic

Across the nation, hospital emergency departments are struggling with the issues of overcrowding and understaffing. For many emergency departments, resources are strained to the point where they cannot keep up with patient demand. This could potentially pose a major issue if, for example, patients receiving insurance under the Affordable Care Act increase their use of emergency services.

Ambulance diversion represents one unfortunate spillover effect of overcrowded, understaffed hospitals. During ambulance diversion, an emergency department is closed temporarily, and ambulance traffic is diverted to neighboring hospitals.

When a local emergency department goes on ambulance diversion, patients could face critical delays in treatment that could negatively affect their chances of survival. Even if another emergency department can see patients in a reasonable amount of time, the patients may still have to bear an additional burden. If patients are transferred to emergency departments without the appropriate medical technology and resources to treat them, they might receive substandard care. Lower quality care could impact patients’ long-term health as a result.

A recent study in Health Affairs by Yu-Chu Shen and Renee Hsia examined data from California to better understand the effects of ambulance diversion on patients. They studied the effects of diversion on patients’ access to care, the quality of care they received, and their overall health outcomes. The team examined over 10 years (2001-2011) of Medicare claims, with geographic information on the driving distance between each patient and the nearest emergency department.

Next, the team looked at ambulance diversion logs to determine the number of hours that the emergency departments closest to each patient spent diverting patients on the day they were supposed to be admitted. The team then examined the emergency department to which each patient was eventually admitted, determining if it had appropriate medical technology and resources to treat the patient. Finally, Shen and Hsia determined whether each patient was readmitted to the hospital or died following discharge from the hospital.

Overall, patients facing high rates of ambulance diversion received lower quality treatment and had significantly higher mortality rates than those who were not diverted. The researchers attributed these results to the fact that patients who were diverted were more likely to be admitted to emergency departments without the proper technology to treat them. Compared to patients who were not diverted, patients whose emergency departments were on diversion for more than 12 hours on the day of admission were 4.3 percent less likely to be admitted to a hospital with a cardiac care intensive unit and 3.5 percent less likely to be admitted to one that could perform coronary artery bypass graft (CABG) surgery. They were, in turn, 4.6 percent less likely to receive catheterization treatment for heart attacks. Due in part to these issues with available technology and treatment, these patients saw a 9.8 percent increase in mortality within a year of discharge.

Further, even when comparing patient outcomes across facilities that have similar levels of medical technology, patients facing high ambulance diversion still had significantly higher mortality rates. The authors did not find that patients received lower levels of treatment if facilities had similar technology and resources, but high-diversion patients still saw an 8.2 percent increase in mortality relative to those who were not diverted.

This study concludes that delays and resource constraints associated with ambulance diversion have a significant impact on long-term patient outcomes. The authors note that the effects on mortality associated with diversion are larger than most clinical or pharmacological interventions, suggesting that broader systemic factors can impact patients almost as much as the care that is actually provided. Shen and Hsia argue that negative effects of diversion could be remedied through policies that, for example, guarantee that a patient suffering from a heart attack be diverted to a hospital that has the technology necessary to provide treatment. However, the study shows that time delays from diversion are still costly, even if the patients receive the treatment they need.

Patients living near overburdened hospitals might face access and treatment challenges that could affect them in critical situations. Without addressing broader staffing and technology issues that impact the need for ambulance diversion, patients will continue to be left out in the cold.

Article Source: Ambulance Diversion Associated With Reduced Access To Cardiac Technology And Increased One-Year Mortality, Shen and Hsia, Health Affairs, August 2015, 34(8): 1273-1280.

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