Ambulance Diversion and Offload Delay ED Crowding and the EMS …€¦ · Diversion and Transport...
55
Ambulance Diversion and Offload Delay ED Crowding and the EMS System Derek R. Cooney, MD, FF/NREMT-P, FACEP Associate Professor of Emergency Medicine SUNY Upstate Medical University Syracuse, New York
Transcript of Ambulance Diversion and Offload Delay ED Crowding and the EMS …€¦ · Diversion and Transport...
Am
bula
nce
Div
ersi
on
and
Offl
oad
Del
ay
ED C
row
ding
and
the
EMS
Syst
em
Der
ek R
. Coo
ney,
MD
, FF/
NR
EM
T-P,
FA
CE
PA
ssoc
iate
Pro
fess
or o
f Em
erge
ncy
Med
icin
eS
UN
Y U
psta
te M
edic
al U
nive
rsity
Syr
acus
e, N
ew Y
ork
Dec
lara
tion
•I h
ave
no fi
nanc
ial c
onfli
cts
to re
port.
•I a
m a
mem
ber o
f the
Boa
rd o
f Dire
ctor
s of
the
Nat
iona
l A
ssoc
iatio
n of
EM
S P
hysi
cian
s.
•I a
m a
Med
ical
Dire
ctor
of a
num
ber o
f EM
S a
genc
ies.
•Li
ke e
very
one
else
, I a
m a
pot
entia
l pat
ient
.
Obj
ectiv
es
•D
escr
ibe
wha
t am
bula
nce
dive
rsio
n an
d of
fload
are
and
ho
w th
ey d
iffer
•D
escr
ibe
the
liter
atur
e on
div
ersi
on a
nd o
ffloa
d de
lay
•D
iscu
ss th
e re
latio
nshi
p be
twee
n th
e tw
o
•D
iscu
ss th
e em
ergi
ng im
porta
nce
of A
OD
as
a be
nchm
ark
for E
D q
ualit
y
•D
iscu
ss p
oten
tial s
trate
gies
to d
ecre
asin
g A
OD
Def
initi
ons
Am
bula
nce
dive
rsio
n: re
dire
ctin
g or
lim
iting
des
tinat
ion
of a
n am
bula
nce
carry
ing
a pa
tient
to a
hos
pita
l as
its
dest
inat
ion
Am
bula
nce
offlo
ad d
elay
: th
e tim
e be
twee
n ar
rival
of
an a
mbu
lanc
e, a
nd th
e tim
e th
at th
e pa
tient
is b
oth
(1)
off t
he s
tretc
her a
nd (2
) EM
S re
port
has
been
giv
en
His
toric
al P
rosp
ectiv
e
•A
mbu
lanc
e di
vers
ion
used
to d
ecom
pres
s cr
owde
d E
D b
y di
rect
ing
ambu
lanc
es to
an
ED
with
less
pat
ient
vol
ume
at
the
time
•Fi
rst p
aper
des
crib
ing
succ
ess
was
pub
lishe
d in
199
0 –
Lago
eR
J, J
astre
msk
iMS
. Rel
ievi
ng o
verc
row
ded
emer
genc
y de
partm
ents
thro
ugh
ambu
lanc
e di
vers
ion.
Hos
pita
l Top
ics.
19
90; 6
8 (3
): 23
.•
Mor
e re
cent
ly, d
iver
sion
site
d as
cau
se o
f pat
ient
har
m a
nd
EM
S S
yste
m d
ysfu
nctio
n–
CO
BR
A / E
MTA
LA
DIV
ERSI
ON
LIT
ERAT
UR
E
Am
bula
nce
Div
ersi
on
Lago
eR
J, J
astre
msk
iMS
. Rel
ievi
ng o
verc
row
ded
emer
genc
y de
partm
ents
thro
ugh
ambu
lanc
e di
vers
ion.
H
ospi
tal T
opic
s. 1
990;
68
(3):
23.
–Fi
rst p
aper
to d
escr
ibe
phen
omen
on o
f div
ersi
ons
–U
sed
as a
nov
el w
ay to
dec
ompr
ess
ED
–O
rigin
ally
des
crib
ed fo
r pat
ient
s w
ith
rela
tivel
y m
inor
in
jurie
s.–
ten
adm
itted
pat
ient
s w
ere
awai
ting
inpa
tient
bed
s or
al
l inp
atie
nt m
onito
rs w
ere
in u
se–
3/4
hosp
itals
on
dive
rsio
n -s
end
to o
utly
ing
hosp
itals
–Li
mite
d ef
fect
-la
stin
g on
ly 4
mon
ths
Am
bula
nce
Div
ersi
on
Whi
le a
mbu
lanc
e di
vers
ion
may
dec
ompr
ess
the
ED
, the
re is
con
cern
that
div
ersi
on m
ay
also
cau
se h
arm
.
Am
bula
nce
Div
ersi
onN
eely
KW
, Nor
ton
RL,
You
ng G
P. T
he e
ffect
of h
ospi
tal
reso
urce
una
vaila
bilit
y an
d am
bula
nce
dive
rsio
ns o
n th
e E
MS
sy
stem
. Pre
hosp
italD
isas
ter M
edic
ine.
199
4; 9
(3):
172-
7.–
Five
mon
th p
rosp
ectiv
e st
udy
–91
1 di
vers
ions
com
pare
d to
5%
rand
om s
ampl
e of
non
-di
vers
ions
–M
ean
trans
port
time
non-
dive
rted
11.5
min
vs.
16.
5 m
in (p
<
0.00
2)–
Dis
tanc
e to
inte
nded
des
tinat
ion
1.3
to 4
.6 m
iles
furth
er fo
r di
verte
d–
Sug
gest
ed w
as re
late
d to
una
vaila
bilit
y of
spe
cial
ty s
ervi
ces
–R
ecom
men
ded
rese
arch
into
out
com
e di
ffere
nces
Am
bula
nce
Div
ersi
onS
loan
EP,
et a
l. th
e ef
fect
of u
rban
trau
ma
syst
em h
ospi
tal b
ypas
s on
pr
ehos
pita
ltra
nspo
rt tim
es a
nd le
vel 1
trau
ma
patie
nt s
urvi
val.
Ann
als
of E
M. 1
989;
18
(11)
: 114
6-50
.
–S
tudi
ed in
fluen
ce o
f hos
pita
l byp
ass
on p
reho
spita
ltim
es a
nd
patie
nt s
urvi
val
–D
irect
tran
spor
t pat
ient
s (n
= 6
6) v
s. th
ose
that
requ
ired
bypa
ss (n
= 1
37)
–Tr
avel
tim
e in
byp
ass
grou
p 3
min
long
er (p
< 0
.05)
–N
o di
ffere
nce
in s
urvi
val 8
6% v
s. 8
5%–
Add
ition
al 3
min
add
ed o
nly
5% to
tota
l tra
nspo
rt tim
e
Am
bula
nce
Div
ersi
on
Red
elm
eier
, et a
l. N
o pl
ace
to u
nloa
d: a
pre
limin
ary
anal
ysis
of
the
prev
alen
ce, r
isk
fact
ors,
and
con
sequ
ence
s of
am
bula
nce
dive
rsio
n. A
nnal
s of
EM
. 199
4; 2
3 (1
): 43
-7.
–O
bser
vatio
nal c
ohor
t stu
dy o
ver a
4 y
ear p
erio
d–
153,
167
tota
l tra
nspo
rts; 5
% d
iver
ted
–Lo
nger
tran
spor
t tim
e 13
.3 m
in (±
7.5)
vs
11.6
min
(±
6.9)
; p <
0.0
05–
No
diffe
renc
e in
rate
of t
rans
port
asso
ciat
ed d
eath
Am
bula
nce
Div
ersi
on
Stil
l a c
once
rn th
at d
iver
sion
is h
arm
ful
and
redu
ctio
n is
favo
rabl
e...
Am
bula
nce
Div
ersi
on
Lago
eR
J, e
t al.
Red
ucin
g am
bula
nce
dive
rsio
n: a
mul
tihos
pita
l ap
proa
ch. P
reho
spita
lEm
erge
ncy
Car
e. 2
003;
7 (1
): 99
-108
–R
etro
spec
tive
revi
ew o
f pro
cedu
res
for r
educ
ing
dive
rsio
n •
syst
em-w
ide
exch
ange
of i
nfor
mat
ion
on d
iver
sion
sta
tus
•ho
spita
l com
mitm
ent t
o pr
ovid
ing
reso
urce
s ne
eded
to re
duce
di
vers
ion
•in
divi
dual
hos
pita
ls s
pot c
heck
ing
by m
anag
emen
t lev
el
pers
onne
l–
Bet
wee
n 20
00 a
nd 2
001
hour
s on
div
ersi
on w
ere
redu
ced
by 3
3.3%
–P
revi
ous
pape
r (20
02) b
y La
goe,
Hun
t, et
al.
show
ed
51%
tim
e on
div
ersi
on
Am
bula
nce
Div
ersi
on
Vilk
eG
M, e
t al.
Com
mun
ity tr
ial t
o de
crea
se a
mbu
lanc
e di
vers
ion
hour
s: th
e S
an D
iego
Cou
nty
patie
nt d
estin
atio
n tri
al.
Ann
EM
. 200
4; 4
4 (4
): 29
5-30
3.–
Ret
rosp
ectiv
e st
udy
post
impl
emen
tatio
n of
a d
iver
sion
pro
toco
l–
Pre
-tria
l 12
mon
ths
/ Tria
l 3 m
onth
s / P
ost-t
rial 9
mon
ths
–A
utho
rizat
ion
of d
iver
sion
requ
ired
ED
atte
ndin
g an
d ch
arge
nu
rse.
Afte
r 3 h
ours
then
aut
horiz
atio
n by
hos
pita
l adm
inis
trato
r–
Out
com
es: n
umbe
r of p
atie
nts
trans
porte
d by
am
bula
nce;
nu
mbe
r of p
atie
nts
take
n to
ano
ther
ED
due
to d
iver
sion
; nu
mbe
r of h
ours
on
dive
rsio
n•
Dec
reas
ed h
ours
on
dive
rsio
n–
Pre
-tria
l = 4
,007
/ D
urin
g tri
al =
1,0
79 /
Pos
t-tria
l = 1
,774
•D
ecre
ased
num
ber o
f pat
ient
s di
verte
d –
Pre
-tria
l = 1
320
/ Dur
ing
trial
= 3
22 /
Pos
t-tria
l = 4
99–
75%
redu
ctio
n of
div
ersi
on a
way
from
requ
este
d E
D
Am
bula
nce
Div
ersi
on
•W
hat d
o w
e kn
ow s
o fa
r??
–A
mbu
lanc
e di
vers
ion
may
dec
ompr
ess
an
over
whe
lmed
ED
in th
e sy
stem
–A
mbu
lanc
e di
vers
ion
may
incr
ease
tra
nspo
rt tim
es
–P
olic
ies
to d
ecre
ase
dive
rsio
n ho
urs
have
be
en e
ffect
ive
Div
ersi
on a
nd T
rans
port
Tim
e
Silk
aPA
, et a
l. D
iver
sion
of A
LS a
mbu
lanc
es.
Pre
hosp
itale
mer
genc
y ca
re. 2
001;
5 (1
): 23
-8.
–R
etro
spec
tive
stud
y du
ring
cons
ecut
ive
3 m
onth
s
–ca
se m
atch
ed c
ontro
ls o
f pat
ient
s no
t div
erte
d w
ere
com
pare
d to
div
erte
d pa
tient
s
–2,
534
ALS
runs
: 147
(5.8
%) d
iver
ted;
123
ana
lyze
d
–M
ost c
omm
on re
ason
s fo
r div
ersi
on
•P
atie
nt re
ques
t = 6
9
•E
D s
atur
atio
n =
45
–N
on-p
atie
nt re
ques
t div
ersi
ons
vs. N
on-d
iver
ted
•To
tal p
re-h
ospi
tal i
nter
val
–33
.35
min
(95%
CI 3
1.14
-35
.55)
vs.
33.
43 m
in (9
5% C
I 32.
13 -
34.7
0)
Div
ersi
on a
nd T
rans
port
Tim
e
Sch
ullM
J, e
t al.
Em
erge
ncy
depa
rtmen
t ove
rcro
wdi
ng a
nd
ambu
lanc
e tra
nspo
rt de
lays
for p
atie
nts
with
che
st p
ain.
Can
M
ed J
. 200
3; 1
68 (3
): 27
7-83
.–
Ana
lysi
s of
two
4 m
onth
per
iods
in 1
997
and
1999
that
cor
rela
ted
with
low
and
hig
h ED
by
pass
–Ty
pes
of b
ypas
s
•N
orm
al -
i.e. n
o by
pass
•R
edire
ct -
Acc
ept o
nly
criti
cal c
are
•C
ritic
al c
are
bypa
ss -
cann
ot a
ccep
t crit
ical
car
e
•G
ridlo
ck -
all h
ospi
tals
in q
uadr
ant o
n by
pass
–To
tal p
reho
spita
lint
erva
l
•44
.8 m
in v
s. 4
6.2
min
; cha
nge
of 1
.4 m
in; p
= 0
.2
Div
ersi
on a
nd T
rans
port
Tim
eS
chul
lMJ,
et a
l. E
mer
genc
y de
partm
ent g
ridlo
ck a
nd o
ut-
of-h
ospi
tal d
elay
s fo
r car
diac
pat
ient
s. A
cad
EM
. 200
3;
10 (7
): 70
9-16
.–
Ret
rosp
ectiv
e da
ta o
n co
nsec
utiv
e am
bula
nce
patie
nts
with
che
st p
ain
–11
,400
pat
ient
s ov
er 2
yea
r per
iod
–S
tudy
of o
ut-o
f-hos
pita
l int
erva
ls fo
r pat
ient
s tra
nspo
rted
on d
ays
with
gr
idlo
ck v
s. d
ays
with
out g
ridlo
ck
–M
ain
outc
ome
stud
ied:
90%
tran
spor
t int
erva
l fro
m s
cene
to h
ospi
tal
–4,
223
(37%
) of p
atie
nts
trans
porte
d on
day
with
grid
lock
–R
esul
ts
•Tr
ansp
ort i
nter
val
–17
.4 m
in (9
5% C
I 16.
8 -1
7.8)
vs.
15.
5 (9
5%C
I 15.
3 -1
5.9)
•E
very
hou
r of g
ridlo
ck in
crea
sed
trans
port
by 0
.2 m
in
•A
ll ot
her f
orm
s of
div
ersi
on n
ot a
ssoc
iate
d w
ith lo
nger
inte
rval
s
Div
ersi
on a
nd T
rans
port
Tim
e
Car
ter A
JE, G
riers
on R
. The
impa
ct o
f am
bula
nce
dive
rsio
n on
EM
S re
sour
ce a
vaila
bilit
y. P
reho
spita
lem
erge
ncy
care
. 200
7; 1
1 (4
): 42
1-26
–R
etro
spec
tive
stud
y of
per
iods
on
dive
rsio
n vs
. per
iods
of
f div
ersi
on–
Onl
y on
e ho
spita
l in
syst
em o
n di
vers
ion
at a
tim
e–
Div
ersi
on c
an la
st u
p to
1 h
our w
ith e
xten
sion
gra
nted
by
heal
th d
epar
tmen
t–
Res
ults
-N
o di
ffere
nce
in:
Res
pons
e tim
e O
n-sc
ene
time
Tran
spor
t tim
e H
ospi
tal t
urna
roun
d tim
eO
ut-o
f-ser
vice
tim
e
Div
ersi
on a
nd T
rans
port
Tim
e
So w
hat?
–A
mbu
lanc
e di
vers
ion
in a
nd o
f its
elf m
ay
NO
T in
crea
se tr
ansp
ort t
ime
–If
ther
e is
an
incr
ease
in tr
ansp
ort t
ime
it is
no
min
al
Div
ersi
on
•P
ham
JC
, et a
l. T
he e
ffect
s of
am
bula
nce
dive
rsio
n:
a co
mpr
ehen
sive
revi
ew. A
cad
EM
. 200
6; 1
3 (1
1):
1220
-27.
–S
yste
mat
ic re
view
and
met
a-an
alys
is o
f am
bula
nce
dive
rsio
n lit
erat
ure
–P
auci
ty o
f stu
dies
on
the
effe
cts
of A
D–
No
adeq
uate
stu
dies
on
the
effe
ct o
f AD
on
ED
cr
owdi
ng, o
r mor
bidi
ty/m
orta
lity
Div
ersi
on
Say
it is
nt s
o...
dive
rsio
n ha
s to
be
evil!
NA
EM
SP
Pos
ition
Sta
tem
ent
Glu
shak
C, e
t al.
Am
bula
nce
dive
rsio
n -p
ositi
on p
aper
. P
reho
spita
lem
erge
ncy
care
. 199
7; 1
(2):
100-
3.–
Div
ersi
on m
ay h
ave
nega
tive
impa
ct o
n pa
tient
car
e an
d E
MS
sys
tem
–N
eces
sary
that
EM
S s
yste
ms
take
mea
sure
s to
avo
id
dive
rsio
n w
hich
may
resu
lt in
...•
Una
ccep
tabl
y pr
olon
ged
trans
port
times
•P
rolo
nged
out
of h
ospi
tal c
are
whe
n de
finiti
ve c
are
need
ed
for u
nsta
ble
patie
nts
•In
appr
opria
te a
ttem
pts
by fi
eld
pers
onne
l to
pred
ict
reso
urce
s ne
eded
•D
elay
s in
or l
ack
of a
mbu
lanc
e av
aila
bilit
y to
com
mun
ity
beca
use
of d
iver
sion
to d
ista
nt h
ospi
tals
Div
ersi
on –
Clin
ical
Effe
ctMostly
unim
pressiv
e,bu
t…
Shen
YC,H
siaRY.A
ssociatio
nbetw
eenam
bulancediversionan
dsurvivalam
ongpa
tientsw
ithacutemyocardialinfarction.JAMA.
2011
Jun15
;305
(23):244
07
•expo
sure
to<6,6
to<12,and
12ho
urso
fdiversio
n•
<12ho
urso
fdiversio
n=no
diffe
rence
•>12or
moreho
urso
fdiversio
nwas
associated
with
higher
30daymortality392patie
nts[19
%]vs5
45patie
nts[15
%]
–higher
90daymortality(537
patie
nts[26
%]vs7
62patie
nts[22
%])
–higher
9mon
thmortality(680
patie
nts[33
%]vs9
80patie
nts[28
%])
–higher
1year
mortality(731
patie
nts[35
%]vs1
034patie
nts[29
%])
Div
ersi
on R
educ
tion
Asa
moa
hO
K, e
t al.
A n
ovel
div
ersi
on p
roto
col d
ram
atic
ally
re
duce
s di
vers
ion
hour
s. A
m J
EM
. 200
8; 2
6 (6
): 67
0-75
–R
etro
spec
tive
stud
y of
a c
ount
ywid
e di
vers
ion
prot
ocol
–H
ospi
tal c
ould
go
on d
iver
t for
1 h
our o
nly
and
then
off
dive
rsio
n fo
r nex
t 8 h
ours
–O
utco
mes
: num
ber o
f hou
rs o
n di
vers
ion
and
drop
off
times
for d
iver
sion
per
iods
co
mpa
red
to n
on-d
iver
sion
per
iods
.
–R
esul
ts
•Pr
otoc
ol d
ecre
ased
div
ersi
on b
y 82
%
•In
crea
sed
unit
time
= 17
8 ho
urs/
mon
th (9
5% C
I 74
-283
)
–(U
nit t
ime
= [9
0% d
rop
off t
ime
-15
min
] X n
o of
tran
spor
ts]/6
0 m
in)
•Al
so, l
ittle
effe
ct o
n E
D o
verc
row
ding
•In
crea
sed
drop
offt
ime
= 1.
66 m
in/m
onth
(95%
CI 0
.33
-2.9
8)
–In
crea
se o
f 32%
Div
ersi
on R
educ
tion
... fo
r eve
ry a
ctio
n th
ere
may
be
unin
tend
ed c
onse
quen
ces.
EM
S S
yste
m•
Wha
t is
the
botto
m li
ne fo
r the
EM
S s
yste
m?
–U
nits
bac
k in
ser
vice
in ti
mel
y m
anne
r
–M
aint
ain
acce
ptab
le re
spon
se ti
mes
–C
over
age
in th
e co
mm
unity
at t
he lo
wes
t cos
t pos
sibl
e
requ
iring
mor
e un
its to
mee
t com
mun
ity n
eeds
=
high
er c
ost t
o th
e co
mm
unity
(ie:
low
er U
HU
)
–H
ighl
ight
ed a
noth
er fa
ctor
-dr
opof
ftim
e(o
ffloa
d de
lay)
AM
BU
LAN
CE
OFF
LOA
D
DEL
AY
Inte
rval
sC
one
DC
, et a
l. A
time-
mot
ion
stud
y of
the
emer
genc
y m
edic
al s
ervi
ces
turn
arou
nd in
terv
al. A
nn E
mer
gM
ed. 1
998
Feb;
31(2
):241
-6
Am
bula
nce
Offl
oad
Del
ay•
Sch
war
tz B
, et a
l. Im
prov
ing
acce
ss to
em
erge
ncy
serv
ices
: a
syst
em c
omm
itmen
t. R
epor
t to
the
Min
istry
of H
ealth
and
Lo
ng-te
rm c
are,
Gov
ernm
ent o
f Ont
ario
, Can
ada.
200
5.–
Com
mitm
ent f
rom
all
stak
ehol
ders
is th
e fu
ndam
enta
l re
quire
men
t for
impr
ovem
ent i
n em
erge
ncy
depa
rtmen
t ov
ercr
owdi
ng a
nd a
mbu
lanc
e of
fload
del
ay.
•C
anno
t foc
us s
olel
y on
the
emer
genc
y de
partm
ent
•E
D o
verc
row
ding
is a
sym
ptom
s of
sys
tem
ic is
sues
; no
the
sour
ce o
f the
pro
blem
–S
take
hold
ers
mus
t be
held
acc
ount
able
–P
rinci
ple
caus
e of
off-
load
tim
e is
lack
of c
apac
ity to
tre
at h
ospi
tal i
n-pa
tient
s–
Sol
utio
n to
pro
blem
mus
t loo
k at
in-p
atie
nt c
apac
ity–
Set
goa
l of 3
0 m
inut
es fo
r offl
oad
Am
bula
nce
Offl
oad
Del
ay•
Cen
ters
for M
edic
are
and
Med
icai
d S
ervi
ces
(CM
S).
EM
TALA
-P
arki
ngof
EM
S P
atie
nts
in H
ospi
tals
. Jul
y 13
, 20
06.
–C
MS
has
rece
ived
repo
rts fr
om E
Ds
conc
erni
ng p
atie
nts
bein
g le
ft on
stre
tche
rs fo
r ext
ende
d pe
riods
of t
ime,
pos
sibl
y in
vi
olat
ion
of E
MTA
LA.
–C
MS
reco
gniz
es th
e st
rain
on
ED
s; h
owev
er th
is p
ract
ice
is n
ot
a so
lutio
n.–
Par
king
patie
nts
in h
ospi
tals
impa
cts
the
abili
ty o
f the
EM
S
pers
onne
l to
prov
ide
emer
genc
y se
rvic
es to
the
com
mun
ity
Am
bula
nce
Offl
oad
Del
ay•
CM
S. E
MTA
LA Is
sues
rela
ted
to e
mer
genc
y tra
nspo
rt se
rvic
es. A
pril
27, 2
007.
[Cla
rific
atio
n of
7/1
3/06
lette
r]–
EM
TALA
resp
onsi
bilit
y of
hos
pita
l beg
ins
whe
n an
in
divi
dual
arri
ves
and
not w
hen
the
hosp
ital
acce
pts
the
indi
vidu
al fr
om th
e gu
rney
–H
ospi
tal h
as a
n ob
ligat
ion
to p
rovi
de a
ppro
pria
te
med
ical
scr
eeni
ng e
xam
and
nec
essa
ry s
tabi
lizat
ion
–Fa
ilure
to m
eet t
hese
requ
irem
ents
con
stitu
tes
a vi
olat
ion
of E
MTA
LA»
But
then
they
wen
t on
to s
ay...
.
Am
bula
nce
Offl
oad
Del
ay–
Not
nec
essa
rily
a vi
olat
ion
if th
e ho
spita
l doe
s no
t im
med
iate
ly a
ssum
e ca
re o
f pat
ient
–It
may
be
reas
onab
le fo
r hos
pita
l to
ask
EM
S
prov
ider
s to
sta
y w
ith p
atie
nt u
ntil
such
tim
e as
the
ED
st
aff i
s ab
le to
car
e fo
r pat
ient
. S
uch
an in
stan
ce w
ould
oc
cur i
n tim
e of
man
agin
g m
ultip
le tr
aum
a pa
tient
s or
ot
her c
ritic
ally
ill p
atie
nts.
–H
owev
er, t
he h
ospi
tal M
US
T tri
age
the
patie
nts
cond
ition
imm
edia
tely
upo
n ar
rival
to e
nsur
e th
at a
n em
erge
nt in
terv
entio
n is
not
requ
ired
and
the
EM
S
prov
ider
s ca
n ca
re fo
r the
pat
ient
.
Am
bula
nce
Offl
oad
Del
ay
Coo
ney
DR
, et a
l. A
mbu
lanc
e di
vers
ion
and
emer
genc
y de
partm
ent o
ffloa
d de
lay:
reso
urce
doc
umen
t for
the
Nat
iona
l A
ssoc
iatio
n of
EM
S P
hysi
cian
s po
sitio
n st
atem
ent.
Pre
hosp
Em
erg
Car
e. 2
011
Oct
-Dec
;15(
4):5
55-6
1
–R
evie
wed
lite
ratu
re a
nd n
oted
lack
of d
ata
supp
ortin
g sp
ecifi
c ne
ed to
use
or l
ose
conc
ept o
f div
ersi
on–
Not
ed p
ossi
ble
sign
ifica
nt p
atie
nt c
are
impa
ct o
f offl
oad
dela
y–
Sup
porte
d N
AE
MS
P po
sitio
n–
Rec
omm
ende
d A
OD
be
track
ed b
y E
M a
nd E
MS
adm
inis
trato
rs
Am
bula
nce
Offl
oad
Del
ayC
oone
y D
R, e
t al.
Eva
luat
ion
of a
mbu
lanc
e of
fload
del
ay a
t a u
nive
rsity
ho
spita
l em
erge
ncy
depa
rtmen
t. In
tJ E
mer
gM
ed. 2
013
May
10
;6(1
):15
–O
ffloa
d de
lay
was
ass
ocia
ted
with
NE
DO
CS
sco
re
Am
bula
nce
Offl
oad
Del
ay
SU
NY
Ups
tate
unp
ublis
hed
data
•A
12-m
onth
con
veni
ence
sam
ple
of 1
892
•A
OD
rang
ed fr
om 0
min
. to
122
min
. with
a m
ean
of 1
4.01
min
. (S
D±1
4.2)
. •
Mea
n A
OD
for p
edia
tric
patie
nts
(10.
77 m
in.)
was
less
than
adu
lts
(14.
92 m
in.)
(p<0
.001
). •
NE
DO
CS
gro
ups
(p<0
.001
): –
1=9.
18 m
in.
–2=
12.7
2 m
in.
–3=
18.1
4 m
in.
–4=
20.6
2 m
in.
•E
SI w
as e
valu
ated
–
leve
l 3 w
as th
e lo
nges
t mea
n
Am
bula
nce
Offl
oad
Del
ay
Hos
pita
ls a
nd E
MS
Sys
tem
, Lee
Cou
nty,
Flo
rida
–S
ix S
igm
a P
roje
ct 2
007
•Id
entif
ied
offlo
ad d
elay
as
a pr
oble
m•
Est
imat
ed c
ost o
f AO
D a
t $35
0,00
0/yr
•G
oal o
f 15
min
90%
of t
he ti
me
and
30 m
in 1
00%
•Th
ree
inte
rven
tions
–Tr
ansp
orta
tion
Des
tinat
ion
Coo
rdin
ator
con
tact
prio
r to
trans
port
–E
MS
yste
ms
upda
te b
y ho
spita
ls–
ED
nur
se fi
ndin
g be
d sp
ace
prio
r to
EM
S a
rriv
al
Am
bula
nce
Offl
oad
Del
ay
Hos
pita
ls a
nd E
MS
Sys
tem
, Lee
Cou
nty,
Fl
orid
a –
Six
Sig
ma
Pro
ject
200
7
13.2
1883
657
44.2
05101520253035404550
Feb-
07Fe
b-M
ar 2
006
Time In Minutes
Mon
th
Aver
age
Offl
oad
Tim
es In
Sea
son
2006
& 2
007
Am
bula
nce
Offl
oad
Del
ayH
ospi
tals
and
EM
S S
yste
m, L
ee C
ount
y, F
lorid
a –
Six
S
igm
a P
roje
ct 2
007
•R
esul
ts:
–P
ilot p
rove
d a
stat
istic
ally
sig
nific
ant r
educ
tion
in th
e av
erag
e of
f-lo
ad ti
mes
for L
ee M
emor
ial H
ospi
tal
–A
decr
ease
in th
e va
riatio
n (r
ange
)
AD
/AO
D a
nd C
row
ding
Han
del D
A, a
t al.
Varia
tions
in c
row
ding
and
am
bula
nce
dive
rsio
n in
ni
ne e
mer
genc
y de
partm
ents
. Aca
dE
mer
gM
ed. 2
011
Sep
;18(
9):9
41-6
AD
/AO
D a
nd C
row
ding
McL
eod
B, e
t al.
Mat
chin
g ca
paci
ty to
dem
and:
a re
gion
al d
ashb
oard
re
duce
s am
bula
nce
avoi
danc
e an
d im
prov
es a
cces
sibi
lity
of re
ceiv
ing
hosp
itals
. Aca
dE
mer
gM
ed. 2
010
Dec
;17(
12):1
383-
9
AD
/AO
D a
nd C
row
ding
McL
eod
B, e
t al.
Mat
chin
g ca
paci
ty to
dem
and:
a re
gion
al d
ashb
oard
redu
ces
ambu
lanc
e av
oida
nce
and
impr
oves
acc
essi
bilit
y of
rece
ivin
g ho
spita
ls. A
cad
Em
erg
Med
. 201
0 D
ec;1
7(12
):138
3-9
AD
/AO
D a
nd C
row
ding
McL
eod
B, e
t al.
Mat
chin
g ca
paci
ty to
dem
and:
a re
gion
al d
ashb
oard
redu
ces
ambu
lanc
e av
oida
nce
and
impr
oves
acc
essi
bilit
y of
rece
ivin
g ho
spita
ls. A
cad
Em
erg
Med
. 201
0 D
ec;1
7(12
):138
3-9
AD
/AO
D a
nd C
row
ding
•B
urke
LG
, et a
l. T
he e
ffect
of
an a
mbu
lanc
e di
vers
ion
ban
on
emer
genc
y de
partm
ent l
engt
h of
sta
y an
d am
bula
nce
turn
arou
nd
time.
Ann
Em
erg
Med
. 201
3 M
ar;6
1(3)
:303
-311
.e1 .
–B
efor
e an
d af
ter d
iver
sion
ban
•A
mbu
lanc
e Tu
rn-a
roun
d-tim
e un
chan
ged
–N
ot s
ame
as o
ffloa
d
•E
D L
OS
for p
atie
nts
unch
ange
d as
wel
l
The
Big
Pic
ture
•E
Ds
are
conc
erne
d th
at c
row
ding
is
unsa
fe
•E
MS
sys
tem
is a
crit
ical
par
t of t
he s
afet
y ne
t ne
ed to
get
uni
ts b
ack
in s
ervi
ce a
s qu
ickl
y as
pos
sibl
e
•D
ropo
ffde
lay
the
criti
cal f
acto
r in
getti
ng u
nits
bac
k in
se
rvic
e (re
st o
f Tur
n-A
roun
d-Ti
me
can
be c
ontro
lled)
•E
MS
pro
vide
rs s
houl
d no
t be
held
up
at h
ospi
tals
car
ing
for
patie
nts
•E
MTA
LA v
iola
tion
for h
ospi
tal t
o no
t acc
ept p
atie
nt
Pos
ition
Sta
tem
ent
Pos
ition
Sta
tem
ent:
Am
bula
nce
Div
ersi
on a
nd E
mer
genc
y D
epar
tmen
t Offl
oad
Del
ay
The
Nat
iona
l Ass
ocia
tion
of E
MS
Phy
sici
ans®
bel
ieve
s th
at:
•E
MS
sys
tem
s, a
nd th
eir p
atie
nts,
are
sig
nific
antly
impa
cted
by
emer
genc
y de
partm
ent (
ED
) cro
wdi
ng.
•D
espi
te p
revi
ous
stat
emen
ts, n
o da
ta s
uppo
rt th
at th
ere
is d
irect
pat
ient
har
m
from
org
aniz
ed s
yste
ms
of a
mbu
lanc
e di
vers
ion
in a
mod
ern
EM
S s
yste
m. I
n ad
ditio
n, a
mbu
lanc
e di
vers
ion
has
not b
een
show
n to
impr
ove
ED
pat
ient
th
roug
hput
.•
Pro
toco
ls d
esig
ned
to li
mit
dive
rsio
n m
ay le
ad to
an
incr
ease
in E
D o
ffloa
d de
lay,
the
inte
rval
bet
wee
n ho
spita
l arri
val a
nd tr
ansf
er o
f the
pat
ient
from
the
ambu
lanc
e st
retc
her a
nd a
ssum
ptio
n of
car
e by
ED
sta
ff.
•E
D a
nd h
ospi
tal l
eade
rshi
p sh
ould
wor
k w
ith th
e E
MS
age
ncie
s an
d sy
stem
le
ader
ship
to li
mit
the
time
that
am
bula
nces
are
out
of s
ervi
ce d
ue to
di
vers
ion
or o
ffloa
d de
lay.
•
Ove
rall
impr
ovem
ent o
f ED
cro
wdi
ng b
y ho
spita
l thr
ough
put i
nitia
tives
will
likel
y de
crea
se b
oth
ED
offl
oad
dela
y an
d ho
urs
on d
iver
sion
.•
Sur
veilla
nce
and
com
mun
icat
ion
of E
D o
ffloa
d de
lay,
div
ersi
on s
tatu
s an
d ot
her f
acto
rs re
late
d to
ED
cro
wdi
ng s
houl
d be
em
ploy
ed th
roug
hout
the
EM
S s
yste
m.
•R
egul
ar re
view
of b
ench
mar
ks s
houl
d be
use
d to
gui
de lo
cal s
yste
m a
nd
inst
itutio
nal i
nitia
tives
.•
Reg
ulat
ors,
acc
redi
ting
bodi
es, a
nd q
ualit
y im
prov
emen
t org
aniz
atio
ns
shou
ld tr
ack
ED
cro
wdi
ng b
ench
mar
ks.
AO
D: a
Qua
lity
Mar
ker
•A
mbu
lanc
e of
fload
del
ay re
pres
ents
a
dela
y in
pat
ient
car
e•
In s
ome
stat
es E
MS
pro
vide
rs a
re
not a
llow
ed to
car
e fo
r pat
ient
s in
side
the
hosp
ital
•P
atie
nt s
atis
fact
ion
and
priv
acy
at
risk
durin
g A
OD
•E
MTA
LA in
opp
ositi
on to
AO
D•
AO
D w
ill b
e fo
rwar
ded
to J
CA
HO
an
d D
NV
AO
D: a
Qua
lity
Mar
ker
•W
here
to s
et th
e ba
r?–
Est
ablis
hing
a b
asel
ine
–E
valu
atin
g th
e ris
k–
Con
side
ring
a go
al•
Avai
labl
e da
ta s
ugge
sts
–<1
5 m
inut
e id
eal (
90%
of t
he ti
me)
= h
igh
qual
ity–
>60
min
ute
= re
porta
ble
inci
dent
Futu
re S
tudy
•Id
entif
y ris
k fa
ctor
s re
late
d to
incr
ease
d A
OD
–N
ED
OC
S s
corin
g (E
D C
row
ding
)–
???
Oth
er fa
ctor
s•
Pat
ient
spe
cific
•S
taffi
ng s
peci
fic•
Faci
lity
spec
ific
Futu
re S
tudy
•Q
uant
ify e
ffect
s on
EM
S S
yste
m–
UH
U–
Res
pons
e tim
es–
Pro
vide
r sat
isfa
ctio
n / a
ttriti
on
Futu
re S
tudy
•E
valu
ate
the
cost
of A
OD
–E
MS
Sys
tem
–U
HU
dec
line
–E
D/h
ospi
tal –
cost
of i
nter
vent
ions
–P
atie
nts
•m
orbi
dity
/mor
talit
y•
patie
nt s
atis
fact
ion
Futu
re S
trate
gies
•Id
entif
y in
terv
entio
ns–
Offl
oad
nurs
e/pr
ovid
er (C
anad
a)–
Pre
hosp
itald
ashb
oard
of s
yste
m h
ospi
tals
–E
D b
ed a
ssig
nmen
t pio
rto
arriv
al–
NE
DO
CS
sco
re tr
igge
rs th
roug
hput
resp
onse
–A
mbu
lanc
e D
iver
sion
•B
ased
on
NE
DO
CS
sco
re o
r AO
D•
Lim
itatio
ns–
Tim
e lim
its?
–Ty
pe o
f pat
ient
s?–
Bui
lt-in
reas
sess
men
t trig
gers
AD
off
–H
ospi
tal t
hrou
ghpu
t ini
tiativ
es•
Gen
eral
impr
ovem
ent i
n pe
rform
ance
Than
ks…
Key
Poi
nts
•A
mbu
lanc
e di
vers
ion
may
be
a us
eful
tool
if u
tiliz
ed
judi
cial
ly a
nd in
con
text
with
hos
pita
l thr
ough
put
adva
ncem
ent
•A
mbu
lanc
e of
fload
del
ay is
an
evol
ving
mar
ker o
f ED
pa
tient
car
e qu
ality
•A
OD
and
AD
are
inte
r-rel
ated
and
hos
pita
l thr
ough
put i
s a
key
caus
ativ
e fa
ctor
•A
OD
repr
esen
ts a
real
and
pot
entia
l del
ay in
pat
ient
car
e–
In th
e E
D–
In th
e pr
ehos
pita
lenv
ironm
ent
•Fu
rther
stu
dy is
nee
ded
QU
ESTI
ON
S?EM
AIL
IN
FO@
UR
GEN
TMAT
TER
S.O
RG
