1. Emergency Department Overcrowding and Ambulance Diversion Brad Prenney, M.S., M.P.A. Deputy Director Bureau of Health Quality Management Massachusetts Department of Public Health

2. Brad Prenney Statement of the Problem n Ambulances are diverted away from the closest appropriate hospital because that hospital can not provide timely care. n Diversion results in a delay in definitive care. n Diversion is a public health problem that has worsened over the last several years. n A related problem is the “boarding” of patients in the ED for extended periods of time while waiting for an inpatient bed.

3. Brad Prenney Region IV Hospital Diversion Hours 2000-2002

4. Brad Prenney Selected Highlights of Massachusetts Initiatives to Address Ambulance Diversion n May 1999First meeting of Ambulance Diversion Task Force n December 1999Issuance of Best Practice Guidelines to Hospitals n December 2000 Issuance of Recommended Measures to Hospitals n February 2001 DPH Diversion Survey of Hospitals n June 2001Publication of Issue Brief/Brandeis Forum n February 2002Diversion Uniform Rules/Definitions Distributed n October 2002Disaster/Gridlock Plan Developed n November 2002Completion of Hospital Patient Flow Study

5. Brad Prenney Focus of Initiatives to Address Ambulance Diversion and ED Overcrowding n Providing guidance to hospital and pre- hospital providers n Management of the problem n Understanding the factors contributing to the problem

6. Brad Prenney Diversion Measures within the Hospital (12/2000) n Integrate written diversion policies within hospital disaster plans. n Fast-track non-emergency patients. n Staff all licensed beds during peak demand periods. n Establish admissions plans for periods of ED overcrowding that: ä give priority to emergency patients ä schedule surgeries in a way to maximize bed capacity ä allow for rescheduling of elective surgeries to care for higher acuity patients.

7. Brad Prenney Uniform Definitions/Rules Governing Ambulance Diversion n Definitions for boarder, ED saturation, diversion n Honoring diversion requests n Exceptions to diversion n Immediate life-threatening situations n Patient preference/ insistence/ refusal n When contiguous hospitals request diversion n Selective diverting of ambulances

8. Brad Prenney Demand Factors n Increase in volume of patients presenting to the ED (hospital closures, demographics — aging population, decreased access and/or satisfaction with community-based care) n Increase in acuity n Increased diagnostic and treatment capability in the ED n Seasonal variation in communicable disease (i.e. flu)

9. Brad Prenney Supply Side Factors n Lack of staffed inpatient beds (financial constraints faced by hospitals, conversion to other uses, no longer staffing for the peaks) n Shortage of staff (especially nursing, difficulty recruiting and retaining) n Hospital closures (Massachusetts has lost about 1/3 of its hospitals over the last 20 years)

10. Brad Prenney Internal Hospital Operations n Factors that impede a hospital’s ability to move patients efficiently through the system a) Variability in scheduling OR/beds for elective and emergency surgery b) Variability in admission and discharge processing c) Variability between discharge and next admission to a bed n Lack of sufficient coordination and communication between services

11. Brad Prenney “While increasing use of the ED, especially for non- urgent needs, causes significant problems in patient flow, staff burn-out, and ED operations, we do not think that it is those who seek care for non- urgent issues who are responsible for the recent crisis of ambulance diversions. It is really the acutely ill patient who is waiting in the ED for a hospital bed who creates the bottleneck that leads to overcrowding, diversions, and essentially a breakdown in the entire system.” - Brent Asplin, M.D., M.P.H., Director of Research, Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota

12. Brad Prenney Current Initiatives To Address Ambulance Diversion and ED Overcrowding n Quarterly meetings of Ambulance Diversion Task Force n Completion of patient flow study and dissemination of simulation model to hospitals n Development of disaster/gridlock plan n Continued Promotion of Best Practices

13. Brad Prenney DPH Gridlock Preparedness Saturation/Gridlock Disaster Response Plan DPH Hospitals EMS Region Multiple contiguous regions/geographies in gridlock and situation deteriorating despite implementation of Stage II intervention DPH Commissioner determines implementation based on risk to public safety Stage I conditions persist or worsen or expand geographically despite stage I interventions, and The EMS Regional Director believes public safety remains jeopardized Multiple contiguous hospitals are saturated, on diversion or requesting at same time, and The EMS Regional Director believes public safety is in jeopardy Action Steps Stage IIIStage IIStage IBaseline Activity

14. Brad Prenney Influenza and Pneumonia* Hospital Admissions from Sept 1999 – Sept 2000 ICD-9-CM 480-487

15. Brad Prenney Massachusetts Acute Care Hospital Discharges FFY 2000 ER Charges No ER Charges Number of Number of Payer Type Discharges (%) Discharges (%) Medicare/Medicare 203,171 (58) 117,031 (27) Managed Care HMO47,390 (13)118,383 (27) Medicaid/Medicaid 34,065 (10)64,944 (15) Managed Care Blue Cross/Blue Cross25,481 (7) 65,957 (15) Managed Care Self Pay/Free Care 15,423 (4)12,545 (3) All Other26,566 (8)55,786 (13) TOTAL352,096 (100)434,646 (100)