Ambulance diversion and ED overcrowding

Letters

CJEM 2002;4(4):244

To the Editor:

The 2 related articles^1,2 on ED overcrowding in the March 02 issue of CJEM are highly interesting and relevant to Australian emergency medicine clinicians and managers. Most of the same issues, problems, misconceptions and proposed solutions are reflected here.

Like Schull's group,¹ many of us have sought a consistent and meaningful definition of ED overcrowding. Schull's proposed definition -- that of the requirement to invoke ambulance diversion -- has presented problems for EDs in my region (New South Wales, Australia) over several years.

Using similar logic to Schull's group, it had been assumed that ambulance diversion is a reasonable (and reproducible) surrogate for ED overcrowding. In an attempt to improve the situation for EDs, our regulators and funders have used this definition as a performance measure for hospitals in incentive/disincentive schemes. Although this has produced some motivation to improve bed management, the result has also been to create perverse incentives not to divert ambulances.

Over time, each institution has developed different thresholds for the trigger to divert. Different responses are required if the overcrowding is predominantly due to inpatient bed access block or to an influx of new ED patients.

Many EDs, after years of working in dangerous conditions, have also chosen to eliminate corridor beds and only manage patients in designated treatment spaces. The result of this, combined with avoiding ambulance diversion, is that ambulances frequently wait at the ED entrance for some time -- perhaps hours -- before they are able to unload their patients.

As a result, ambulance unloading times are now being proposed as a more realistic measure of ED overcrowding. There is also current discussion about creating logical guidelines for prehospital diversion initiated by the ambulance service, for patients assessed as being safe to travel to a hospital with greater capacity, perhaps bypassing the nearest facility. This will require frequent and accurate communication of acute hospital capacity to the ambulance coordination centre.

I therefore advise caution in the use of ambulance diversion as a definition of ED overcrowding, and would welcome trans-Pacific collaboration in trying to solve this most frustrating issue in both our health systems.

Sue Ieraci, FACEM
Emergency Physician
Sydney, Australia
Sue.Ieraci@swsahs.nsw.gov.au

References

1. Schull MJ, Slaughter PM, Redelmeier DA. Urban emergency department overcrowding: defining the problem and eliminating misconceptions. CJEM 2002;4(2):76-83.
2. Drummond AJ. No room at the inn: overcrowding in Ontario's emergency departments. CJEM 2002;4(2):91-7.