FIGURE 2-1 The overlapping roles and responsibilities of EMS.

SOURCE: NHTSA, 1996.

gling to manage a very crowded ED often greet arriving EMS units with, at best, a lack of enthusiasm. As a result, clinically important information is sometimes lost in patient handoffs between EMS and hospital staff.

Second, there is little doubt that ED crowding has had a very adverse impact on prehospital care. When an ED is crowded, ED staff may be unable to find the physical space needed to off-load patients. Under these circumstances, EMS units may be stuck in the ED for prolonged periods of time, leaving them out of service for other emergency calls. In addition, ED diversion has become commonplace in many major cities, further hindering the performance of EMS. In major metropolitan areas, it is not uncommon for all of the city’s trauma centers to request ambulance diversion at the same time. When hospital EDs go on diversion status, ambulances may have to drive longer distances and take patients to less appropriate facilities (GAO, 2003). Fully 45 percent of EDs reported going on diversion at some point in 2003, and the problem was especially pronounced in urban areas. Overall, it is estimated that 501,000 ambulances were diverted during that year (Burt et al., 2006).

Although it is likely that ambulance diversions endanger patients, there are no data directly linking ambulance diversions with higher mortality rates. No agency has sponsored a systematic study to examine this question, and fears of legal liability inhibit candid disclosure of adverse events (IOM, 2000). However, a study by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) revealed that more than