To remain viable, some hospitals consolidated and reduced their number of inpatient beds (Brewster and Felland, 2004). Others closed important but unprofitable services, such as trauma, burn, and psychiatric care (IOM, 2003). When no vacant bed is available for an admitted ED patient, most hospitals require ED staff to provide ongoing care to the patient until one becomes available. Many patients are forced to wait hours for an inpatient bed, but some wait days (GAO, 2003). Because most EDs have a limited number of examination rooms and treatment bays, it is not uncommon for admitted patients to be kept on stretchers in ED hallways. This phenomenon, often called “boarding,” creates a logjam in the ED because these patients require ongoing attention and care, reducing the resources available to evaluate and treat incoming ED patients. EDs can quickly become overwhelmed by boarders and the crush of patients waiting for care. When patient volume becomes too high for the ED to handle, the hospital may order the ED to go “on diversion,” meaning that inbound ambulance traffic is directed to other hospitals. Diversion has become a common occurrence in many areas. In 2003, 45 percent of EDs were on diversion at some point, resulting in the diversion of an estimated 501,000 ambulance runs (Burt et al., 2006).

Diversion has a ripple effect throughout the community, impacting patients, other hospitals, and the community’s EMS system. Diversion delays lifesaving care to seriously ill and injured children and adults. By redirecting ambulances to a hospital farther away, it causes valuable time for treating patients to be lost (Neely et al., 1994). For patients who have suffered serious trauma, a heart attack, or a stroke, timely care is essential to prevent death. In these instances, extra minutes spent in transit can have dire, even fatal consequences. For patients with non-life-threatening injuries and illnesses, the extra commute time to an ED bed can cause unnecessary pain and stress. Also, when one hospital goes on EMS diversion, others often follow, either because the inflow of patients becomes too great to handle or because they wish to limit exposure to an influx of uninsured patients to the ED. The result is the health care equivalent of a “rolling blackout” as hospital after hospital closes its doors to ambulance traffic.

When hospitals are on diversion, ambulance transport teams spend more time in transit. The result is not only less accessibility for the community, but also higher levels of stress to providers who are regularly pressured to find an open hospital or care for patients in the ambulance for an extended period of time.

Boarding and ambulance diversion have been prevalent over the past several years. A number of studies have documented the problem, but perhaps most telling is a point-in-time study based on a survey sent to a random sample of hospitals. On Monday, March 12, 2001 (a typical Monday), at 7:00 PM (local time for hospitals), 11 percent of responding hospitals reported being



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