State orders hospital ERs to halt 'diversions'

Bid to ease overcrowding seen to sometimes delay care

The state has ordered Massachusetts hospitals to stop turning away ambulances when their emergency rooms are overcrowded, a decades-old practice that can delay treatment and has upset patients denied care at their usual hospitals.

Officials at the state Department of Public Health said yesterday that hospitals would in almost all cases have to discontinue temporary ER closures, called "diversion," by Jan. 1. While the practice may give hospitals temporary breathing room, Paul Dreyer, director of healthcare safety and quality, said it has done nothing to solve the underlying problem in the healthcare system - patients backing up in ER hallways because hospitals have no open beds.

In fact, diverting ambulances has caused problems, he said, interfering with patient choice, increasing the time patients spend in ambulances, tying up the vehicles, and shifting crowding to other hospitals.

"Diversion potentially creates more problems than anyone thinks it solves," Dreyer said.

ERs regularly shut their doors to most ambulances for hours at a time when they have too many patients, with the busy Massachusetts General and Brigham and Women's hospitals in Boston accounting for the majority of closures statewide. When this happens, ambulances often cannot take patients to the hospital where their regular doctor works and where their medical records are kept.

In a letter to hospital executives this summer, Dreyer said several national patient safety groups and the American College of Emergency Physicians discourage the routine use of diversion to solve ER overcrowding. Under the new policy, hospitals will be allowed to close their ERs to ambulances only if they have a serious internal emergency such as a major fire, called a "code black."

"Undoubtedly this [ban on diversion] is going to be better for patients," said Dr. Alasdair Conn, chief of emergency services at Mass. General. "It makes no sense for a patient with 20 years of history at a hospital, where they had their surgery, where their EKG and other test results are, to have to go somewhere else."

But, he said, the change will be a serious challenge for hospitals, especially Mass. General, which has relied more heavily than any other hospital on temporary closures of its ER. The hospital, he said, is working to prepare for the change in January by focusing on ways to discharge patients from the hospital earlier in the day, thereby freeing up beds for patients waiting in the ER.

Mass. General, which sees about 85,000 patients a year in its emergency room, accounted for about 35 percent of the 1,826 hours hospitals closed their ERs to ambulances last year, he said. That means the hospital's ER was on diversion for the equivalent of almost a month.

Dr. Ron Walls, chairman of emergency medicine at the Brigham, said sometimes the hospital went on diversion because another hospital had done so, which directed more patients to the Brigham. "It's pretty challenging for one hospital to stop diverting because other hospitals are still doing it," he said.

When a hospital is on diversion, it still takes trauma and burn patients who come in by ambulance, Conn said. And, if a patient is a longtime Mass. General patient, ambulance personnel will call the hospital and ask ER staff to make an exception. But the ER cannot accommodate all of these patients, who often have chest pain, pneumonia, or minor broken bones, Conn said.

Because hospitals on diversion still take walk-in patients, sometimes patients who have been diverted to another hospital will return home and take a cab or have a friend drive them to the ER, Conn said.

Dr. Brien Barnewolt, chairman of emergency medicine at Tufts Medical Center in Boston, agreed that the new policy will be good for patients but challenging for hospitals. But, he and other ER directors said, Boston hospitals stopped ER closures for two weeks as an experiment, and there was no increase in the time it took for patients to be seen in the ER or in patients "boarding" in ER hallways. During that period, hospitals found ways to more quickly treat those patients and admit them to a hospital bed if necessary.

Dreyer said allowing hospitals to use ambulance diversion as a release valve may have taken away their incentive to focus on the internal backlogs in their institutions. Now hospitals are addressing the problem.

Barnewolt said Tufts stopped temporarily closing its ER to ambulances in August to prepare for the change. The hospital took several measures to free up beds in the hospital so ER patients could be admitted more quickly, including performing blood tests on overnight patients earlier in the morning, at 5 or 6 a.m. This allows doctors to get test results faster so they can discharge patients who are well enough to go home earlier in the day.

Conn said Mass. General also is working to expedite treatment in the hospital, and that he does not expect the ER to become more crowded once the new policy goes into effect in January.

"We'll have some strategies in place so we'll squeeze by," he said, "with one caveat:" a bad flu season.

Liz Kowalczyk can be reached at kowalczyk@globe.com.