Sunday, February 15, 2004

Ambulance Diversion, Crowding and Patient Flow: The Headbone’s Connected to the Footbone—and Everything In-between

Sometimes we hear it said that things “come in threes.” I guess those believers were talking about my 309 patient day (in an ED built for 140 patients/day), the EMS Insider cover story reporting that Memphis had adopted a “No-Ambulance-Diversion” Policy[1] and the JCAHO’s promulgation of a new patient flow standard, LD.3.4., which includes, for example, among the nine elements of performance two elements covering space and facilities for both admitted patients held in temporary areas such as the ED and for ED patients themselves.

Memphis’ experience in doing away with diversion excited me. During the decade plus that I served as Philadelphia’s EMS Medical Director, I used to hear plenty of complaints from colleagues about patients brought to an already busy ED that had been “closed” to ambulance patients. I always responded that any ED, regardless of how stressed, had more resources than did two paramedics on the ambulance. It wasn’t a popular response. I’m not sure how my colleagues at Maimonides would feel about not using diversion. Seeing 80,000 patients annually in 17,000 square feet is a strain; seeing 309 patients in a day in the same space is a patient-safety nightmare.

Perhaps the space constraints of my Brooklyn emergency department limit the opportunity for a Memphis style experiment, though I am not one who would invoke the clich├ęd, “New York is different.” Los Angeles is struggling too: In the January 2004 Annals of Emergency Medicine Eckstein, Chan and colleagues report on “The Effect of Emergency Department Crowding on Paramedic Ambulance Availability.” This symptom of system overload and pending failure has now been scientifically measured and its impact quantified in one large city. Yet this report demonstrates to me yet again that departmental leadership of system improvements alone may be an inadequate response. Why? Because “form follows finance.”

Last month in this space, my colleague Dan Murphy commented, “Form follows finance,” in talking about palliative care and the need to focus on the whole person, not merely an ill organ system. He’s right about that, but implicit in his comment I also see the resource mismatch we confront (almost) every shift. Though few of us seem prepared for planned rationing, the phenomenon is already here in our overcrowded emergency departments and our requests for ambulance diversion.

Overcrowding and its consequences for patient safety are on my mind as I contemplate the 2004 JCAHO patient safety goals—effectively mandates. Patient identification by two means not to include the patient’s location is one of these “goals.” Not relevant to me in the ED you may think; my patient declares his or her need for intervention right in front of me, identification isn’t an issue. But has the wrong patient ever received the wrong x-ray in your ED? Such occurrences are more common than we’d like to acknowledge. Too often the complex cascade creating such error includes the all too “human error” of inadequate identification not because the transport aide and x-ray technologist just don’t care, but because they are harried by too many competing demands—perhaps fed by overcrowding.

As the expression goes, “The headbone’s connected to the footbone” and everything in-between. We’ve all come to realize that the functioning of the whole hospital connects to overcrowding in the ED. Improving patient flow and moving admitted patients out of the ED more quickly can reduce strain on the ED staff.

Just recently we had Carolyn Santora, RN and Peter Viccellio, MD of SUNY Stony Brook; speak to a wide cross-section of our hospital staff—including nursing leadership about their approach to managing over-crowding and patient flow. At Stony Brook they admit patients to the hallways. Of interest to me was their finding that over 40% of their patients admitted to hallways are moved into a room either on arrival (~20%) or within an hour of arrival to the floor (~20+%). The nursing units where these patients are admitted are nominally staffed at a ratio of one nurse to six patients. Contact Peter or Carolyn through Peter’s assistant ( for further information about the Stony Brook experience. For a variety of operational and cultural reasons, this is an unlikely step at Maimonides, though our nearest competitor hospital has implemented just such a process.

At Maimonides we are implementing tracking and communication software throughout the hospital that will make bed status explicit to everyone while facilitating communication with patient transport staff through pagers and telephone based interactive voice-response. This tool purportedly achieves substantial improvements in the speed of bed turnovers. Presumably, consequent to the publication of bed resources and their statuses along with improved communication and enhanced accountability of all staff responsible for bed turnover all steps in bed turnover take less time and beds become available more quickly. I’m optimistic for improvement in patient flow, but mindful that these measures are more “tinkering” when one looks at the totality of the hospital environment and how “form follows finance.”

Nonetheless, within my scope as director of a single emergency department this is what I can do. As a younger man through political activity and what’s come to be called, “direct action” I endeavored along with others to change our world. A bit older and somewhat battered—hopefully not cynical—I’m making efforts at the level where I can have some effect and sharing some of these efforts with you through this column.

I’ve regularly mentioned the emergency medicine mailing list, “emed-l.” (Join using the ED Subscriber) in this column. Setting your preferences to “digest” will result in only one message a day in your e-mail inbox, yet you can still read or quickly skip through the comments. As at least one presidential candidate has shown this season, the internet can provide a powerful organizing for a leader with a vision. Perhaps somewhere in the mix of clinical, financial, operational and political issues discussed on emed-l there may be some opportunity to address the “form follows function” observation and engender a formal public policy debate on healthcare rationing rather than limit ourselves to tinkering with ambulance diversion, ED crowding and patient flow.

[1]“Memphis Adopts No-Ambulance-Diversion Policy," EMS Insider 30(12):1-3; December 2003.