APP Honors: Emergency Rooms

by atasha Mihal and Renee Moilanen

For full report click here [1].

Los Angeles County allows an overcrowded emergency room to close its doors to additional paramedic transports, a procedure known as "diversion." During these temporary closures, which come with little warning, paramedics scramble to find the next closest facility. They must drive longer distances, delaying patient care and prolonging response times to new incidents. In addition, other hospitals must shoulder the increased patient load when one emergency room takes itself out of the network.

This study constitutes one of the first comprehensive studies of diversion in Los Angeles County. It focuses on the West San Fernando Valley, a region noted for its higher-than-average diversion rates. This project analyzes the impact of diversion on the West Valley, identifies major problems related to diversion, and proposes recommendations to reduce inappropriate emergency room closures in this region.

This analysis found that one in seven emergency patients is diverted due to emergency room crowding. At the same time, individual hospitals may not see a dramatic decline in patient volume while on diversion. On the contrary, a hospital on diversion still takes in more than half of its ambulance runs. Diversion may reduce a hospital's probability of receiving patients, but it by no means closes an emergency room to all transports.

In addition, as more hospitals close, fewer patients are diverted, further eroding diversion's value as a volume control mechanism. Once all hospitals are closed to paramedic transport, everyone is open to paramedic transport. The system reverts back to status quo, making diversion irrelevant. Diversion, then, seems a poor tool for communicating emergency room crowding.

This study identifies three broad policy problems that contribute to high diversion rates and emergency room closures when no crowding exists:

• Policies and Compliance: The county does not adequately define emergency room saturation. Neither the county nor hospitals comply to existing regulations.
• Coordination and Communication: Insufficient coordination within and among hospitals may increase diversion. In addition, diversion is not a descriptive communication tool.
• Oversight and Consequences: There is no real-time monitoring of diversion or consequences for inappropriate diversions.

This study recommends policy solutions for each of these problems.