Since the health department regulation, believed to be the first statewide ban on ambulance diversion in the U.S., took effect Jan. 1, 2009, 73 hospitals have reported the time from patient arrival in the ED to disposition. Through September 2009, ED patients admitted to Massachusetts hospitals spent about 5½ hours in the emergency department. Patients who were not admitted spent 2½ hours receiving treatment in the ED, according to state data shared with American Medical News.
 
The ED wait times were largely unchanged from the first month of reporting in January 2009 through the last month of reporting in September 2009.

The Massachusetts College of Emergency Physicians pushed for the ban on ambulance diversion, which is the practice of referring ambulance-driven patients elsewhere because a hospital's emergency department has hit capacity. The organization's president, Joseph M. Bergen, DO, said the health department's data show that the policy appears to have worked well, despite trepidations.

"There were concerns that we would see ambulances stacked up and unable to unload patients and that emergency departments would become even more crowded with even poorer flow numbers," said Dr. Bergen, chair of emergency medicine at Emerson Hospital in Concord, Mass. "We have not, to my knowledge, had any major patient care problems as a result of this action, and I submit that most emergency directors would say quite the opposite -- that patient care has improved, because patients are going to the appropriate hospital, where the specialists know them and where their medical records are stored."

Hospitals have made administrative changes to improve patient flow, said Karen Nelson, RN, senior vice president of clinical affairs at the Massachusetts Hospital Assn. Examples include discharging inpatients before noon, adjusting ED staffing, adding overflow units, streamlining admissions and changing elective surgery times.

"Overall, our hospitals are now addressing emergency department overcrowding and diversion as a facilitywide issue, not just an ED issue," Nelson said.

Avoiding diversion

The ambulance diversion ban did not come suddenly. A state task force with representation from physicians, hospitals and others had been working on the issue, and many hospitals in the state already had adopted internal no-diversion policies.

"Many hospitals already were doing a lot of work on patient flow," said Elizabeth Daake, MPH, director of policy development, planning and research for the Bureau of Health Care, Safety and Quality in the Massachusetts Dept. of Public Health. "It is due to the hard work of everyone involved, from policymakers to hospitals themselves to ambulance workers, that [wait times] have stayed so reasonable."

The state's diversion task force is now focusing on ED patient boarding and patient flow, Daake said. Under the regulation, hospitals are still allowed to divert ambulances in the event of facility problems such as loss of electrical power. Daake said health officials from around the country have inquired about adopting the Bay State's policy.

Nationally, one ambulance is diverted every minute, according to the American College of Emergency Physicians. At any moment, one in 10 hospitals is on diversion, said Sandra Schneider, MD, ACEP's president-elect. She said she hopes other states take a tougher line on diversion.

"What I think you're going to see out of [the Massachusetts experience], and what I hope people will begin to understand, is that using the emergency department as an overflow unit for the hospital is dangerous," said Dr. Schneider, professor of emergency medicine at the University of Rochester School of Medicine and Dentistry in New York.

"The bottom line is about what's good for the patients," she said. "In Massachusetts, we've seen that they decided to look at what was good for the patient and that means no ambulance diversion and asking, 'How do we get there?' I give them an amazing amount of credit -- they have done the right thing for people."