QUALITY: Ambulance Diversions are Tip of Emergency Care Iceberg

What happens when your local emergency room is full? For a troubling number of Americans, the ambulance is put on diversion and forced to seek the nearest hospital with open beds. These diversions were the focus of a recent article in Seattle Times and, more importantly, are a warning of the troubling times ahead for our over-burdened health care system.

The Seattle paper told the story of  Sara Nakagawa, who had complications 10 days after gall bladder surgery. She waited in an ER for six or seven hours,without being seen, went home and dialed 911. The ambulance then spent 20 minutes parked near her home trying to find a place that would take her. Later, the same thing happened to her 12-year-old stepson in the midst of an acute diabetic crisis. 

Ambulance diversion was rare before 1999, but it has since become increasingly prevalent and dangerous. Every minute, one ambulance is diverted from a U.S. hospital, according to a 2006 study in the Annals of Emergency Medicine. A study of New York City hospitals found that periods of ambulance diversion were associated with a 47 percent increase in the mortality rates for heart attacks.

While the effects of ambulance diversion are increasingly apparent, the origins of our current crisis are systematic and date back to the 1990s with the rise of managed care and the Balanced Budget Act of 1997. The calculus of managed care led many hospitals to cut beds, while the budget law meant that the federal government reduced its payments meant to partly reimburse hospitals for treating the uninsured (care that occurred largely in emergency rooms). This one-two punch left hospitals with too few beds and too little money to face an increased demand for emergency services, resulting in the overcrowding of emergency rooms and the diversion of ambulances seen today.

The U.S. has been in the midst of a hospital building boom, but the evidence is that it has focused on high-margin operations such as back surgery, orthopedic surgery, and heart surgery and not on the kinds of services needed by patients with emergency medical conditions, which are less profitable for hospitals.

The nation's emergency services system in most communities is a patchwork of ambulance services all working in isolation taking patients to a group of hospitals that don't talk to each other.Coordination of services is not only crucial to curbing ambulance diversion, but, more broadly, it is a principle for reforming our health care system as a whole. Electronic medical records, medical homes, and host of other reforms have the potential to ensure that individuals have access to the right care when they need it, making sure their primary care physician manage their heartburn and their the ER can manage heart attack.