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19-12-2011 | Article

Simple full-capacity protocol could reduce diversion rates in emergency rooms


Free abstract

MedWire News: Use of a simple three-step protocol to avoid emergency room overcrowding can significantly reduce ambulance diversion rates by two-thirds, research suggests.

The findings could have important policy implications, given that ambulance diversion as a result of overcrowding has been associated with increased patient mortality and significant hospital financial losses.

Taketo Watase (Oregon Health and Science University, Portland, USA) and colleagues assessed the impact of an emergency department (ED) full-capacity protocol on diversion rates and other outcomes at an ED with approximately 43,000 annual visits. Data were analyzed 12 months before and 12 months after the initiation of the protocol.

During the implementation period, attending physicians and charge nurses were educated with clear and simple figures on the criteria for the initiation of the new protocol.

The protocol used consists of three steps: first, a predivert status when the initial awareness of ED crowding is announced; second, an assessment of the situation 30 minutes following the announcement of step one; third, initiation of the "full capacity" status should the situation have worsened following step two. If all criteria at step three are met, then the ED is put on divert and all ambulances are sent to other hospitals.

The proportion of days when the ED went on diversion at least once during a 24-hour period was significantly reduced following implementation of the protocol, from 60.4% to 20.0%. The new protocol also significantly reduced average admittance length of stay ([LOS] 5.7 vs 6.4 hours), average discharge LOS (3.7 vs 4.1 hours), average bed wait (2.6 vs 3.0 hours/patient), and the proportion of patients leaving without being seen (1.4 vs 3.1%).

Logistic regression analysis showed that implementation of the protocol was significantly associated with a decreased likelihood of ambulance diversion, at an odds ratio of 0.32. Discharge LOS, admission rate, and the intensive care unit or wards being at full capacity were also significantly associated with diversion.

Reporting their findings in the American Journal of Emergency Medicine, Watase and colleagues conclude: "Our predivert/full-capacity protocol is a simple, generalizable and sustainable strategy that can be implemented within the boundaries of the ED and is significantly associated with decreased diversion hours."

By Iain Bartlett