Emergency department overcrowding in Massachusetts: making room in our hospitals.

In the past year, stories of Emergency Department (ED) crowding and ambulance diversion have entered Massachusetts headlines with increasing frequency. Hospitals throughout the state now report record numbers of hours on " diversion status, " unable to accept new ambulance arrivals because they are overwhelmed. When emergency responsiveness is threatened, public confidence in the entire health care system is undermined and immediate solutions are sought. Yet those who have followed the Emergency Medical Services (EMS) systems for many years recall similar stories and concerns in the late eighties and early nineties. The question therefore arises: Is it different this time? This Issue Brief will detail the nature of the problem, summarize the factors contributing to ambulance diversion in Massachusetts today, and conclude that yes, it is different this time, in the following ways: Changing balances of supply and demand During the nineties, penetration of managed care paralleled an unprecedented decrease in the demand for emergency services. Crowding problems of the early nineties came under control readily as the number of ED visits fell and local strategies for managing temporary peaks of demand were implemented. At the same time, decreasing demand for hospital services generally, combined with a changing financial environment, led to wave after wave of hospital closure. Today, there are roughly one quarter fewer hospitals and emergency departments left in Massachusetts to serve a slightly greater population. For reasons that should be investigated, over the past two years the demand for emergency services has begun to increase once again. While the total number of visits still remains below that of the early nineties, these visits are now funneled into fewer hospitals. As a result, while hospital efficiency is higher than ever before, the entire system is now severely stressed during periods of peak demand. The diversion problem is no longer a limited one While earlier difficulties were confined to the largest urban hospitals during busy winter months, all regions of Massachusetts now report increasing numbers of requests for diversion status— even during summer months. It is now commonplace for several hospitals within the same region to request diversion status simultaneously, necessitating complex mechanisms for rotating ambulance flow when requests for diversion must be denied. Diversion is now more of a hospital than an emergency department problem Increasingly, calls for diversion status now arise because of gridlock when hospitals are full and EDs are occupied with patients awaiting admission. As …