Observation Unit Helps Prevent ED Diversion : Solutions to overcrowding and ambulance diversion 'crisis' proven to be effective.


NEW YORK — Observation units may be an answer that overcrowded emergency departments seek to reduce ambulance diversion, Robbin S. Dick, M.D., said at the annual meeting of the Society for Academic Emergency Medicine.

“Ambulance diversion has become a crisis in many cities in the United States. Sometimes every hospital is on divert at the same time, with ambulances driving around looking for a place to deliver the patient,” said Dr. Dick of the department of emergency medicine at the University of Rochester (N.Y.).

“I think [the observation unit] is going to be the solution for emergency departments that are high in volume” and have high admission and inpatient occupancy rates, he predicted.

While observation units show promise, some experts cautioned that true solutions must reach beyond the ED to reform the hospital systems and practices that ultimately fuel overcrowding.

A Diverting Solution

In hospitals with an inpatient occupancy rate of 90%, observation units may provide breathing room for seasonal and monthly fluxes in EDs that see patient volumes of 50,000–70,000 or more per year and have admission rates of 20% or higher, Dr. Dick told this newspaper.

Ambulances can be diverted for a variety of reasons: ED overcrowding, large numbers of patients presenting to an ED, staff shortages (mostly nurses), closure of other EDs, and ED boarding patients—those who remain in the ED waiting for an inpatient bed to open up.

In the last 7 years, Rochester experienced the closure of two emergency departments, each of which had a patient volume of about 30,000 per year, he said.

Strong Memorial Hospital, a teaching institution in Rochester where Dr. Dick practices, had almost 4,000 hours of ED overcrowding in 2003, which averages out to more than 300 hours per month. “Rochester is a poster child for ED overcrowding,” Dr. Dick quipped.

Rochester follows a community-wide standard in which an ambulance can be diverted if three out of four criteria are met: No inpatient beds are available, no ICU beds are available, a 4-hour or longer wait exists for treat-and-release patients, and more than 40% of the beds in the ED are occupied by inpatients.

In January 2004, Strong Memorial opened a 24-bed observation unit for ED patients. The new unit accepted patients who are commonly observed as a part of treatment, such as those with chest pain, heart failure, asthma, or kidney stones. Stable ED boarding patients who were awaiting an inpatient bed and ED patients who required consultation or extended testing also went to the observation unit.

During 2004, more than 6,800 patients came through the unit; 90% of the patients required observation of their condition, 5% were ED boarding patients, and 5% required additional consultation or testing.

The unit averaged 95% occupancy and admitted a mean of 19 patients per day to the inpatient floor—a 12% rate of admission overall.

In a prospective study, Dr. Dick and his colleagues found that the observation unit significantly reduced the number of ambulance diversion hours from 3,447 in 2003 (40% of the time) to 1,585 in 2004 (18% of the time). This decline occurred despite increases in both ED patient volume (from 87,101 in 2003 to 88,962 in 2004) and ambulance arrivals (from 25,774 in 2003 to 29,441 in 2004). The ED admitted about 800 more patients in 2004 than in 2003.

Dr. Dick said he chose ambulance diversion time as the primary end point rather than ED boarding time because diversion time is the one indicator that stands out regardless of the primary cause of overcrowding, such as a decrease in nursing staff or bed availability in the hospital.

Diversionary hours will increase along with the primary cause of overcrowding even when other factors remain the same.

The study's results could be limited, Dr. Dick acknowledged, if the decrease in ambulance diversion hours was due to unrecognized changes in community factors. But “we don't know of anything specifically that changed during 2004,” he added.

Building Buy-In

To establish the unit at Strong Memorial, Dr. Dick had to create new protocols to drive the unit and change the mindset of practitioners, especially nurses, to be comfortable with the fact that the unit's occupancy will turn over every 24 hours.

The availability of the observation unit has not led physicians to keep ED patients longer or admit them to the unit rather than immediately as an inpatient, Dr. Dick said.

In the Strong Memorial ED, an emergency physician decides whether a patient can or cannot go home after an evaluation. A utilization review nurse decides if the patient satisfies InterQual criteria for admission to an inpatient floor bed or if the patient can be sent to the observation unit.


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