On Sept. 1, Indiana became the third state to ban hospital diversion, a practice that Massachusetts has had for 17 years. But has hospital diversion actually worked?
On Jan. 1, 2009, Massachusetts became the first state to enact a hospital diversion ban. Under the ban, hospitals cannot use diversion unless there is an internal disaster that renders the ED unusable.
A predicted consequence of the diversion ban was more severe ED crowding and that ambulances would spend more time at hospitals waiting to transfer the patient to ED personnel, delaying their response to the next emergency, a 2010 American Medical Association report said. However, a year after the ban was implemented, preliminary reports found operational changes made by hospitals in anticipation for the ban alleviated many of these concerns. Many hospitals reported improved efficiency on the impatient units to promote earlier hospital discharge and one Boston hospital built a “surge pod” for ED patients awaiting inpatient beds. Boston EMS also reported there were no long wait times for patients transferring from EMS to hospital staff.
In the last 17 years, a few studies have analyzed the effects of the hospital diversion ban. Here is what they found.
1. An August 2022 study, published in Springer Nature Link, compared 744,791 Medicare Fee for Service enrollee records from 2007 to 2012 across 3,331 ZIP codes. It found the Massachusetts diversion ban was associated with a reduced proportion of white and Black EMS patients being transported to the most frequent ED destination for white patients, “highlighting the role of non-proximity factors in EMS transport destination,” the study authors wrote. They also found that Hispanic patients were more likely to be transported to a safety-net ED.
2. A May 2014 study, published in PubMed, interviewed leaders at nine Massachusetts hospitals, and found most described some positive effect from the ban, including some who said the ban had no direct effect on their individual hospital. Most leaders said they believed the ban had improved quality of care, and relationships between EMS and hospital staff.
3. A February 2013 study, published in The Journal of Emergency Medicine, compared seven EDs in Massachusetts. Two, including the only level 1 trauma center, were “high” diversion EDs and five were “low” diversion EDs. The study compared total volume, number of admission, number of elopements and length of stay for all admitted and discharged patients over the course of a year. The study found no clinically significant changes in any ED group in mean monthly volume, admissions, elopements or length of stay for any patient disposition group — meaning the diversion ban was not associated with significant changes in throughput measures.
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