Effects of Hospital Closure and Hospital Characteristics on Emergency Department Ambulance Diversion, Los Angeles County, 1988 to 2004

University of California, Los Angeles, Los Ángeles, California, United States
Annals of emergency medicine (Impact Factor: 4.68). 05/2006; 47(4):309-16. DOI: 10.1016/j.annemergmed.2005.12.003
Source: PubMed


We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion.
The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation.
Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility's diversion hours increased during the study period.
Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility's diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

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    • "Although ED use by the uninsured is a major contributor to the recent surge in volume seen at many hospitals, the majority of growth in recent years has been attributed to the privately insured seeking a “one-stop” healthcare source.10 In addition to these factors, there are staffing shortages, lack of materials to measure and manage patient flow, and fewer available beds due to local hospital closures.12,13 "
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    ABSTRACT: THE OBJECTIVE OF THIS STUDY WAS TO EVALUATE THOSE FACTORS, BOTH INTRINSIC AND EXTRINSIC TO THE EMERGENCY DEPARTMENT (ED) THAT INFLUENCE TWO SPECIFIC COMPONENTS OF THROUGHPUT: "door-to-doctor" time and dwell time. We used a prospective observational study design to determine the variables that played a significant role in determining ED flow. All adult patients seen or waiting to be seen in the ED were observed at 8pm (Monday-Friday) during a three-month period. Variables measured included daily ED volume, patient acuity, staffing, ED occupancy, daily admissions, ED boarder volume, hospital volume, and intensive care unit volume. Both log-rank tests and time-to-wait (survival) proportional-hazard regression models were fitted to determine which variables were most significant in predicting "door-to-doctor" and dwell times, with full account of the censoring for some patients. We captured 1,543 patients during our study period, representing 27% of total daily volume. The ED operated at an average of 85% capacity (61-102%) with an average of 27% boarding. Median "door-to-doctor" time was 1.8 hours, with the biggest influence being triage category, day of the week, and ED occupancy. Median dwell time was 5.5 hours with similar variable influences. The largest contributors to decreased patient flow through the ED at our institution were triage category, ED occupancy, and day of the week. Although the statistically significant factors influencing patient throughput at our institution involve problems with inflow, an increase in ED occupancy could be due to substantial outflow obstruction and may indicate the necessity for increased capacity both within the ED and hospital.
    The western journal of emergency medicine 02/2010; 11(1):10-5.
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    • "Long-lasting hospital closure are associated with significant but temporary increase in ambulance diversions to the nearest ED. Fewer EDs and increasing number of patient visits over time, may also cause ED-overcrowding and consequent ambulance diversions [9,22]. Ambulance diversion has a huge impact on public health, since it may place the patient at risk for poor outcome, prolonged pain and suffering. "
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    ABSTRACT: A hospital's capacity and preparedness is one of the important parts of disaster planning. Hospital-related incidents, a new phenomenon in Swedish healthcare, may lead to ambulance diversions, increased waiting time at emergency departments and treatment delay along with deterioration of disaster management and surge capacity. We aimed to identify the causes and impacts of hospital-related incidents in Region Västra Götaland (western region of Sweden). The regional registry at the Prehospital and Disaster Medicine Center was reviewed (2006-2008). The number of hospital-related incidents and its causes were analyzed. There were an increasing number of hospital-related incidents mainly caused by emergency department's overcrowdings, the lack of beds at ordinary wards and/or intensive care units and technical problems at the radiology departments. These incidents resulted in ambulance diversions and reduced the prehospital capacity as well as endangering the patient safety. Besides emergency department overcrowdings, ambulance diversions, endangering patient s safety and increasing risk for in-hospital mortality, hospital-related incidents reduces and limits the regional preparedness by minimizing the surge capacity. In order to prevent a future irreversible disaster, this problem should be avoided and addressed properly by further regional studies.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 02/2009; 17(1):26. DOI:10.1186/1757-7241-17-26 · 2.03 Impact Factor
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    • "The increased number of hospital-related alerts during the study period raises concern, since it has a negative impact on preparedness ("surge capacity") for medical emergencies as well as major incidents within the affected area. This has been reported by other investigators [17-19], but seems to be a new and emerging problem for Sweden. The reduction of hospital beds as a consequence of economic constraint, increased sub-specialization of hospitals as well as increased dependency on high-tech equipments can be factors contributing to this problem, making the whole healthcare system more vulnerable in case of major incidents [20]. "
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    ABSTRACT: Although disasters and major incidents are difficult to predict, the results can be mitigated through planning, training and coordinated management of available resources. Following a fire in a disco in Gothenburg, causing 63 deaths and over 200 casualties, a medical disaster response centre was created. The center was given the task to coordinate risk assessments, disaster planning and training of staff within the region and on an executive level, to be the point of contact (POC) with authority to act as "gold control," i.e. to take immediate strategic command over all medical resources within the region if needed. The aim of this study was to find out if the centre had achieved its tasks by analyzing its activities. All details concerning alerts of the regional POC was entered a web-based log by the duty officer. The data registered in this database was analyzed during a 3-year period. There was an increase in number of alerts between 2006 and 2008, which resulted in 6293 activities including risk assessments and 4473 contacts with major institutions or key persons to coordinate or initiate actions. Eighty five percent of the missions were completed within 24 h. Twenty eight exercises were performed of which 4 lasted more than 24 h. The centre also offered 145 courses in disaster and emergency medicine and crisis communication. The data presented in this study indicates that the center had achieved its primary tasks. Such regional organization with executive, planning, teaching and training responsibilities offers possibilities for planning, teaching and training disaster medicine by giving immediate feed-back based on real incidents.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 02/2009; 17(1):32. DOI:10.1186/1757-7241-17-32 · 2.03 Impact Factor
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