Ambulance Diversion Research Articles

Association of Ambulance Diversion Policy on EMS Transport and Ambulance Patient Offload Times: A Comparison of Three Strategies

Objectives Despite limited supporting data, hospitals continue to apply ambulance diversion (AD). Thus, we examined the impact of three different diversion policies on diversion hours, transport time (TT; leaving scene to arrival at the hospital), and ambulance patient offload time (APOT; arrival at the hospital to patient turnover to hospital staff) for 9-1-1 transports in a 22-hospital county Emergency Medical Services (EMS) system. Methods This retrospective study evaluated metrics during periods of three AD policies, each 27 days long: hospital-initiated (Period 1), complete suspension (Period 2), and County EMS-initiated (Period 3). We described the median transports and diversion hours, and compared the daily average and daily 90th percentile TT and APOT during the three study periods. Results Over the study period, there were 50,992 total transports in the county; Period 3 had fewer median transports per day than Period 1 (581 vs 623, p < 0.001), while Period 2 was similar to Period 1 (606 vs 623, p = 0.108). Median average daily diversion hours decreased from 98.1 h during Period 1 to zero hours during both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily average TT decreased from 18.3 min in Period 1 to 16.9 min in both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily 90th percentile TT showed a similar decrease from 30.2 min in Period 1 to 27.5 in Period 2 (p < 0.001), and to 28.1 in Period 3 (p = 0.001). Median average daily APOT was 26.0 min during Period 1, similar at 25.2 min during Period 2 (p = 0.826) and decreased to 20.4 min during Period 3 (p < 0.001). The median daily 90th percentile APOT was 53.9 min during Period 1, similar at 51.7 min during Period 2 (p = 0.553) and decreased to 40.3 min during Period 3 (p < 0.001). Conclusions Compared to hospital-initiated AD, enacting no AD or County EMS-initiated AD was associated with less diversion time; TT and APOT showed statistically significant improvement without hospital-initiated AD but were of unclear clinical significance. EMS-initiated AD was difficult to interpret as that period had significantly fewer transports. EMS systems should consider these findings when developing strategies to improve TT, APOT, and system use of diversion.

Reward function design method to achieve system-level objectives in ambulance diversion problem

This study addresses a reward function design problem in multi-agent systems, using ambulance diversion (AD) problem in emergency medical services (EMS) as an application. While Emergency Departments (EDs) may declare AD to alleviate overcrowding, excessive use of this strategy by individual EDs can have negative consequences, such as limited access and delayed care for emergency patients. To eliminate negative consequences caused by individual decisions, we propose a reward function design method to align individual agents’ decisions with socially optimal strategies. This method ensures that an equilibrium status is achieved under socially optimal operation by removing incentives for deviations from socially optimal behavior while maximizing system welfare without extra investment. The proposed method offers an exact solution for designing reward function of a stochastic game model with finite state and action spaces. We conduct numerical experiments for a 2-ED system and demonstrate that the designed reward function properly guides the EDs toward a socially optimal AD strategy.

An Effective Methodology for Scoring to Assist Emergency Physicians in Identifying Overcrowding in an Academic Emergency Department in Thailand

BackgroundEmergency Department (ED) overcrowding is a global concern, with tools like NEDOCS, READI, and Work Score used as predictors. These tools aid healthcare professionals in identifying overcrowding and preventing negative patient outcomes. However, there’s no agreed-upon method to define ED overcrowding. Most studies on this topic are U.S.-based, limiting their applicability in EDs without waiting rooms or ambulance diversion roles. Additionally, the intricate calculations required for these scores, with multiple variables, make them impractical for use in developing nations.ObjectiveThis study sought to examine the relationship between prevalent ED overcrowding scores such as EDWIN, occupancy rate, and Work Score, and a modified version of EDWIN newly introduced by the authors, in comparison to the real-time perspectives of emergency physicians. Additionally, the study explored the links between these overcrowding scores and adverse events related to ED code activations as secondary outcomes.MethodThe method described in the provided text is a correlational study. The study aims to examine the relationship between various Emergency Department (ED) overcrowding scores and the real-time perceptions of emergency physicians in every two-hour period. Additionally, it seeks to explore the associations between these scores and adverse events related to ED code activations.ResultsThe study analyzed 459 periods, with 5.2% having Likert scores of 5–6. EDOR had the highest correlation coefficient (0.69, p < 0.001) and an AUC of 0.864. Only EDOR significantly correlated with adverse events (p = 0.033).ConclusionEDOR shows the most robust link with ‘emergency physicians’ views on overcrowding. Additionally, elevated EDOR scores correlate with a rise in adverse events. Emergency physicians’ perceptionof overcrowding could hint at possible adverse events. Notably, all overcrowding scores have high negative predictive values, efficiently negating the likelihood of adverse incidents.

Decision-making model for hospital selection in the emergency medical system

We designed a decision model for hospital selection in the emergency medical system, which integrates its actors, such as the dispatch center, emergency medical services (EMS), and emergency departments (ED). We designed and simulated the model using colored Petri nets to evaluate two policies: the nearest hospital policy (in time) and the proposed policy that integrates the proximity criteria and ED congestion. The simulation results for the Massachusetts Region 3 case study indicate that the proposed policy that considers the shortest transfer times (travel time + wait time) appropriately allocates ambulance patients to EDs. In addition, the proposed improves and balances indicators, such as average patient waiting times per ESI, physician utilization, and average patient queues, in each ED. For example, the proposed policy best scenario that adds a physician to all hospital EDs would reduce waiting times for ESI 2 and 3 patients between (26.16%–71.65%) and (74.69%–88.84%), respectively, and improve the patient queue and the allocation of ambulance patients. Finally, the proposed decision policy allows the planning of medical staff in EDs and scenario analysis using performance indicators focused on the timeliness of patient care. This approach would avoid problems such as overcrowding, delayed discharge, retention, and diversion of ambulances, putting patient health and life at risk.

Chronic Disease Prevention 2024 Update Essential to our Health and Future

To the great frustration of public health practitioners and healthcare providers alike, preventable chronic conditions and risk factors continue to be present and, in some cases, grow in influencing our collective health and wellbeing. Despite some reduction in demand on health systems with a lessening of the Covid-19 pandemic, we continue to read of long waits for appointments for primary and specialty care, and our definitions of “Urgent” and “Emergency” bear scrutiny. Workforce shortages remain an issue across jurisdictions and other functional challenges remain including ambulance diversion and delays on entry to emergency rooms, closing floors while demand for beds increases, shortages of supplies and medications, and continued presence of risk factors (i.e. tobacco and related products, unhealthy foods, community challenges to regular physical activity). These are important, but an incomplete picture without addressing the proven opportunities for prevention of chronic conditions and risk factors that lead to these troubling phenomena. When we consider what could be gained by preventing many cases of overweight and obesity, reducing stress on our bodies through better diet and more activity, better outcomes through earlier screening for common cancers and other public health strategies, we see clearly that investing in these efforts on a national basis must be part of the solution. Further, these challenges must be addressed in a way the levels the playing field so people now subject to disparate conditions have equitable access comparable to all.

Management of emergency department diversion during the COVID-19 pandemic and disaster periods.

Recent news has shown the strain on hospital emergency departments (EDs) and emergency medical services agencies due to the surge of COVID-19; however, compared to all emergency medical service transports, is it true that the United States is seeing an increase in the frequency of diversions? In this quantitative research report, data were collected and analyzed from a national prehospital emergency medical services information system, which allowed for a comparison of the frequency of diverted ambulances, transport times, and final patient acuity of patients arriving by diverted ambulances before and during the COVID-19 pandemic. Statistical analysis was performed on data obtained from the National Emergency Medical Services Information System to compare the frequency of ambulance diversion prior to the COVID-19 disaster and during COVID-19. Analysis of data obtained from the National Emergency Medical Services Information System found that there was not a significant increase in the percentage of ambulance transports that were diverted during the COVID-19 pandemic compared to before the pandemic. However, there were significant increases in the volume of all transports and diverted transports during the COVID-19 pandemic (p < 0.01 for both measures). The significant increases seen in the demand for services, combined with an overall downward trend in the number of healthcare facilities, have resulted in an increase in the volume of diversions, despite the overall demand increasing as well. The COVID-19 pandemic serves as a disaster/public health crisis that is subject to the same phases compared to other types of disasters. The significant findings of this report should provide the emergency services field a big picture, understanding that the problem at hand is multifaceted, with these findings shining light on the effects of current issues between emergency services and hospital EDs.

Patterns in Patient Encounters and Emergency Department Capacity in California, 2011-2021

The health care system has undergone major changes in the past decade, and emergency department (ED) crowding has worsened over time; however, the most recent patterns in ED capacity and use in California have yet to be studied. To analyze patterns in ED capacity and utilization in California hospitals from 2011 to 2021. This retrospective cohort study used data from the California Department of Health Care Access and Information and the US Census Bureau to analyze ED facility characteristics from more than 400 general acute care hospitals with more than 320 EDs in California as well as patients who presented to those EDs between January 1, 2011, and December 31, 2021. Linear patterns (measured by percentage change) in total annual ED capacity (volume of hospital beds, EDs, ED treatment stations, and trauma centers) and ED use (ED visits by disposition and acuity) were assessed as primary outcomes. Patterns in ambulance diversion hours and the number of patients who left the ED without being seen were also examined as secondary outcomes. Visit acuity was categorized into 5 levels by increasing severity (minor, low to moderate, moderate, severe without threat, and severe with threat) based on California Department of Health Care Access and Information descriptions corresponding to Current Procedural Terminology codes. In the prepandemic period (2011-2019), the total population of California increased from 37 638 369 to 39 512 223 (5.0%; 95% CI, 4.1%-5.8%), then decreased to 39 237 836 in 2021 (0.7%; 95% CI, -3.9% to 2.5%). Over the entire study period (2011-2021), the total California population increased by 4.2% (95% CI, 3.3%-5.2%). From 2011 to 2019, the annual number of ED visits increased from 12 054 885 to 14 876 653 (23.4%; 95% CI, 20.0%-26.8%) before decreasing to 12 944 692 in 2021 (-13.0%; 95% CI, -33.1% to 7.1%); from 2011 to 2021, total ED visits increased by 7.4% (95% CI, 5.6%-9.1%). From 2011 to 2021, the total number of EDs decreased from 339 to 326 (-3.8%; 95% CI, -4.4% to -3.2%) and the total number of hospital beds decreased from 75 940 to 74 052 (-2.5%; 95% CI, -3.3% to -1.6%), while the number of ED treatment stations in these fewer EDs increased from 7159 to 8667 (21.1%; 95% CI, 19.7%-22.4%). The number of visits rated as severe with threat also increased, from 2 011 637 in 2011 to 3 375 539 in 2021 (67.8%; 95% CI, 59.7%-75.9%), while visits rated as minor decreased from 913 712 to 336 071 (-63.2%; 95% CI, -75.2% to -51.2%) over the same period. In this cohort study, multiple measures of ED capacity did not proportionally increase with the increasing demand for services; however, the COVID-19 pandemic appears to have substantially affected some of these patterns. These findings may be helpful to policy makers and health care stakeholders when planning resource allocation of limited health care resources.

Management of emergency department diversion during the COVID-19 pandemic and disaster periods.

Recent news has shown the strain on hospital emergency departments (EDs) and emergency medical services agencies due to the surge of COVID-19; however, compared to all emergency medical service transports, is it true that the United States is seeing an increase in the frequency of diversions? In this quantitative research report, data were collected and analyzed from a national prehospital emergency medical services information system, which allowed for a comparison of the frequency of diverted ambulances, transport times, and final patient acuity of patients arriving by diverted ambulances before and during the COVID-19 pandemic. Statistical analysis was performed on data obtained from the National Emergency Medical Services Information System to compare the frequency of ambulance diversion prior to the COVID-19 disaster and during COVID-19. Analysis of data obtained from the National Emergency Medical Services Information System found that there was not a significant increase in the percentage of ambulance transports that were diverted during the COVID-19 pandemic compared to before the pandemic. However, there were significant increases in the volume of all transports and diverted transports during the COVID-19 pandemic (p < 0.01 for both measures). The significant increases seen in the demand for services, combined with an overall downward trend in the number of healthcare facilities, have resulted in an increase in the volume of diversions, despite the overall demand increasing as well. The COVID-19 pandemic serves as a disaster/public health crisis that is subject to the same phases compared to other types of disasters. The significant findings of this report should provide the emergency services field a big picture, understanding that the problem at hand is multifaceted, with these findings shining light on the effects of current issues between emergency services and hospital EDs.

Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children.

Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Inpatient boarding definitions and mitigation strategies: A cross-sectional survey of academic emergency departments in the United States

ObjectiveConceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management. MethodsThis was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated. ResultsOf the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%). ConclusionsWe found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

Factors and Solutions Addressing Overcrowding in Emergency Department

Overcrowding in emergency departments is a significant challenge in the world of medicine. Approximately 90% of the emergency departments face the issue of overcrowding. The causes of the phenomena are intensely contested, which makes it challenging to come up with effective, focused solutions. Individual patients, healthcare systems, and entire communities are all impacted by emergency department overcrowding. Crowding's detrimental effects on the delivery of healthcare services lead to delays, subpar care, and inefficiency, all of which have an adverse impact on the health outcomes of emergency patients. The purpose of this research is to review the available information about factors and solutions addressing overcrowding in emergency departments. Increased number of patients arriving in the emergency department, lack of resources, and the number of admitted patients waiting for transfer from the emergency department to a hospital ward are all contributing factors to the problem of overcrowding in the emergency department. The quality of medical care is directly impacted by emergency department overcrowding, which causes medication to be administered later than intended and raises the risk of morbidity and mortality among hospitalized patients. It also contributes to a number of unintended issues, including increased duration of waiting times, a decline in patient satisfaction, and a loss of revenue for medical facilities. Additional staff, observation units, hospital bed access, non-urgent referrals, ambulance diversion, destination control, congestion controls, and queuing theory are some of the possible solutions to overcrowding. Effective implementation of the strategies managing overcrowding at emergency department is needed.

Ethical Approaches to Public Policy for Health: A Focus on Principles and Working Together

News about the healthcare crisis, including strikes in multiple countries, workforce shortages, ambulance diversion and delays on entry to emergency rooms, closing floors while demand for beds increases, long waits for appointments in primary and specialty care, and shortages of supplies and medications all lead to proposed solutions for each issue. The point must be noted that these also point to some basic questions. This Commentary calls for a “back to basics” approach that requires dialogue (not just talking but listening) and a focus on some of our primary principles.

Trends in Ransomware Attacks on US Hospitals, Clinics, and Other Health Care Delivery Organizations, 2016-2021

Anecdotal evidence suggests that health care delivery organizations face a growing threat from ransomware attacks that are designed to disrupt care delivery and may consequently threaten patient outcomes. To quantify the frequency and characteristics of ransomware attacks on health care delivery organizations. This cohort study used data from the Tracking Healthcare Ransomware Events and Traits database to examine the number and characteristics of ransomware attacks on health care delivery organizations from 2016 to 2021. Logistic and negative binomial regression quantified changes over time in the characteristics of ransomware attacks that affected health care delivery organizations. Date of ransomware attack, public reporting of ransomware attacks, personal health information (PHI) exposure, status of encrypted/stolen data following the attack, type of health care delivery organization affected, and operational disruption during the ransomware attack. From January 2016 to December 2021, 374 ransomware attacks on US health care delivery organizations exposed the PHI of nearly 42 million patients. From 2016 to 2021, the annual number of ransomware attacks more than doubled from 43 to 91. Almost half (166 [44.4%]) of ransomware attacks disrupted the delivery of health care, with common disruptions including electronic system downtime (156 [41.7%]), cancellations of scheduled care (38 [10.2%]), and ambulance diversion (16 [4.3%]). From 2016 to 2021, ransomware attacks on health care delivery organizations increasingly affected large organizations with multiple facilities (annual marginal effect [ME], 0.08; 95% CI, 0.05-0.10; P < .001), exposed the PHI of more patients (ME, 66 385.8; 95% CI, 3400.5-129 371.2; P = .04), were less likely to be restored from data backups (ME, -0.04; 95% CI, -0.06 to -0.01; P = .002), were more likely to exceed mandatory reporting timelines (ME, 0.06; 95% CI, 0.03-0.08; P < .001), and increasingly were associated with delays or cancellations of scheduled care (ME, 0.02; 95% CI, 0-0.05; P = .02). This cohort study of ransomware attacks documented growth in their frequency and sophistication. Ransomware attacks disrupt care delivery and jeopardize information integrity. Current monitoring/reporting efforts provide limited information and could be expanded to potentially yield a more complete view of how this growing form of cybercrime affects the delivery of health care.

The Mortality and Ethical Impacts of Hospital Strain: How Can Hospitals Prepare for Future Capacity Crises?

The COVID-19 pandemic created significant strain on adult hospitals. Pediatric hospitals are now experiencing similar strain in the setting of an early spike in RSV cases. Hospitals use ambulance diversion and inpatient transfer restrictions to reduce flow to the hospital. However, there are mortality and ethical concerns related to these methods. Other methods that are frequently explored are confined to individual health systems despite the capacity strain typically being widespread, impacting multiple hospitals across a region at one time. In the setting of seeing more frequent hospital strain in both adult and pediatric populations, it is important to examine the options available and to plan for similar events in the future with cooperation across multiple health systems in an effort to provide the best possible outcomes for patients in a region while minimizing moral distress among patients and providers.

Multi-objective optimization for enhancing hospital network resilience under earthquakes

The catastrophic earthquakes will cause numerous casualties requiring medical treatment, resulting in overcrowding in hospitals. To maintain the functionality of the hospital network, ambulance diversion (AD) between hospitals is required to relieve the stress of crowded hospitals. This research proposes a multi-objective optimization (MOO)-based emergency response model to enhance the resilience of the regional-level hospital network following earthquakes. The proposed model determines the optimal AD plan between hospitals for a given earthquake scenario. The average waiting time in the emergency department (ED) and the shortage of inpatient beds are selected as the objectives to measure the functionality of the hospital network, where the optimal solution is obtained by the Non-dominated Sorting Genetic Algorithm II (NSGA-II). The hospital network of Chengdu, China with the earthquake scenario of the Wenchuan earthquake is selected as the case study to demonstrate the validity of the proposed model. Important findings are: (1) in the optimal response plan, 66.2% of medical demands is transported to other hospitals by AD, (2) compared with the baseline situation, the average waiting time and the shortage of inpatient beds improve by 99.4% and 94.2% with the optimal emergency plan, (3) the high medical demand, low transportation efficiency, and the lack of ambulances have significant adverse impacts on the functionality of the hospital network, and (4) the proposed model is composed of high-effective coordination and a comprehensive hospital network, which avoids the waste of medical resources.

Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts’ ambulance diversion ban

BackgroundThe impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED).MethodsWe obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states.ResultsOur study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2).ConclusionMassachusetts ambulance diversion ban was associated with a reduction in the 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.

Effect of Designating Emergency Medical Centers for Critical Care on Emergency Medical Service Systems during the COVID-19 Pandemic: A Retrospective Observational Study.

During the coronavirus disease 2019 (COVID-19) pandemic, prehospital times were delayed for patients who needed to arrive at the hospital in a timely manner to receive treatment. To address this, in March 2020, the Korean government designated emergency medical centers for critical care (EMC-CC). This study retrospectively analyzed whether this intervention effectively reduced ambulance diversion (AD) and shortened prehospital times using emergency medical service records from 219,763 patients from the Gyeonggi Province, collected between 1 January and 31 December 2020. We included non-traumatic patients aged 18 years or older. We used interrupted time series analysis to investigate the intervention effects on the daily AD rate and compared prehospital times before and after the intervention. Following the intervention, the proportion of patients transported 30–35 km and 50 km or more was 13.8% and 5.7%, respectively, indicating an increased distance compared to before the intervention. Although the change in the AD rate was insignificant, the daily AD rate significantly decreased after the intervention. Prehospital times significantly increased after the intervention in all patients (p < 0.001) and by disease group; all prehospital times except for the scene time of cardiac arrest patients increased. In order to achieve optimal treatment times for critically ill patients in a situation that pushes the limits of the medical system, such as the COVID-19 pandemic, even regional distribution of EMC-CC may be necessary, and priority should be given to the allocation of care for patients with mild symptoms.

7 Impact of a Hospital Cyberattack on EMS Arrivals at Neighboring Emergency Departments

Cyber attacks, including ransomware on health care delivery organizations (HDO), are increasing in severity and frequency. Emergency medical services (EMS) plays a significant role in emergency care and disaster response, including the rapid transport of acute patients to receiving emergency departments (EDs). EMS ambulance diversion from one facility to another is a common occurrence with ED crowding, but it can be a result of internal or external disasters as well. The effects of health care cyber attacks on EMS transports and census has yet to be reported in the literature. The purpose of this study is to report regional EMS census impacts during an active cyber-attack on a neighboring HDO. We performed a retrospective analysis of the daily combined EMS transport census of two large urban academic EDs in San Diego, CA during the first week of a ransomware cyber-attack on a nearby multi-hospital HDO (May 2nd - 8th 2021). We then compared the mean to the previous 4 weeks. A one-way analysis of variance (ANOVA) and Tukey test were used to compare EMS transport numbers by week. The mean combined daily EMS census for weeks 1 - 4 (no cyber-attack) were: week 1 (April 4th – 10th) – 69 (SD 10), week 2 (April 11th – 17th) – 68 (SD 5), week 3 (April 18th – 24th) – 71 (SD 7), and week 4 (April 25th – May 1st) – 75 (SD 9). For week 5 (week of the cyber-attack) the mean was 116 (SD 24). There was a statistically significant higher EMS census during the cyber-attack when compared to the 4 weeks prior (Table 1), with most days experiencing double the normal volume (Range 78 -144). This study reports a significant increase in EMS ambulance arrivals at two EDs in proximity to a multi-hospital HDO under active cyber-attack. This result suggests cyber-attacks can have significant regional impacts on EMS volumes, and therefore, cyber disaster planning should take into consideration potentially large diversions of patients to other facilities via EMS.

Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System.

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.

Transient queueing analysis for emergency hospital management

Strategic and tactical capacity planning are critical decisions faced by hospitals. While these problems have received significant attention, current queueing-based approaches do not address realistic healthcare constraints such as blocking, transient arrivals, transient capacity assignments, and surge capacities. A queueing methodology is developed to extend the analysis of these constructs. The methodology developed is generic for hospitals responding to demand surges during epidemics and pandemics such as the recent COVID-19, and in other application areas in manufacturing, supply chain management, and logistics. The medical staff and patient chairs in the emergency room, beds in the operating theater, ICU, and medical/surgical care units are used in patient treatment at a hospital. They can be considered as servers in a system, where capacity and operational policies affect performance measures such as patient throughput. The methodology develops the probabilities from which system performance measures can be estimated for a serial queueing network with blocking. Transient analysis is employed, due to the time varying nature of the patient arrival patterns. The methodology has the capability to analyze different interventions such as increasing and decreasing capacities, and ambulance diversion. In order to handle typical hospital sized problems that result in thousands of ordinary differential equations defining the system probabilities, a transient version of Kanban queueing network decomposition is developed along with procedures for dealing with the discontinuities that arise at capacity changes. Verification/validation is presented along with several scenarios that illustrate the potential application of this methodology in emergency hospital management.