February 16, 2001

Hospitals across the nation have been suffering from emergency room overload, forcing many — including the MGH — to go on what is commonly referred to as "divert" status. Diversion occurs when a hospital can no longer safely and adequately care for noncritical patient transports, forcing ambulances to take those patients to other hospitals. The good news is that the MGH, which went on divert twice as often as any other Boston hospital last year, has steadily decreased its diversion rate for the past several months, despite an increase in volume in the Emergency Department (ED) and inpatient areas.

A divert means that all emergency room stretchers are full, patients are backed up in the triage area and the hospital can't accept any additional noncritical emergency patients. The decision to go on divert results from a high occupancy rate in the hospital, which would cause longer-than-usual wait times for patients being admitted from the ED. Having too many patients in the ED at any given time, even if beds are available, also can result in the need to go on divert. While a hospital is on divert status, the ED still accepts walk-ins, patients transported by helicopter and certain other trauma referrals.

"The decision to go on divert is always a last resort," says Alasdair Conn, MD, chief of MGH Emergency Services. "However, the quality and safety of our patient care comes first. We still are going on divert more than most hospitals, but we have made substantial efforts to reduce our divert times."

ED volume has continued to rise at the MGH, showing a 9 percent increase between fiscal years 1996 and 2000. In addition, the percentage of those emergency room patients who are admitted to the hospital has increased 28 percent in that time period, indicating a high acuity of patients being brought to the hospital through the emergency room. MGH leadership has established a hospitalwide approach to alleviating the diversion problem. An advisory committee was formed almost two years ago to identify possible solutions, incorporating the help of each service to improve the process and flow of emergency care.

Important steps that have been taken to help decrease the divert problem include:

• decreasing the average length of stay in the ED and throughout the hospital;

• enhancing lab testing and imaging services to decrease wait times for patients;

• adding physician, nursing and support staff to the ED;

• developing a Rapid Diagnostic Unit in the ED;

• admitting certain patients — from physician offices, health centers and other hospitals — directly to inpatient units, bypassing the ED;

• referring patients who do not need emergency treatment to the Medical Walk-In Unit; and

• opening new inpatient beds.

These efforts are showing success at the MGH. However, the diversion problem is widespread and is just one symptom of an ailing health care system in Massachusetts. Reasons for emergency room diversions can be attributed to a number of factors: an increase in uninsured patients seeking care in emergency rooms; sick patients making emergency room visits instead of calling their primary care physicians; and reduction in available beds and emergency room capacity because of hospital closures, conversions and consolidations.

Financial pressures on hospitals also have aggravated the diversion problem. Underpayment by managed care companies and Medicaid, an inadequate free care system that puts an undue burden on hospitals and excessive cuts in Medicare related to the Balanced Budget Act have caused a number of hospitals to close, putting additional strain on other health care institutions.

The diversion problem has plagued hospitals statewide to the point that Gov. Paul Cellucci recently convened a health care task force to help find solutions. The Department of Public Health also has been working with the Massachusetts Hospital Association to address the issue.