How Will It Affect Your Emergency Department?

The EDBA data over the past 15 years find that EMS arrival and admission rates are very stable and that patients arriving by ambulance continue to represent higher acuity. At the same time, many emergency departments have been unable to open sufficient space to provide care for all arriving patients, and some hospitals have developed processes for diverting ambulances. This issue was recognized by the Centers for Disease Control and Prevention in studies years ago but has not been resolved.² This winter, the media highlighted the ongoing danger of ambulance diversion.^3,4

Patients who are high-frequency emergency system users can be identified by case managers, hospitals, emergency departments, or the EMS system. Is the use of out-of-hospital health services a mark of quality for these individuals? There is still a legal issue to address in which a 911 call can be linked to an EMTALA responsibility and the mandate for a medical screening examination before the patient is released.

Will improving field care reduce costs and improve outcomes? Will it decrease less urgent uses of EMS and reduce transports of these lower-acuity patients? If that occurs, will reducing ambulance traffic be good for the emergency department? Might it reduce ED diversion and crowding?

Novel models in an evolving health care delivery platform that utilize mobile resources will be developed. There are already programs to provide follow-up care for patients released from inpatient status back to their home, patients with recurrent admissions for long-term health problems (eg, congestive heart failure), and patients with a variety of health problems who have demonstrated frequent use of EMS service in the past.5

In the current model, hospitals survive on revenue from inpatient service, and patients admitted through the emergency department after EMS transport are major contributors to that revenue stream. The cost of diversion, therefore, is significant. To calculate that cost, let’s count the average number of EMS patients arriving during the busy hours of the day (not including the middle of the night, when diversion is rarely utilized). Assume that arrival rate is a modest two EMS patients per hour. The average hospital revenue for ED services for those two patients is at least $1,000. If 40 percent of the EMS patients are admitted, and they generate $6,000 above the direct costs of service per patient, then ambulance diversion for five hours reduces hospital revenue by $6,000 in direct revenue for the 10 diverted patients plus $24,000 for the four diverted admissions. That $30,000 is a direct loss of $6,000 per hour, plus the loss of the patient for future visits and admissions as well as loss of relationship with EMS.