EMS: Diversion Or Not: That Is The Question?

It seems that hospital diversions are becoming more of an issue for fire services around the country.


Paramedic Company 14 to Mercy Hospital, we are inbound with a 68-year-old male, substernal chest pain—” “Stand by, Paramedic Company 14, this is Mercy Hospital, we have no beds available, you need to divert to another hospital.” “OK! We’ll try another hospital. This is...


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A 1997 report showed that hundreds of hospitals violate the EMTALA laws. The report, Hospital Violations of Emergency Medical Treatment and Labor Act, revealed that between April 1, 1995, and Sept. 30, 1996, over 250 hospitals across the country – listed in the report – were named for violating the federal law.

The report showed that a new type of “patient dumping” was occurring, other than that involving patients who had no insurance. The new trend finds that patients are being “dumped” because their managed care insurance plans refuse to pay for emergency care.

So what are fire agencies, hospitals, and communities doing to address the issue of hospital diversions?

First, patient care and safety should be the central consideration in all diversion decisions. A balance needs to be struck between the safety of patients in the community who may require transport to an emergency room and that of patients who may be currently receiving care in the emergency room.

A decision to divert should be based on the immediate capabilities of the emergency department to care for certain specific categories of patients. For example, an emergency room may be able to accept a fractured leg injury, but cannot accept a gunshot victim, since all the hospital’s trauma teams are tied up and unavailable. To help facilitate this method, standardized terminology needs to be used by everyone in the community as to what is a “total diversion,” “critical diversion” or any other term your community uses.

Objective criteria should be developed to help define when overcrowding in an emergency room leads to unsafe conditions:

  • Diversion policies should allow for the occasional need to minimize transport times of critically ill patients, especially those requiring immediate interventions. Many agree, these patients should be transported to the nearest appropriate facility, unless that facility is physically closed.

  • Inpatient bed availability should not directly affect decisions regarding diversion. There have been many instances of hospitals diverting patients because no beds were available on the floors with the emergency room empty. Diversion should not be indicated if the patient can be stabilized and transported to another hospital.

  • The decision to divert patients should be made by an attending emergency physician in conjunction with the nurse leader who is physically present in the emergency room and should be based upon considerations of patient treatment effectiveness and safety. There have been reported cases when typist clerks put emergency rooms on diversion only because they chose not to work certain shifts.

  • Fire agencies should develop plans with local hospitals or an agency representing the area hospitals if multiple hospitals request diversions.

  • Patient choice should override diversion status. Patients should be advised of the situation at the hospital of their choice and there may be a significant delay receiving treatment. However, if they insist, they should be transported there.

  • Some hospitals have responded to the crunch by adjusting their operational status. Some hospitals have chosen to keep their clinics open during evening hours to handle the extra load of patients of a minor nature who may need some medical care.

One thing is for sure, diversions are a courtesy which fire agencies grant to hospitals. As the population grows older, managed care penetrates health care more and no short-term fix for the nursing shortage appears, diversion problems will continue. Only those fire agencies that aggressively address this issue will provide the best care for their patients.


Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief paramedic for the St. Louis Fire Department and is the vice chairman of the EMS Executive Board for the International Association of Fire Chiefs. He has lectured nationally and internationally on fire-based EMS topics and operates The Ludwig Group, a consulting firm specializing in EMS and fire issues. He can be reached at GaryLudwig@aol.com.