I will never figure out the ED visit cycles. The last week of November and the first two weeks of December a lot of us had decided that our ED had fallen out of favor with the community. I mean, people weren’t coming in, and we were staring at each other wondering where we would go to get new jobs.

As with all cycles, that has definitely ended. We’ve had a ‘full’ hospital for a couple of weeks, we’re holding admitted patients in the ED (sometimes up to a third of our real beds). We’ve been on and off EMS diversion continuously, and when off diversion we’re usually ‘forced off’ by the EMS powers that be.* (Forced off diversion by the EMS powers that be: shared pain is at least fair).

Diversion is a continuous hot topic in the EM/EMS world, and there is no easy answer. It’s a problem for everyone, make no mistake. If I were to call an ambulance I’d be right ticked if I couldn’t go where I wanted to go. (As an aside, I’ve had 3 patients in 2 1/2 years here ticked because they got diverted to us; many more didn’t care. Maybe that’s my control-issue thing popping out).

Diversion is Bad because:
it over-rides choice of hospital
it keeps people out of the hospital where their docs and records are
it puts the EMS folks in the middle, where they shouldn’t be
it can erode public confidence in EMS

Diversion is Good because:
Resources are finite
The ED’s walls aren’t really rubber
Safety is compromised when pt/staff levels get big
Load sharing, therefore resourse sharing, is more efficient
It gets attention of hospital managers

That last thing cannot be overstated. As much as hospitals gripe over the (very real) monetary losses they take by having an ED, when the ED closes they aren’t happy. I’ve been astonished how beds upstairs can be magically found when the ED closes because we’re holding too many and the inn is full.

Our charge nurses are under a heck of a lot of pressure not to close until the roof caves in. This, despite no increase in resources, just ‘work harder, work faster’. No wonder the nursing burnout rate is high in EM; the same nurse can go work in the ICU and have a stable number of patients.

Our hospital is considering something that shouldn’t be a radical idea: boarding hall patients upstairs, in the ward hallways. A hall is a hall is the mantra. I hope we try it, as I think it’ll help some.



  1. Nurse Kelley says:

    Many ER nurses will jump for joy to see that first patient go up to a floor hall bed!
    And, yes, you’re right, we’re under intense pressure to stay open at all times. In our present environment, I’m beginning to think there should be NO diversion at all. For anyone in town. That’s what it boils down to anyway. We can hold our own with the best of them (euphemistically known as “flexing up”), as long as everyone else does. It’s when that hospital down the street closes and we get all THEIR patients, too, that we start sinking fast.

  2. True..a hall is a hall…UNLESS it’s the lobby! I kid you not, one day I found two very ill patients post- admission in the lobby outside the gift shop on stretchers!! Guess who went ballistic when told that their “rooms weren’t ready” ? GEEZ.

  3. Should the pre-test probability for ischemia or TB change based on the availability of telemetry or isolation beds? While the pressures of working in the ER are great, patient care should not be compromised. Do I want to be a patient in a four-bed room with another patient who may have pulmonary TB? I support diversion if it means better patient care and safety.