Emergency Room Diversions: A Symptom of Hospitals Under Stress

Emergency Room Diversions: A Symptom of Hospitals Under Stress

Issue Brief | By the Center for Studying Health System Change

Emergency department diversions -- the practice of redirecting ambulances away from hospitals too full or understaffed to accept additional emergency patients -- had become a growing concern across the United States. While diversions were intended as a temporary safety valve during periods of peak demand, they were occurring with increasing frequency in many communities, signaling deeper systemic problems in hospital capacity and emergency care delivery.

Root Causes of Rising Diversions

Several converging factors contributed to the rise in emergency diversions. Hospital bed capacity had been declining for years as the industry consolidated and shifted care to outpatient settings. At the same time, emergency department visits were climbing, driven partly by growing numbers of uninsured and underinsured patients who used the ED as their primary source of care. Nursing shortages compounded the problem -- even hospitals with available beds sometimes could not staff them, effectively reducing operational capacity.

Boarding -- the practice of holding admitted patients in emergency department beds because no inpatient beds were available -- created bottlenecks that rippled through the entire emergency care system. When ED beds were occupied by boarders, fewer spaces were available for incoming emergency patients, forcing diversions even when the emergency department itself was not overwhelmed by volume.

Community-Level Variation

HSC's community site visits revealed substantial variation in the frequency and severity of diversions across different markets. Communities with higher rates of uninsured residents, fewer hospital beds per capita and more severe nursing shortages experienced the most frequent diversions. Urban teaching hospitals and safety net facilities were disproportionately affected because they served larger numbers of uninsured patients and handled more complex cases.

Consequences for Patient Care

Diversions raised serious concerns about patient safety and access. Rerouted ambulances traveled longer distances, delaying treatment for time-sensitive conditions like heart attacks and strokes. Patients diverted from their closest hospital might end up at facilities where their medical records were not available, complicating treatment decisions. In some communities, multiple hospitals went on diversion simultaneously, leaving paramedics with few options and patients with longer transport times.

Policy Responses

Addressing the diversion problem required tackling the underlying capacity constraints rather than simply managing the symptom. Policy options included expanding hospital bed capacity in underserved areas, strengthening the primary care safety net to reduce non-emergency ED visits, addressing nursing workforce shortages through training and retention programs, and improving patient flow within hospitals to reduce boarding. Some communities experimented with regional coordination systems that distributed ED patients more evenly across available facilities.

Sources and Further Reading

This analysis was published by the Center for Studying Health System Change, a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.