Emergency Department Diversions: Hospital and Community Strategies Alleviate the Crisis

Hospital emergency department diversions -- when hospitals temporarily redirect ambulances to other facilities because their emergency departments are overcrowded -- declined in severity in several communities, as hospitals and communities adopted strategies to alleviate the crisis, according to research from the Center for Studying Health System Change (HSC). Based on site visits to 12 nationally representative communities, the study found that while ED crowding remained a serious concern, innovative approaches at both the hospital and community level were producing measurable improvements.

Root Causes of ED Crowding

ED crowding stemmed from a combination of factors. Growing numbers of uninsured patients used emergency departments for conditions that could have been treated in primary care settings. Hospital bed shortages in some markets meant that patients who needed admission waited for extended periods in the ED, occupying treatment spaces. Increasing acuity of patients -- those arriving sicker and with more complex conditions -- extended treatment times and tied up resources. Staffing shortages, particularly among emergency physicians and nurses, limited the number of patients departments could handle simultaneously.

The consequences of diversions were significant. Patients diverted to more distant hospitals faced longer transport times that could be critical in emergencies. Receiving hospitals experienced increased strain on their own already-busy departments. And in extreme cases, when multiple hospitals in a region went on diversion simultaneously, the entire emergency care system risked breakdown.

Hospital-Level Strategies

Individual hospitals pursued several approaches to reduce ED crowding and diversion episodes. Some expanded or renovated their emergency departments, adding treatment bays and fast-track areas for lower-acuity patients. Others implemented operational improvements such as streamlined triage processes, bedside registration, and more efficient patient flow management. Hospitals worked to reduce boarding times -- the period admitted patients spent waiting in the ED for inpatient beds -- by improving bed management and discharge planning on inpatient units.

Some hospitals created observation units that allowed patients to be monitored for up to 24 hours without formal admission, freeing ED treatment spaces while providing appropriate care. Others established urgent care centers or clinics adjacent to their emergency departments to redirect lower-acuity patients to more appropriate settings while keeping them within the hospital's care system.

Community-Wide Approaches

Several communities adopted system-wide strategies that proved more effective than individual hospital efforts. Regional diversion protocols established rules about when and how hospitals could go on diversion, limiting the duration and frequency of diversions. Real-time monitoring systems allowed EMS dispatchers and hospitals to track diversion status across the region, enabling more efficient ambulance routing.

Some communities invested in expanding primary care access for uninsured populations, aiming to reduce inappropriate ED use by providing viable alternatives. Community health centers, free clinics, and nurse-staffed telephone triage lines all served to redirect patients with non-emergency conditions away from hospital EDs. Public education campaigns also sought to help patients understand when emergency department visits were necessary and when other care settings might be more appropriate and accessible.

Ongoing Challenges

Despite progress, the underlying drivers of ED crowding persisted. The number of uninsured Americans continued to grow, and even insured patients increasingly turned to EDs when they could not get timely appointments with primary care physicians. Hospital capacity constraints showed no signs of easing in markets with aging facilities and limited capital for expansion. As long as EDs served as the default access point for patients who lacked other options, crowding and diversions would remain significant challenges for the health care system.

Sources and Further Reading

Based on HSC Community Tracking Study site visits to 12 nationally representative metropolitan communities.