Reducing Ambulance Diversion in California: C A L I FOR N I A Strategies and Best Practices H EALTH C ARE F OU NDATION Introduction hospitals in the collaborative experienced a Ambulance diversion that results from the significant reduction of diversion hours during overcrowding of emergency departments is a the collaborative time period. serious issue, not only in California, but in many parts of the United States as well. Diversion occurs This issue brief provides an overview of ambulance Issue Brief when a hospital emergency department is unable diversion throughout the United States and in to provide care for additional patients and redirects California, and summarizes the work completed ambulances to other hospitals nearby. Ambulance on The California ED Diversion Project. It finds diversion has a negative impact on patient that while diversion is typically a symptom of a outcomes, patient safety, continuity of care, and community experiencing considerable stress as a surrounding hospitals. result of diminishing hospital capacity, those with lower diversion rates do not necessarily have higher The California HealthCare Foundation retained capacity or lower utilization. The collaborative The Abaris Group to measure and track model and best practices presented here offer ambulance diversion in California and collect useful tools to communities that are committed to and analyze corresponding data on emergency reducing or eliminating diversion. department (ED) demand and capacity. This data includes utilization rates, licensed treatment Overview of Ambulance Diversion beds and their utilization, and total emergency Ambulance diversion is a statewide and national medical services transports. Called the California issue. Communities across the country have ED Diversion Project, the study also involved reported struggling with the challenges caused the formation of a one-year, multi-region, multi- by hospitals diverting ambulances. A 2003 study hospital collaborative, intended to help reduce found that an estimated 501,000 ambulances diversion hours and act as a diversion-reduction in the United States were rerouted as a result model for the state as a whole.1 In addition, the of ambulance diversion, which amounts to project inventoried best and promising practices to approximately one ambulance diverted each assist hospitals in improving flow and capacity. minute.2 And approximately 45 percent of all EDs reported they were “on diversion” at some point The study found that when hospitals and during the year.3 their local emergency medical services agency (LEMSA) are focused and united in reducing The same 2003 study also identified the inability diversion, employing a collaborative process and to transfer admitted patients from the emergency best practices can aid in reducing ambulance department to inpatient beds as the most common diversion, improving patient flow, and opening factor for ED overcrowding. This indicates that communication among participants. All of the J uly 2009 diversion is the result of factors more complex than it can create long delays in transferring patients from emergency department capacity alone. ambulances into overcrowded EDs, interfering with patient safety and continuity of care. Ambulance diversion was once thought to be a “novel” solution for ED overcrowding.4 However, it is now However, these agencies are not unique in adopting understood that diversion is not an effective means for no-divert policies. New Hampshire also does not allow alleviating overcrowding, because when one hospital is its hospitals to divert ambulances, and Massachusetts overcrowded, others in the area are likely to be full as initiated a “no-divert” policy on January 1, 2009. In well. Another study found that when a hospital diverts California, Riverside County converted to “no-divert” ambulances, it artificially creates more diversion at approach last year, and San Bernardino initiated a no- surrounding hospitals.5 divert policy in January 2009. Ventura County also has also indicated it intends to adopt a no-divert policy More significant is the fact that ambulance diversion sometime in 2009 or early 2010. has been found to be unsafe for patients because it increases their transport times, which interferes with While some EMS regions in California have reduced continuity of care, causes delays (e.g., in reperfusion diversion by implementing these policies, others have therapy for patients with acute myocardial infarction), successfully reduced diversion hours through a series of and increases mortality for severe trauma patients. More best practices. Alameda, Riverside, Sacramento, and Santa than one dozen articles and studies have been published Clara Counties have implemented effective diversion on this topic, providing evidence of adverse patient strategies independent of this study that do not completely outcomes associated with ambulance diversion or ED eliminate diversion, but instead provide very stringent overcrowding.6-18 standards for when hospitals can divert patients and for how long they may remain on diversion. In addition, Ambulance Diversion in California many of the hospitals within the jurisdiction of these local The initial report from the California ED Diversion EMS agencies have developed improved ED and inpatient Project, published in March 2007, examined the status flow strategies that have dramatically improved hospitals’ of ambulance diversion for each emergency medical ability to accommodate ambulance patients and better services (EMS) region in California. At the time, Inland handle emergency department visits overall. Counties, Los Angeles, San Diego, San Francisco, San Mateo, and Ventura EMS regions had the highest number The Sacramento region, and in particular Sacramento of diversion hours per hospital ED treatment station.19 County, has seen a sharp reduction in diversion hours The study used the number of licensed ED treatment and has been recently recognized for its success.20 This stations as a surrogate of emergency department capacity reduction began after a three-year collaboration among for comparing EMS regions in the state. all hospitals, EMS providers, and the EMS agency in the county.21 Nine of the 31 LEMSAs in California initially approached the issue of ambulance diversion by prohibiting hospitals Best practices such as these, as well as other nationally from diverting patients (i.e., implementing a “no-divert” accepted best practices and those discovered during The policy). While this approach solves the diversion problem, California ED Diversion Project, may be applicable it risks shifting the burden elsewhere. For instance, to remaining California regions that are experiencing 2  |  California HealthCare Foundation high ambulance diversion rates. Many of these Table 1: Statewide Trends, 2003–2007 practices have been published and are available on the 2003 2007 Percent Change California ED Diversion Project website (http://www. Population 35,944,213 37,771,431 5.1% caeddiversionproject.com). ED Volume 9,780,948 10,402,309 6.4% EMS Transports* 1,637,411 1,876,212 14.6% Diversion Project Methodology California’s 58 counties are organized into 31 local Diversion Hours† 302,169 165,180 -45.3% LEMSAs. Some of these agencies, particularly in rural * Unavailable data was estimated based on average growth rate (four counties in 2007). † When data was not provided by the EMSA, OSHPD was used (six counties in 2003 and three areas, represent more than one county. The first phase of counties in 2007). the California ED Diversion Project involved contacting Source: California Department of Finance, OSHPD, EMSAs each LEMSA to determine the state of ambulance diversion in the corresponding region. Copies of LEMSA In spite of the overall rise in emergency department visits, diversion policies were also collected and studied to total diversion hours have continued to decline. In 2003, determine EMS and diversion trends. California hospitals were on diversion status for a total of 302,169 hours. By 2007, hospitals were on diversion for The study also involved collecting five years of data 165,180 hours, a 45.3 percent decrease from 2003. regarding EMS transport and diversion hours for the entire state (2003 through 2007). If data such as the The most substantial decrease occurred from 2005 to number of 9-1-1 transports were unavailable, estimates 2006, when diversion was reduced by 30.5 percent, were made using generally accepted utilization ratios followed by a 15.3 percent decrease from 2006 to 2007. based on the region’s population. (See Appendix A for Most of the decrease in hours for 2006 occurred in Los detailed statewide EMS, ED, and diversion results for the Angeles County after it changed its diversion policy. (The years 2003 to 2007). In addition to data collected, each new policy limits the number of hours a hospital may go LEMSA was asked about diversion issues particular to the on diversion at any given time.) region, as well as needs and progress made if diversion was a problem. Although the diversion rates do appear to be declining in some regions and in general statewide, eight regions According to data provided by each LEMSA, there experienced increases in diversion levels during the 2003 were 1.6 million emergency EMS transports in 2003 to 2007 time period: compared with nearly 1.9 million in 2007 (an increase n Imperial County of 14.6 percent). In that same period, emergency n Marin County department visits increased 6.4 percent, with a peak increase of 7.6 percent from 2004 to 2005. Bear in mind n Northern California EMS, Inc. (an 11-county region that analysis performed as part of the study also found that includes Redding) that California’s population grew by 5.1 percent from n San Diego County 2003 to 2007, increasing from 35.9 million to 37.8 n San Luis Obispo County million.23 See Table 1 for details. n San Mateo County n Santa Clara County n Santa Cruz County Reducing Ambulance Diversion in California: Strategies and Best Practices  |  3 Most of these regions had only nominal increases, but Table 2. Statewide Trends 2005–2007 two counties’ increases were substantial. Imperial County’s 2005 2007 Percent Change diversion hours increased from 806 hours in 2003 to Population 36,896,220 37,771,431 2.4% 1,120 hours in 2007, and San Mateo County’s diversions ED Volume 9,865,864 10,402,309 5.4% increased from 1,948 to 2,499, respectively. However, EMS Transports* 1,749,039 1,876,212 7.3% ambulance diversion is sometimes implemented as a result of other unique variables, such as the closure of a hospital Diversion Hours† 280,466 165,180 -41.1% in the area. * Unavailable data was estimated based on average growth rate (four counties in 2007). † When data was not provided by the EMSA, OSHPD was used (two counties in 2005 and three counties in 2007). Another two of these eight EMS regions, Marin County Source: California Department of Finance, OSHPD, EMSAs and Santa Barbara County, had zero hours of ambulance diversion in 2003 but began increasing diversion in 2007. For diversion data by region and other comparison However, these increases were very small. Marin County’s metrics, see Appendix A. diversions rose to 65 hours in 2007. With a total of three hospitals in the county, this amounts to an average of 1.8 Statewide Data Study Findings diversion hours per hospital per month. Santa Barbara The hypothesis of this study, prior to analyzing the County’s diversions increased to 236 hours in 2007. With collected data, was that regions with higher diversion a total of five hospitals in the county, this amounts to an levels would likely have more emergency department average of only 3.9 hours per hospital per month. visits per population, higher emergency department bed utilization (annual ED patients per ED bed), and In addition, San Luis Obispo County experienced an higher acuity emergency department visits (percent of increase from just 56 diversion hours in 2003 to 376 ED patients admitted to the hospital). However, this hours in 2007. This LEMSA region has four hospitals in trend could not be verified; in fact, for some regions the the area, so its average hours per hospital each month was opposite was true. also relatively low. Contra Costa County, for example, is a no-divert region, While the annual diversion hours for these three regions despite the fact that it has some of the highest ED are all relatively minimal, the fact that rates have increased utilization rates in the state—much higher than other so drastically is cause for concern. regions that have higher diversion rates. And it also has an ED bed utilization rate that is approximately the same as Twelve of the total EMS regions reduced their ambulance regions with higher diversions. In addition, Los Angeles diversion from 2003 to 2007, realizing a reduction of County has the second highest number of diversion hours anywhere from 4 percent to 75 percent. This data does per hospital (next to San Diego County), but it also has not include regions that have adopted no-divert policies. one of the lowest ED utilization rates. In the two-year period from 2005 to 2007, diversion hours But in reviewing the differences among the diversion decreased in the state by 41 percent, despite corresponding policies for each region, some trends begin to emerge. increases in ED volume and EMS transports (5.4 and While no two diversion policies are exactly alike, regions 7.3 percent, respectively). Inland Counties, Los Angeles, that tend to have low diversion hours have stricter and Riverside LEMSAs saw the majority of the non-rural policies, with more supervision from the local EMS regional reductions, although other LEMSAs had significant agency as to when a hospital can activate diversion, decreases as well. See Table 2 for details. how long it can divert, and when it should discontinue 4  |  California HealthCare Foundation diversion. In some regions, hospitals are at risk of having Table 3. Collaborative Participants by Region a LEMSA staff member visit the site when the emergency EMS Region/Hospital City department is diverting ambulances. Los Angeles EMSA Commerce St. Francis Medical Center Lynwood Nowhere is there a better example of how policy affects Presbyterian Intercommunity Hospital Whittier diversion than in Los Angeles County. This LEMSA Methodist Hospital Arcadia region instituted a limit to its diversion policy in late 2005, requiring hospitals in the region that are actively San Bernadino County ICEMSA San Bernadino diverting ambulances to stop diverting every two hours Arrowhead Regional Medical Center Colton for a minimum of 15 minutes. This policy change alone Loma Linda University Medical Center Loma Linda reduced diversion hours from 174,952 in 2005 to 81,741 St. Mary Medical Center Apple Valley in 2007—a 53 percent drop. Santa Clara County EMSA San Jose Regional Medical Center San Jose The Sacramento collaborative, mentioned earlier in this Ventura County EMSA Oxnard report, had a similar decrease in diversion hours. All hospitals in that region agreed to follow a strict region- Community Memorial Hospital Ventura wide policy, as well as adopt internal policies with Simi Valley Hospital Simi Valley characteristics similar to the diversion policies of other St. John’s Medical Center Oxnard nearby hospitals. During the first month following the Ventura County Medical Center Ventura adoption of those policies, diversion hours fell by 50 percent. During the initial year of the collaborative, the drop in diversion hours continued with another 50- During the 12-month period (September 2006 to August percent reduction. The data for the second and third years 2007) prior to the implementation of the collaborative showed similar results. portion of the project, the four LEMSA regions had accumulated 17,618 diversion hours. At the completion Collaborative Methodology of the collaborative, diversion hours had decreased by The second phase of the California ED Diversion Project 19.9 percent, to 14,117. (Two months of diversion data involved forming a 12-month collaborative among four post-project were added for the purpose of matching LEMSA regions and 11 hospitals within those regions. them to the 12 months of the pre-project period. ) The Table 3 lists each region and participating hospitals. monthly average for hospital diversion hours from pre- to post-project periods also decreased by 19.9 percent, from The goals of the collaborative were to reduce diversion, 1,468 to 1,176. For both years studied (before and during identify best practices for minimizing diversion, and help the collaborative), the diversion hours followed typical implement these practices in communities less successful seasonal trends, reaching lows in the summer (June to in resolving their EMS diversion problems. August), and highs in the winter (December to February). Each LEMSA was asked to work with a sample number Aside from Santa Clara County, which had only one of hospitals in its region to reduce diversion hours. hospital participating in the collaborative, Los Angeles Through mentoring by outside experts, each hospital County’s participating hospitals had the lowest total of chose interventions, best practices, and new policies to diversion hours throughout the project. San Bernardino improve its ED and inpatient flow. County (part of the Inland Counties LEMSA region, and the only county of the three Inland Counties that Reducing Ambulance Diversion in California: Strategies and Best Practices  |  5 participated in the collaborative) experienced the greatest While there are a number of regions in the state and difference in its monthly average for hospital diversion elsewhere that have gone to a “no-divert” policy, this is hours (reduced by 161 hours per hospital on average), not a simple fix. Some communities have experienced followed by Los Angeles County (reduced by 80.4 hours long delays in the transfer of patients from ambulances per hospital on average). The greatest number of diversion to EDs, as mentioned earlier in this issue brief, because hours in the project period were in Ventura County. no-divert policies do not fix underlying problems with However, this data is confounded in part because of the hospital capacity. To move in the direction of a no-divert closure of one of the county’s hospitals for six weeks. For policy statewide would require a joint effort, not only tables of these metrics, see Appendix B. among the groups that participated in the collaborative, but among all LEMSAs in the state and all the hospitals Collaborative Findings in each county. None of the counties involved in the collaboration completely eliminated diversion during the 12-month Another major outcome of the collaboration was a project. However, ambulance diversion for each month heightened awareness of the importance of tracking, during the project was lower than the same month of collecting, and applying diversion data to help LEMSAs the previous year (pre-project), except for winter. The and hospitals address diversion issues. Table 4 shows spike in diversion hours during winter months is largely the overall results for the project’s data points, or key attributable to a heavy influenza season, which caused a performance indicators (KPIs). surge in ED volume. Table 4. KPI Comparison, Sept. ‘07–June ‘08 The collaborative nature of the project increased the KPI Percent Change visibility of issues surrounding ambulance diversion in Hospitals the four participating communities and provided a much- Time to Heart Treatment -28.4% needed platform for working toward reducing diversion. Time to Pain Management n/a It also demonstrated the beneficial effects of sharing Bed Assignment to Placement 8.1% experiences and solutions. Not only did the participating Time of Discharge 3.9% LEMSAs and hospitals gain a better sense of how diversion at one hospital directly affects other hospitals in the region, Bed Empty to Clean/Available n/a but they also witnessed how working together can be more Total Hospital Discharges n/a effective in addressing the growing problem of diversion. ED TAT – Admitted* 12.2% ED TAT – Fast Track n/a The partnership also reinforced the conclusion that ED TAT – Treated and Released* -1.4% ambulance diversion is a systemic problem and cannot be ED Volume 12.1% solved by any single hospital or LEMSA. However, with ED Admissions 22.7% coordinated and improved hospital and LEMSA policies and practices, ED diversion can be reduced. In addition, Incomplete Treatment -2.4% the collaborative made it apparent that reducing diversion Boarding Hours -14.5% hours is not the only solution to ED overcrowding and EMSAs that additional remedies and best practices can also be Diversion Hours (monthly) -39.8% implemented to alleviate it. n/a: Not available due to incomplete data availability * The percent change for ED TAT (turn-around-time) for admitted and treated and released was calculated comparing data from Sep 1-15, 2007 to April 1-15, 2008, because the period June 16-30, 2008 had insufficient data for comparison. 6  |  California HealthCare Foundation The collaborative also revealed that diversion actually Diversion Project Best Practices affects only a small number of EMS patients transported Hospitals that participated in the collaborative chose compared with the number of diversion hours. During best or promising practices they felt would be valuable in this project, an average of 78 patients were diverted per meeting the specific capacity challenges that were driving LEMSA per month. This would equate to approximately their diversions. 0.2 patients per diversion hour, a very modest number of actual patients diverted. Some of the more common best practices initiated at many hospitals include the following: While there were many positive results from the n Created, expanded or re-engineered bed control collaboration, there were also some lessons learned. Many meetings; of the participants felt that the data collection process was n Added bed control czars; difficult because of limited staff resources, and because in some cases it was necessary to collect data manually. n Created new reporting processes (e.g., fax report) or improved nurse communication interfaces; and LEMSAs and hospitals also realized that some issues need n Created a bed crisis or surge model with color-coded to be considered when measuring the full impact of the thresholds. reduction in diversion hours. Historical data show that In addition, the following are some examples of best diversion hours were declining statewide prior to the practices that were chosen by each hospital to address start of this project, and it could be said that the drop their specific challenges. experienced as a result of the collaborative may have occurred without the project initiative. Unfortunately, Methodist Hospital of Southern California statewide diversion data during the study period was not (Los Angeles County): available. • Re-engineered its ED triage process; • Developed a Rapid Admission Unit; All participants stated that the project was a benefit to • Improved the productivity of bed huddles; and their organization. • Established an electronic bed board and bed czar. Presbyterian Intercommunity Hospital In summary, when a region is focused and united in the (Los Angeles County): goal of reducing diversion, employing a collaborative • Strengthened its hospital diversion policy; process and implementing best practices can aid in • Revamped the pediatric admissions process by reducing ambulance diversion, improving patient flow, having someone from the pediatric inpatient and opening communication among the participating unit retrieve the patient from the emergency hospitals and LEMSAs. department; • Implemented computerized order entry; and • Opened a bed census program that uses a real-time dashboard and capacity-matching resource plan with color coding. Reducing Ambulance Diversion in California: Strategies and Best Practices  |  7 St. Francis Medical Center (Los Angeles County): Community Memorial Hospital (Ventura County): • Developed an ED fast track; • Created an ED medical director/hospitalist task • Created two inpatient discharge lounges; force to improve communications; • Initiated a hospitalist program; and • Expanded the hours of the fast track; • Established a capacity management protocol called • Redefined the criteria for utilizing its inpatient “Code Purple.” telemetry unit; and • Implemented a Capacity Command Center. Arrowhead Regional Medical Center (San Bernardino County): St. John’s Regional Medical Center • Established nurse executive rounding in the ED; (Ventura County): • Sends daily “flash” reports on key capacity issues • Increased the interface with the inpatient tracking throughout the hospital; center so that it could be accessed anywhere in the • Re-engineered the ED triage process to include a hospital; provider who could dismiss patients who did not • Implemented an admission/transfer/discharge require the services of the ED; and nurse position; • Implemented a practice of bed huddles three times • Implemented a “fax report” for all non-ICU a day. admissions; and Loma Linda University Medical Center • Started “slotting” inpatient discharges. (San Bernardino County): Simi Valley Hospital (Ventura County): • Created a larger triage area; • Established a triage bypass policy; • Hired a bed czar; • Made the ED diversion policy stricter • Hired a patient flow director responsible for • Changed medical staff bylaws to require speedier managing flow for both the ED and operating response times for on-call specialists; and room; and • Developed a Service Designation Program for ED • Reorganized the inpatient case management admissions with delayed resident response times, program to improve the review of length of stays. allowing the ED physician to admit the patient. Ventura County Medical Center (Ventura County): St. Mary Medical Center (San Bernardino County): • Made the ED diversion policy stricter; • Established an ED front-end team leader; • Established a triage bypass policy; • Reversed physician rounding and meeting • Developed a color-coded capacity management schedules; policy; and • Created bed flow meetings twice a day; and • Developed a “bed-crisis” mode. • Standardized nursing interfaces for admissions, thus reducing delays. Lessons for Other Communities Ambulance diversion is a national and statewide problem, Regional Medical Center (Santa Clara County): but not all communities experience diversion the same way. • Established a combined Rapid Admission Unit and Clinical Decision Unit; This study was designed to better understand the • Expanded its Rapid Medical Evaluation process differences among communities that have high diversion, (provider at triage); and low diversion, and no diversion. The collaborative • Re-engineered the inpatient admission and incorporated eleven hospitals and four regions that reflect discharge processes. these different diversion levels. 8  |  California HealthCare Foundation The Risks of Ambulance Diversion Similarly, hospitals that have lower diversion hours tend Ambulance diversion is an unhealthy practice for a to have their own stricter internal diversion policies number of reasons. It is unhealthy for the patient from that require high-level approval (e.g., the on-duty the standpoint of quality, outcome, and length of stay. administrator) and convene executive teams during It is unhealthy for the community because it delivers diversion events to resolve the problems in real time. patients to a hospital that may not be the best fit for their There are also hospitals that anticipate capacity challenges individual and immediate needs. It is unhealthy because using color-coded systems so that they can address the patients’ primary physicians may not have privileges, anticipated problems before they occur. and medical records may not be available at the receiving hospital. And it is unhealthy financially because hospitals Best and Promising Practices that divert lose money when they send patients to other This study and other literature on the topic of ambulance hospitals. diversion make it clear that hospital capacity can be improved through the adoption and implementation of Capacity best and promising practices. While each community may have a unique reason for implementing diversion at its hospitals, including In addition to implementing best practices, it is also availability of mental health beds, other specialty care important that hospitals and LEMSAs maintain diversion capability, and patient acuity, ambulance diversion can be data and other pertinent metrics as part of their data minimized through a variety of strategies. dashboard. This can help them track and sustain changes that have already been implemented and make new Diversion is about hospital capacity, not community changes as necessary. capacity. When a diverted patient is accommodated by another hospital, the successful admission of that patient Solving Ambulance Diversion demonstrates that community capacity is sufficient. The Ambulance diversion is a symptom of a community same is true with “boarders” in the emergency department experiencing considerable stress as a result of diminishing (i.e., patients who are waiting for an impatient bed). hospital capacity. However, communities with lower These patients are eventually provided a hospital bed, diversion rates do not necessarily have higher capacity or so the issue lies in a mismatch between the demand lower utilization. Communities that are committed to and capacity at specific hospitals, rather than aggregate resolving diversion can be successful using a collaborative hospital capacity. If a hospital is struggling with capacity, model and best practice tools outlined in this study, or in the solution is not to simply add resources and beds, but other readily available and related studies. to fundamentally re-engineer policies and practices. Despite considerable variability among communities, Policies implementing best practices can help to minimize Communities in California that have lower diversion ambulance diversion in California. Even in areas facing hours have stricter LEMSA policies regarding diversion. severe capacity challenges, diversion can be reduced by These policies often stipulate when a hospital can activate improving regional oversight and re-engineering patient diversion, when it must stop diverting, and in some cases flow in hospitals. set time limits for how long diversion can be active (e.g., no more than two hours). Reducing Ambulance Diversion in California: Strategies and Best Practices  |  9 A more detailed edition of this project report can be 7.Begley CE, Chang Y, Wood RC, et al. Emergency department diversion and trauma mortality: evidence from Houston, Texas. found on the California ED Diversion Project website: J Trauma. 2004; 57: 1260–1265. caeddiversionproject.com. 8.Garza MA. Dangerous detours: Ambulance diversions stall patient delivery. J Emerg Med Serv. 1989; 14: 42-6, 48. 9.Green L, Glied S, Grams M. Ambulance diversion and myocar- Authors dial infarction mortality. Columbia University, Columbia Business School. Working paper 2005. The Abaris Group 10.Neely KW, Norton Rl, Young GP. The effect of hospital resource Mike Williams, MPA/HSA, president unavailability and ambulance diversions on the EMS system. Pam Turner, RN, MBA/HCM, FACHE, Prehospital Disaster Med. 1994; 9: 172–176. senior consultant 11.Pham JC, Patel R, Millin MG, et al. The Effects of Ambulance Diversion: A comprehensive review. Academic Emerg Med. 2006; Maggie Borders, RN, MHA, CEN, consultant 11: 1220–1227. Juliana Boyle, MBA, vice president 12.Punch L. New laws prohibit patient diversion. Mod Healthcare. 1983; 13: 66. 13.Redelmeier DA, Blair PJ, Collins WE. No Place to Unload: A About the F o u n d at i o n preliminary analysis of the prevalence, risk factors, and conse- quences of ambulance diversion. Ann Emerg Med. 1994; 23: The California HealthCare Foundation is an independent 43–7. philanthropy committed to improving the way health 14.Schull MJ, Morrison LJ, Vermeulen M Redelmeir DA. Emergency department gridlock and out-of-hospital delays for care is delivered and financed in California. By promoting cardiac patients. Acad Emerg Med. 2003; 10: 709–16. innovations in care and broader access to information, our 15.Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency depart- goal is to ensure that all Californians can get the care they ment overcrowding and ambulance transport delays for patients need, when they need it, at a price they can afford. For with chest pain. CMAJ. 2003; 168: 277–283. more information about CHCF, visit www.chcf.org. 16.Schull MJ, Vermeulen M, Slaughter G, et al. Emergency depart- ment crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004; 44: 577–585. 17.Sloan EP, Callahan EP, Duda J, Sheaff CM, Robin AP, Barrett JA. The effect of urban trauma system hospital bypass on prehospital transport times and Level 1 trauma patient survival. Ann Emerg Endnotes Med. 1989; 18: 1146–50. 18.Vilke GM, Castillo EM, Metz MA, et al. Community trial 1.caeddiversionproject.com. to decrease diversion hours: the San Diego County Patient 2.General Accounting Office. “Hospital emergency departments— Destination trial. Ann Emerg Med. 2004; 44: 295–303. crowded conditions vary among hospitals and communities.” 19.During 2002, San Diego County implemented a “home-hospi- Washington. D.C. The Office: 2003. tal” policy in which an ambulance transporting a managed-care 3.Catharine WB, McCaig LF, Valverde RH. Analysis of Ambulance patient, takes the patient to his or her payer-contracted hospital, Transports and Diversions Among U.S. Emergency Departments, irrespective of the hospital’s diversion status. Thus, diversion 20 February 2006. Annals of Emergency Medicine. April hours may overstate the total diversion problem, since each 2006;47(4): 317–326). diverted ED may still receive ambulance patients. 4.Lagoe, RJ; Hun, RC; Nadle, PA; Kohlbrenner, JC. Utilization 20.Snapshot—Healthcare, Sacramento Business Journal, October 3, and impact of ambulance diversion at the community level. 2008. Prehospital Emergency Care. 1545–0066, 2002;6(2): 191–198. 21.Patel, P. B., Derlet, R. W., Vinson, D. R., Williams, M., & Wills, J. 5.Silka PA, Geiderman JM, Kim JY. Diversion of ALS ambulances: (2006). Ambulance diversion reduction: the Sacramento solution. characteristics, causes, and effects in a large urban system. Prehosp. The American Journal of Emergency Medicine, 24(2):206–213. Emerg Care. 2001; 5: 23–28. 22.Office of Statewide Health Planning and Development, Hospital 6.Bindman AB, Grumbach K, Keane D, et al. Consequences of Annual Utilization Report, 2005–2007. queuing for care at a public hospital emergency department. 23.State of California, Department of Finance. California County JAMA. 1991; 266: 1091–1096. Population Estimates and Components of Change by Year. July 1, 2000–2007. Sacramento, California. July 2007. 10  |  California HealthCare Foundation Appendix A Diversion by Region 2007 Diversion Hours/ED Hospitals (OSHPD)† (per EMS Agency) (per EMS Agency) Treatment Station Treatment Station Stations (OSHPD) Diversion Hours/ Diversion Hours/ Diversion Hours/ 1,000 Population 1,000 Population Diversion Hours Diversion Hours EMS Transports EMS Transport ED Utilization/ (per CA DOF)* ED Treatment (per OSHPD) (per OSHPD) ED Visits/ED Population ED Volume Hospital EMS Region Alameda 1,530,620 478,353 13 305 82,150 881 714 313 1,568 0.47 0.01 55 2 Central California 1,657,210 521,991 16 340 149,865 72 n/a 315 1,535 n/a n/a n/a n/a Coastal Valleys 707,257 189,801 12 131 41,885 0 n/a 268 1,449 n/a n/a n/a n/a Contra Costa 1,044,201 326,314 9 223 58,213 9 n/a 313 1,463 n/a n/a n/a n/a El Dorado‡ 178,689 44,281 2 27 9,112 0 n/a 248 1,640 n/a n/a n/a n/a Imperial‡,# 174,322 73,452 2 36 11,078 1,120 - 421 2,040 6.42 0.10 560 0 Inland Counties 2,071,775 654,035 19 360 25,142 14,405 19,224 316 1,817 9.28 0.76 1,012 53 Kern 809,903 220,739 9 130 66,708 548 621 273 1,698 0.77 0.01 69 5 Los Angeles 10,294,280 2,653,876 75 1,541 496,896 73,072 81,741 258 1,722 7.94 0.16 1,090 53 Marin§ 256,310 75,733 3 45 15,643 104 65 295 1,683 0.25 0.00 22 1 Merced 252,544 66,313 2 31 14,153 0 n/a 263 2,139 n/a n/a n/a n/a Monterey 425,356 136,971 4 63 20,571 0 n/a 322 2,174 n/a n/a n/a n/a Mountain Valley 626,982 232,882 7 126 44,216 164 1,089 371 1,848 1.74 0.02 156 9 North Coast 225,392 128,939 8 63 17,582 0 n/a 572 2,047 n/a n/a n/a n/a Northern California# 643,505 266,885 19 150 77,210 594 - 415 1,779 0.92 0.01 31 0 Orange 3,098,183 764,169 27 552 55,931 8,445 7,197 247 1,384 2.32 0.13 267 13 Riverside# 2,070,315 564,402 15 300 117,200 2,423 - 273 1,881 1.17 0.02 162 0 Sacramento‡ 1,415,117 389,134 9 231 71,864 3,721 3,905 275 1,685 2.76 0.05 434 17 San Benito 57,493 15,580 1 6 3,771 0 n/a 271 2,597 n/a n/a n/a n/a San Diego** 3,120,088 727,096 17 424 147,639 19,015 24,458 233 1,715 7.84 0.17 1,439 58 San Francisco 817,537 226,942 9 163 57,173 5,689 6,477 278 1,392 7.92 0.11 720 40 San Joaquin 680,183 203,858 7 107 40,575 227 320 300 1,905 0.47 0.01 46 3 San Luis Obispo 267,154 89,623 4 56 14,580 26 376 335 1,600 1.41 0.03 94 7 San Mateo‡ 734,453 179,863 8 119 28,318 2,035 2,499 245 1,511 3.40 0.09 312 21 Santa Barbara 425,710 130,410 5 56 27,487 0 236 306 2,329 0.55 0.01 47 4 Santa Clara 1,820,176 398,334 11 228 59,557 1,965 2,600 219 1,747 1.43 0.04 236 11 Santa Cruz 265,183 62,062 2 36 11,384 677 1,440 234 1,724 5.43 0.13 720 40 Sierra-Sacramento†† 794,063 261,522 8 147 43,558 644 681 329 1,779 0.86 0.02 85 5 Solano 423,970 117,410 4 82 29,430 0 n/a 277 1,432 n/a n/a n/a n/a Tuolumne 56,910 23,150 1 14 4,849 0 n/a 407 1,654 n/a n/a n/a n/a Ventura 826,550 178,189 7 112 32,472 8,858 7,400 216 1,591 8.95 0.23 1,057 66 Total/Average 37,771,431 10,402,309 335 6,204 1,876,212 144,694 161,043 275 1,677 4.26 0.09 481 26 Total diversion hours including OSHPD data, when EMS agency data was not available 165,180 * Population as of July 1, 2007 † Includes all General Acute Care hospitals with at least 1 ED Visit reported in the OSHPD data ‡ EMS transports estimated based on average growth rate § Diversion hours include all types (e.g. ED Sat, CT Failure, Neuro, Trauma) # Diversion hours were not made available from the EMS agency. The diversion hours calculations were estimated using OSHPD data ** During 2002, San Diego County implemented a “home hospital” policy where a managed care patient is transported to their payer contracted hospital irrespective of the hospital’s diversion status. Thus, diversion hours may overstate the total diversion problem as each diverted ED may still receive ambulance patients. ††Region changed to “no divert” policy 7/2007. Thus the data reflect only January through June 2007. n/a = Not applicable. The region has a “no divert” policy or does not have any hospitals “-” = EMS agency did not respond to requests for data Source: OSHPD Annual Hospital Utilization Report 2007 (Pivot Tables), CA DOF, interviews with each EMS agency Reducing Ambulance Diversion in California: Strategies and Best Practices  |  11 Diversion by Region 2006 Diversion Hours/ED Hospitals (OSHPD)† (per EMS Agency) (per EMS Agency) Treatment Station Treatment Station Stations (OSHPD) Diversion Hours/ Diversion Hours/ Diversion Hours/ 1,000 Population 1,000 Population Diversion Hours Diversion Hours EMS Transports EMS Transport ED Utilization/ (per CA DOF)* ED Treatment (per OSHPD) (per OSHPD) ED Visits/ED Population ED Volume Hospital EMS Region Alameda‡ 1,513,859 438,597 12 288 83,882 1,034 1,073 290 1,523 0.71 0.01 89 4 Central California 1,624,906 522,599 17 326 83,927 50 n/a 322 1,603 n/a n/a n/a n/a Coastal Valleys 701,065 208,439 13 149 36,694 49 238 297 1,399 0.34 0.01 18 2 Contra Costa 1,031,012 317,594 8 191 59,517 1,494 1,674 308 1,663 1.62 0.03 209 9 El Dorado 176,969 45,549 2 27 8,991 0 n/a 257 1,687 n/a n/a n/a n/a Imperial 168,979 78,161 2 36 10,670 791 518 463 2,171 3.07 0.05 259 14 Inland Counties 2,043,644 543,740 20 361 103,566 17,177 22,318 266 1,506 10.92 0.22 1,116 62 Kern 790,246 216,728 10 125 39,863 420 1,020 274 1,734 1.29 0.03 102 8 Los Angeles‡ 10,247,672 2,713,973 77 1,544 459,065 102,551 102,609 265 1,758 10.01 0.22 1,333 66 Marin§ 254,000 75,446 3 45 13,093 297 126 297 1,677 0.50 0.01 42 3 Merced 248,258 19,923 1 9 13,026 0 n/a 80 2,214 n/a n/a n/a n/a Monterey‡ 421,463 126,114 4 63 19,755 0 n/a 299 2,002 n/a n/a n/a n/a Mountain Valley 618,847 226,847 7 110 77,688 493 622 367 2,062 1.01 0.01 89 6 North Coast 224,503 127,887 8 66 19,048 3 n/a 570 1,938 n/a n/a n/a n/a Northern California 638,490 245,252 19 150 42,500 529 593 384 1,635 0.93 0.01 31 4 Orange‡ 3,075,341 739,141 26 518 53,371 11,340 9,821 240 1,427 3.19 0.18 378 19 Riverside 2,004,174 535,372 15 285 114,946 1,718 2,573 267 1,878 1.28 0.02 172 9 Sacramento‡ 1,396,496 358,727 9 227 70,428 6,519 6,644 257 1,580 4.76 0.09 738 29 San Benito 57,128 14,838 1 6 2,049 0 n/a 260 2,473 n/a n/a n/a n/a San Diego# 3,077,877 696,161 18 440 142,791 15,182 21,771 226 1,582 7.07 0.15 1,210 49 San Francisco 806,210 227,382 9 163 55,777 4,116 4,725 282 1,395 5.86 0.08 525 29 San Joaquin 671,115 204,525 7 107 48,120 100 196 305 1,911 0.29 0.00 28 2 San Luis Obispo‡ 264,972 87,266 4 48 13,843 24 18 329 1,818 0.07 0.00 5 0 San Mateo 726,260 182,400 8 119 26,703 1,973 2,079 251 1,533 2.86 0.08 260 17 Santa Barbara 421,337 125,622 5 59 26,294 0 402 298 2,129 n/a n/a n/a n/a Santa Clara 1,790,272 354,929 10 224 54,246 1,593 2,546 198 1,585 n/a n/a n/a n/a Santa Cruz 262,150 65,351 2 36 10,588 1,225 686 249 1,815 n/a n/a n/a n/a Sierra-Sacramento 778,231 242,760 8 149 47,708 1,882 1,825 312 1,629 n/a n/a n/a n/a Solano 421,815 112,596 4 71 21,774 4 n/a 267 1,586 n/a n/a n/a n/a Tuolumne 56,882 30,165 2 20 4,765 0 1 530 1,508 n/a n/a n/a n/a Ventura 818,803 194,963 8 108 31,872 12,078 10,836 238 1,805 n/a n/a n/a n/a Total/Average 37,332,976 10,079,047 339 6,070 1,796,560 182,642 194,914 270 1,660 5.22 0.11 575 32 * Population as of July 1, 2006 † Includes all General Acute Care hospitals with at least 1 ED Visit reported in the OSHPD data ‡ EMS transports estimated based on typical 9-1-1 utilization by population § Diversion hours include all types (e.g. ED Sat, CT Failure, Neuro, Trauma) # During 2002, San Diego County implemented a “home hospital” policy where a managed care patient is transported to their payer contracted hospital irrespective of the hospital’s diversion status. Thus, diversion hours may overstate the total diversion problem as each diverted ED may still receive ambulance patients. n/a = Not applicable. The region has a “no divert” policy or does not have any hospitals Source: OSHPD Annual Hospital Utilization Report 2006 (Pivot Tables), CA DOF, interviews with each EMS agency 12  |  California HealthCare Foundation Diversion by Region 2005 Diversion Hours/ED Hospitals (OSHPD)† (per EMS Agency) (per EMS Agency) Treatment Station Treatment Station Stations (OSHPD) Diversion Hours/ Diversion Hours/ Diversion Hours/ 1,000 Population 1,000 Population Diversion Hours Diversion Hours EMS Transports EMS Transport ED Utilization/ (per CA DOF)* ED Treatment (per OSHPD) (per OSHPD) ED Visits/ED Population ED Volume Hospital EMS Region Alameda 1,501,124 442,775 12 286 82,141 1,124 1,319 295 1,548 0.88 0.02 110 5 Central California 1,591,635 508,298 17 310 79,107 115 n/a 319 1,640 n/a n/a n/a n/a Coastal Valleys 698,353 201,612 13 149 37,118 2,088 2,747 289 1,353 3.93 0.07 211 18 Contra Costa 1,021,555 280,237 8 192 54,568 388 506 274 1,460 0.50 0.01 63 3 El Dorado 174,542 45,039 2 27 8,850 0 n/a 258 1,668 n/a n/a n/a n/a Imperial 163,521 79,141 2 36 10,670 1,975 1,073 484 2,198 6.56 0.10 537 30 Inland Counties 2,002,506 518,377 19 319 101,121 24,998 32,661 259 1,625 16.31 0.32 1,719 102 Kern 765,161 211,731 10 124 35,830 543 1,905 277 1,708 2.49 0.05 190 15 Los Angeles 10,197,247 2,679,473 73 1,443 459,065 162,448 174,952 263 1,857 17.16 0.38 2,397 121 Marin 252,179 72,178 3 45 12,734 167 204 286 1,604 0.81 0.02 68 5 Merced 242,260 48,539 2 26 12,662 0 n/a 200 1,867 n/a n/a n/a n/a Monterey‡,§ 421,211 118,579 4 54 19,586 428 n/t 282 2,196 1.02 0.02 107 8 Mountain Valley 609,961 223,575 7 116 73,944 422 253 367 1,927 0.41 0.00 36 2 North Coast 223,443 127,128 8 66 18,750 0 n/a 569 1,926 n/a n/a n/a n/a Northern California§,# 632,023 224,046 18 131 42,075 294 196 354 1,710 0.31 0.00 11 1 Orange 3,056,814 767,336 26 523 53,426 10,808 10,608 251 1,467 3.47 0.20 408 20 Riverside 1,922,209 491,004 14 285 110,898 1,352 3,847 255 1,723 2.00 0.03 275 13 Sacramento 1,378,299 350,457 9 225 69,068 5,809 5,811 254 1,558 4.22 0.08 646 26 San Benito 57,112 14,592 1 6 1,865 0 n/a 255 2,432 n/a n/a n/a n/a San Diego** 3,051,175 718,290 19 426 138,598 13,331 18,841 235 1,686 6.18 0.14 992 44 San Francisco 799,731 225,179 9 154 53,084 6,670 7,106 282 1,462 8.89 0.13 790 46 San Joaquin‡ 659,707 202,230 7 107 44,752 137 n/t 307 1,890 0.21 0.00 20 1 San Luis Obispo 262,480 90,411 4 46 14,857 186 48 344 1,965 0.18 0.00 12 1 San Mateo 722,012 185,588 8 119 26,009 2,287 2,458 257 1,560 3.40 0.09 307 21 Santa Barbara 418,899 128,041 5 59 19,905 8 1,004 306 2,170 2.40 0.05 201 17 Santa Clara 1,763,481 305,690 10 224 57,293 1,723 2,638 173 1,365 1.50 0.05 264 12 Santa Cruz 260,469 64,800 2 36 10,149 1,726 689 249 1,800 2.65 0.07 345 19 Sierra-Sacramento 759,050 217,333 8 128 49,989 1,502 1,516 286 1,698 2.00 0.03 190 12 Solano 419,180 109,017 4 71 17,251 0 n/a 260 1,535 n/a n/a n/a n/a Tuolumne 56,816 31,740 2 20 4,232 0 4 559 1,587 0.07 0.00 2 0 Ventura 812,065 183,428 7 99 29,442 11,376 9,521 226 1,853 11.72 0.32 1,360 96 Total/Average 36,896,220 9,865,864 333 5,852 1,749,039 251,905 279,907 267 1,686 7.59 0.16 841 48 Total diversion hours including OSHPD data, when EMS agency data was not available 280,472 * Population as of July 1, 2005 † Includes all General Acute Care hospitals with at least 1 ED Visit reported in the OSHPD data ‡ Diversion hours calculations estimated using OSHPD data § EMS transports estimated based on typical 9-1-1 utilization by population # Diversion hours (per EMS Agency) estimated from 2003-2004 diversion hours **During 2002, San Diego County implemented a “home hospital” policy in which managed care patients are transported to their payer-contracted hospital irrespective of the hospital’s diversion status. Thus, diversion hours may overstate the total diversion problem as each diverted ED may still receive ambulance patients. n/t = Not tracked by EMS agency n/a = Not applicable. The region has a “no divert” policy or does not have any hospitals Source: OSHPD Annual Hospital Utilization Report 2005 (Pivot Tables), CA DOF, interviews with each EMS agency Reducing Ambulance Diversion in California: Strategies and Best Practices  |  13 Diversion by Region 2004 Diversion Hours/ED Hospitals (OSHPD)† (per EMS Agency) (per EMS Agency) Treatment Station Treatment Station Stations (OSHPD) Diversion Hours/ Diversion Hours/ Diversion Hours/ 1,000 Population 1,000 Population Diversion Hours Diversion Hours EMS Transports EMS Transport ED Utilization/ (per CA DOF)* ED Treatment (per OSHPD) (per OSHPD) ED Visits/ED Population ED Volume Hospital EMS Region Alameda 1,497,110 381,701 11 239 75,424 1,505 1,764 255 1,597 1.18 0.02 160 7 Central California 1,559,868 394,962 12 229 72,501 50 n/a 253 1,725 n/a n/a n/a n/a Coastal Valleys 696,168 163,171 11 110 34,927 798 2,990 234 1,483 4.29 0.09 272 27 Contra Costa 1,011,851 283,104 8 159 49,314 253 257 280 1,781 0.25 0.01 32 2 El Dorado 171,355 45,300 2 27 8,769 0 n/a 264 1,678 n/a n/a n/a n/a Imperial 158,650 68,880 2 36 10,455 2,083 1,276 434 1,913 8.04 0.12 638 35 Inland Counties 1,952,754 466,912 18 298 97,944 26,269 37,114 239 1,567 19.01 0.38 2,062 125 Kern 742,529 171,670 9 110 34,124 519 1,368 231 1,561 1.84 0.04 152 12 Los Angeles 10,127,440 2,658,919 79 1,500 419,644 144,272 165,026 263 1,773 16.29 0.39 2,089 110 Marin‡ 250,703 68,947 3 45 10,733 98 n/t 275 1,532 0.39 0.01 33 2 Merced 236,367 46,357 2 26 11,558 0 n/a 196 1,783 n/a n/a n/a n/a Monterey‡,§ 421,191 119,248 4 54 19,641 603 n/t 283 2,208 1.43 0.03 151 11 Mountain Valley 598,538 213,635 7 123 70,200 246 207 357 1,737 0.35 0.00 30 2 North Coast‡ 222,162 100,356 7 55 19,481 0 n/a 452 1,825 n/a n/a n/a n/a Northern California§ 625,925 235,292 20 153 41,654 926 251 376 1,538 0.40 n/a 13 2 Orange 3,033,026 747,031 28 530 52,301 11,482 10,767 246 1,409 3.55 0.21 385 20 Riverside 1,841,707 481,754 15 266 112,796 1,586 3,216 262 1,811 1.75 0.03 214 12 Sacramento 1,358,046 335,871 9 211 65,704 7,576 7,785 247 1,592 5.73 0.12 865 37 San Benito 56,865 14,046 1 6 1,853 0 n/a 247 2,341 n/a n/a n/a n/a San Diego# 3,027,440 520,859 15 325 133,902 15,051 22,063 172 1,603 7.29 0.16 1,471 68 San Francisco 796,288 220,235 9 148 48,103 6,604 8,015 277 1,488 10.07 0.17 891 54 San Joaquin‡ 643,929 179,606 7 102 41,619 134 n/t 279 1,761 0.21 0.00 19 1 San Luis Obispo 260,146 89,707 4 46 14,512 44 48 345 1,950 0.18 0.00 12 1 San Mateo 719,102 176,967 8 120 22,949 2,030 2,160 246 1,475 3.00 0.09 270 18 Santa Barbara‡ 416,612 78,900 4 47 19,181 3 n/t 189 1,679 0.01 0.00 1 0 Santa Clara 1,747,249 306,481 11 216 54,246 2,397 3,077 175 1,419 1.76 0.06 280 14 Santa Cruz 259,666 81,403 2 36 10,325 892 371 313 2,261 1.43 0.04 186 10 Sierra-Sacramento 740,890 211,243 8 125 45,597 615 623 285 1,690 0.84 0.01 78 5 Solano 417,574 104,984 4 61 16,162 0 n/a 251 1,721 n/a n/a n/a n/a Tuolumne 56,686 30,946 2 20 4,412 0 0 546 1,547 0.00 0.00 0 0 Ventura 806,634 166,371 7 97 28,417 13,265 9,257 206 1,715 11.48 0.33 1,322 95 Total/Average 36,454,471 9,164,858 329 5,520 1,648,448 239,301 277,635 251 1,660 7.62 0.17 844 50 Total diversion hours including OSHPD data, when EMS agency data was not available 278,473 * Population as of July 1, 2004 † Includes all General Acute Care hospitals with at least 1 ED Visit reported in the OSHPD data ‡ Diversion hours calculations estimated by OSHPD data § EMS transports estimated based on typical 9-1-1 utilization by population # During 2002, San Diego County implemented a “home hospital” policy in which managed care patients are transported to their payer-contracted hospital irrespective of the hospital’s diversion status. Thus, diversion hours may overstate the total diversion problem as each diverted ED may still receive ambulance patients. n/t = Not tracked by EMS agency n/a = Not applicable. The region has a “no divert” policy or does not have any hospitals Source: OSHPD Annual Hospital Utilization Report 2004 (Pivot Tables), CA DOF, interviews with each EMS agency 14  |  California HealthCare Foundation Diversion by Region 2003 Diversion Hours/ED Hospitals (OSHPD)† (per EMS Agency) (per EMS Agency) Treatment Station Treatment Station Stations (OSHPD) Diversion Hours/ Diversion Hours/ Diversion Hours/ 1,000 Population 1,000 Population Diversion Hours Diversion Hours EMS Transports EMS Transport ED Utilization/ (per CA DOF)* ED Treatment (per OSHPD) (per OSHPD) ED Visits/ED Population ED Volume Hospital EMS Region Alameda 1,492,709 403,396 12 232 78,660 1,251 3,496 270 1,739 2.34 0.04 291 15 Central California 1,523,446 445,605 16 249 70,253 1,542 n/a 292 1,790 n/a n/a n/a n/a Coastal Valleys‡ 691,607 168,441 11 100 32,439 229 n/t 244 1,684 0.33 0.01 21 2 Contra Costa 1,000,115 302,636 8 157 48,958 369 381 303 1,928 0.38 0.01 48 2 El Dorado 168,310 47,725 2 27 8,637 0 n/a 284 1,768 n/a n/a n/a n/a Imperial 154,138 67,296 2 36 9,555 1,754 806 437 1,869 5.23 0.08 403 22 Inland Counties 1,898,287 479,368 18 301 94,767 36,314 52,387 253 1,593 27.60 0.55 2,910 174 Kern 719,357 180,474 10 114 32,758 2,258 1,532 251 1,583 2.13 0.05 153 13 Los Angeles 10,026,859 2,887,922 84 1,535 438,010 143,900 166,159 288 1,881 16.57 0.38 1,978 108 Marin‡ 250,729 67,134 3 45 11,868 0 n/t 268 1,492 0.00 0.00 0 0 Merced 230,363 49,926 3 40 8,665 540 n/a 217 1,248 n/a n/a n/a n/a Monterey‡,§ 420,068 126,745 4 54 19,448 119 n/t 302 2,347 0.28 0.01 30 2 Mountain Valley 588,185 219,477 7 117 66,456 1,115 2,295 373 1,876 3.90 0.03 328 20 North Coast‡ 220,032 92,427 6 50 18,913 0 n/a 420 1,849 n/a n/a n/a n/a Northern California§ 618,647 268,481 21 160 41,238 459 141 434 1,678 0.23 0.00 7 1 Orange 3,001,168 749,713 28 504 51,902 14,011 14,561 250 1,488 4.85 0.28 520 29 Riverside 1,764,136 486,344 15 258 110,735 3,231 6,712 276 1,885 3.80 0.06 447 26 Sacramento 1,332,815 352,973 9 197 66,348 6,374 6,380 265 1,792 4.79 0.10 709 32 San Benito§ 56,591 15,621 1 6 1,840 0 n/a 276 2,604 n/a n/a n/a n/a San Diego# 2,998,514 670,814 17 359 131,762 16,891 23,084 224 1,869 7.70 0.18 1,358 64 San Francisco 793,715 188,894 8 134 46,152 6,852 13,582 238 1,410 17.11 0.29 1,698 101 San Joaquin‡ 625,556 153,722 6 83 38,706 153 n/t 246 1,852 0.24 0.00 26 2 San Luis Obispo‡ 257,024 89,185 4 44 14,258 56 - 347 2,027 0.22 0.00 14 1 San Mateo 716,773 187,162 8 107 22,468 1,244 1,948 261 1,749 2.72 0.09 244 18 Santa Barbara 413,823 137,950 5 63 16,820 0 0 333 2,190 0.00 0.00 0 0 Santa Clara 1,732,417 323,002 11 217 55,930 1,849 2,084 186 1,488 1.20 0.04 189 10 Santa Cruz 258,565 65,024 2 39 10,133 1,044 479 251 1,667 1.85 0.05 240 12 Sierra-Sacramento 720,819 221,889 8 124 41,773 639 766 308 1,789 1.06 0.02 96 6 Solano 414,759 110,656 4 58 15,980 0 n/a 267 1,908 n/a n/a n/a n/a Tuolumne 56,648 31,800 2 13 4,085 0 0 561 2,446 0.00 0.00 0 0 Ventura‡ 798,038 189,146 7 97 27,894 4,819 n/t 237 1,950 6.04 0.17 688 50 Total/Average 35,944,213 9,780,948 342 5,520 1,637,411 247,013 296,793 272 1,772 8.26 0.18 868 54 Total diversion hours including OSHPD data, when EMS agency data was not available 302,169 * Population as of July 1, 2003 † Includes all General Acute Care hospitals with at least 1 ED Visit reported in the OSHPD data ‡ Diversion hours estimated by OSHPD data § EMS transports estimated based on typical 9-1-1 utilization by population # During 2002, San Diego County implemented a “home hospital” policy in which managed care patients are transported to their payer-contracted hospital irrespective of the hospital’s diversion status. Thus, diversion hours may overstate the total diversion problem as each diverted ED may still receive ambulance patients. n/t = Not tracked by EMS agency n/a = Not applicable. The region has a “no divert” policy or does not have any hospitals “-” = EMS agency did not respond to requests for data Source: OSHPD Annual Hospital Utilization Report 2003 (Pivot Tables), CA DOF, interviews with each EMS agency Reducing Ambulance Diversion in California: Strategies and Best Practices  |  15 Appendix B Diversion Hours for Participating Hospitals, Sept. ‘06—Aug. ‘08 3,000 2,500 2,000 Pre Project 9/06–8/07 Hours 1,500 Project Period 9/07–8/08* 1,000 500 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Month Average Monthly Diversion Hours by EMSA Region Sept. ‘06—Aug. ‘08 600 500 400 Pre Project 9/06–8/07 Hours 300 Project Period 9/07–8/08* 200 100 0 Inland Counties Los Angeles County Ventura County EMS Region Diversion Hours for San Bernardino County 900 800 700 600 Pre Project 500 9/06–8/07 Hours 400 Project Period 9/07–8/08* 300 200 100 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Month 16  |  California HealthCare Foundation Diversion Hours for Los Angeles County EMSA Region 700 600 500 Pre Project 400 9/06–8/07 Hours 300 Project Period 9/07–8/08* 200 100 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Month Diversion Hours for Ventura County EMSA Region 1,200 1,000 800 Pre Project 9/06–8/07 Hours 600 Project Period 9/07–8/08* 400 200 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Month Diversion Hours for Santa Clara EMSA Region 35 30 25 Pre Project 20 9/06–8/07 Hours 15 Project Period 9/07–8/08* 10 5 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Month Reducing Ambulance Diversion in California: Strategies and Best Practices  |  17