Should Emergency Medical Services Based Redirection Be Standard Practice?

Understanding the interplay between Emergency Medical Services (EMS) and Emergency Department (ED) operations is crucial in improving patient care. We aimed to unravel the complex relationship between ED overcrowding and the redirection of EMS. The primary objective was to evaluate the association between ED operational metrics, particularly crowdedness, and redirection of EMS units. It is current practice to redirect 911 participating EMS vehicles away from an ED where dispatched units have an increased turnaround time (TAT). In New York City, redirection occurs when a unit waits at any ED for more than 30 minutes for three consecutive units.¹ Redirection procedures are based on limited EMS TAT data, which does not accurately predict actual ED business. We hypothesized that there would be no significant correlation between ED crowdedness and EMS redirection, especially when accounting for various confounding variables. Furthermore, this process should be distinct from Diversion, which the hospital requests.

A retrospective analysis was conducted at our academic Level 1 Trauma, STEMI (ST-Elevation Myocardial Infarction) and Comprehensive Stroke Center. It covered all EMS-transferred patients over 56 weeks, from April 2021 to May 2022. Key data sources included EMS redirection records from FDNY (Fire Department of New York) and internal ED Operational metrics such as ED length of stay (LOS), ED volume, admission volume, against medical advice (AMA) volume, boarding hours, door to room and door to triage. ED and EMS redirection data were compiled daily. Factors were analyzed using multivariable logistic regression models.

The initial analysis revealed several interesting insights: EMS redirection was activated on 250 out of 392 days. Monday emerged as the most common day for redirection, accounting for 17% of redirections. We further ran our analysis factoring for the week’s busiest day (Monday). The only significant ED metric was Door-to-Room with an increase in 3 minutes of TAT on days of redirection. (19.17 mins vs 16.04 mins)

This analysis is one of the first to evaluate the redirection policy of a 911 agency in relation to meaningful operational indices of the receiving ED. Redirecting patients from one busy ED to another will have a limited impact on solving ED Crowding or EMS TATs. Door-to-room times, while statistically significant, showed minimal operational differences. Additionally, an excellent marker of ED crowding and patient outcome is ED Boarding, for which redirection could not predict.²

Our analysis did have several limitations. ED metrics were averaged for the day and there was no detailed information on the number of redirected patients or their destinations. There was no follow-up on patients who were taken to an outside hospital but then required transfer for definitive care. This study provides a foundation for further research into the impact of ED overcrowding and EMS redirection policies. Understanding these dynamics is vital for optimizing patient flow and care in emergency settings. Future studies could focus on patient outcomes post-redirection, examining the implications of such policies on patient safety and overall healthcare efficiency. These findings open doors for further exploration into how ED operations can be optimized, ensuring timely and efficient patient care, even under conditions of high patient influx.

References

• Greater New York Hospital Association. (2021). FDNY initiatives for emergency department operations. https://www.gnyha.org/wp-content/uploads/ 2021/05/FDNY-initiatives-ED-operations.pdf
• Roussel M, Teissandier D, Yordanov Y, et al. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023;183(12):1378–1385. doi:10.1001/jamainternmed.2023.5961