It seems that diversion is dead in Massachusetts, and even if it isn’t yet everywhere else in the country, it’s probably fair to say that it is fading away: diversion is falling out of favor with many in EMS and emergency medicine fields.

While the data on direct patient harm caused by diversion are inconclusive1, it is likely an ineffective strategy, at least in its “classic” form, when viewed from a system’s perspective. Diversion does nothing to increase ED throughput locally, and may in fact cause EMS offload delays2.

Thus, while it’s unclear when diversion will go away permanently on the national scale, one would be prudent to prepare for its demise. And, as dead things often do, it is leaving us with a legacy, a specter, that in all likelihood will continue to haunt for some time.

While a nostalgic memory of being “on divert” for the select few, for everyone as a whole this legacy is a bouquet of unsolved problems:  ED overcrowding, long patient wait times (including those waiting on EMS gurneys) and no clear strategy yet discovered to effectively deal with what is typically tagged “ED surge”, just to name a few3.

In the May 2014 issue of Annals of Emergency Medicine, O’Keefe and colleagues4 present the results of interviewing ED leaders at nine teaching hospitals in Boston (all receiving 911 traffic) regarding their attitudes toward the statewide ban on ambulance diversion enacted in Massachusetts on January 1, 2009.  Prior related literature from this state includes a 2013 study showing no increases in the length of stay or ambulance turnaround times at the same EDs since the ban5, and a 2013 Western Massachusetts study claiming no significant effect of the ban on throughput at seven various EDs in that region6.

The authors report that “…the majority of key informants indicated that ambulance diversion was not considered an effective strategy for managing crowded conditions in the ED” prior to the ban. While more frequently requested by RNs than MDs, at some sites going on diversion was considered a “failure”. Diversion was noted to potentiate conflicts, “particularly between EMS providers and ED staff”. Importantly, diversion’s seemingly positive effects were frequently described as “mostly psychological” – reassuring “stressed staff that everything had been done to try to ameliorate the situation [crowded conditions]”.

Among the perceived benefits of a no-diversion policy, the paper reports improved hospital ownership of flow, less distraction of staff with regards to planning for diversion instead of “focusing on what’s happening in the moment” and improved working relationships with EMS.

While the authors do not address the issue of patient satisfaction in depth, some respondents described better outcomes here as well – likely due to the reduction of animosities between EMS and ER personnel witnessed by patients, and as fewer patients were brought to hospitals where they were not followed prior.  Most importantly, none of the 18 survey recipients confirmed any “fears” of the pre-ban period as coming true:  neither from the patient safety perspective, nor from the ED volume perspective.

In the grand scheme of things, diversion is passing on, and likely we should not attempt a resuscitation – at least not of the usual practice that took place since its inception7. But recognizing the futility of doing CPR on diversion should not be confused with giving up the search for new and innovative approaches for dealing with the issues at hand (while anticipating new ones on the horizon).

Community paramedicine, “directed destination” and “alternative destination” EMS policies, ED-Urgent Care physical coupling, hospital-wide “Code Help” protocols based on ED surge criteria, EMR integration among non-affiliated hospital networks are just a few examples of strategies being trialed to various degrees (and with variable success rates) across the country’s EMS districts.

The editorial8 entitled “Two Cheers for Regulation” in the same issue as the O’Keefe article concludes: “[the] Boston experience demonstrates that regulation judiciously used is valuable and essential in a variety of circumstances.”  Translation – the gavel has to come down sometimes.

Time will tell.

For now, we should only note that as past experience has shown time and again, collaborative work based on empathy, mutual respect and finding common motivation is always preferred to harsh and abrupt unilateral decisions of the “top to bottom” variety.


  1. Pham JC, et al. The effects of ambulance diversion:  a comprehensive review.  Acad Emerg Med. 2006 Nov.
  2. Position statement by the National Association of EMS Physicians: “Ambulance Diversion and Emergency Department Offload Delay”. (Accessed 8/20/14).
  3. Cooney, et al. “Ambulance Diversion and Emergency Department Offload Delay:  Resource Document for the National Association of EMS Physicians Position Statement”. Prehospital Emergency Care.  October/December 2001.
  4. SD O’Keefe, et al. “No Diversion: A Qualitative Study of Emergency Medicine Leaders in Boston, MA, and the Effects of a Statewide Diversion Ban Policy.” Ann Emerg Med, May 2014.
  5. Burke LG, et al. “The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time.”  Ann Emerg Med, 2013.
  6. Rathlev NK, et al. “No diversion in Western Massachusetts.” J Emerg Med, 2013.
  7. Lagoe RJ, Jastremski MS.  “Relieving overcrowded emergency departments through ambulance diversion.” Hosp Top. 1990.
  8. Wears, RL. “Two Cheers for Regulation”. Ann Emerg Med, May 2014.

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