Challenges and Perceived Impacts of Ambulance Diversions During Emergency Department Overcrowding: A Multi-Stakeholder Study.

Objectives: Ambulance diversion has emerged as a strategy to address Emergency Department (ED) overcrowding, but the question of when or whether diversion should be triggered is widely debated. Although the positive and adverse impacts of diversion have been primarily studied using quantitative data, little is known about the experience and perceptions of key stakeholders involved in diversions. Our study aims to explore the challenges and impacts of ambulance diversion as experienced by key stakeholders and their suggestions for improving the diversion process.

Methods: We conducted semi-structured interviews with key stakeholders including physicians, nurses and paramedics across two EDs and four fire stations. All interviews were audio-recorded following consent and transcribed verbatim. The transcripts were subjected to thematic analysis to identify key themes and sub-themes. Coding discrepancies were resolved through iterative discussions until no new themes were identified.

Results: A total of 33 stakeholders were interviewed. The primary reasons for ambulance diversions were perceived to be resource constraints in EDs, overcrowding and bed block situations. Challenges during diversions included communication breakdowns, operational delays, lack of clarity in diversion criteria and emotional stress for both Emergency Medical Services (EMS) and hospital staff. Participants felt diversions impacted patient safety, staff morale, system efficiency and could generate inter-institutional conflict. Suggestions on improvements focused on use of alternative care pathways, improving hospital's flow issues, better information sharing, and optimizing the diversion process through strategizing the timing and duration of diversions. Reworking the hierarchical approach of dissemination of information to ground staff was also suggested.

Conclusions: This study highlights that while diversions may offer temporary relief for overwhelmed hospitals, they also pose challenges and negative impacts on receiving hospitals and EMS operations. Our findings underscore the need for systemic improvements to address the root causes of ED overcrowding and enhance understanding among stakeholders involved in diversions.