Diversion of ambulances associated with increased risk of death for heart-attack patients
Among Medicare patients with heart attack in 4 California counties, diversion of ambulance traffic by the nearest emergency department for 12 hours or more was associated with an increased risk of death for up to one year, according to a study in the June 15 issue of JAMA.
Recent reports have described the state of emergency departments (EDs) in the United States as reaching a breaking point, with the ED system experiencing increased utilization but decreased capacity. These trends have led to problems for patients, such as longer waiting times, overextended staff and disruptions to ambulance services, according to background information in the article. Ambulance diversion, a practice in which EDs are temporarily closed to ambulance traffic due to overcrowding or lack of available resources, might be especially problematic for patients experiencing time-sensitive conditions, such as acute myocardial infarction (AMI; heart attack). There is little empirical evidence to show whether diversion is associated with worse patient outcomes.
Yu-Chu Shen, Ph.D., of the Naval Postgraduate School, Monterey, Calif., and National Bureau of Economic Research, Cambridge, Mass., and Renee Y. Hsia, M.D., M.Sc., of the University of California, San Francisco conducted a study to examine whether temporary ED closure on the day a patient experiences AMI is associated with increased mortality. The study included 13,860 Medicare patients with AMI within 4 California counties (Los Angeles, San Francisco, San Mateo, and Santa Clara) whose admission date was between 2000 and 2005. Data included 100 percent Medicare claims data that covered admissions between 2000 and 2005, linked with date of death until 2006, and daily ambulance diversion logs from the same 4 counties. The researchers indentified 149 EDs as the nearest ED to these patients. Among the outcomes measured were the percentage of patients with AMI who died within 7 days, 30 days, 90 days, 9 months, and 1 year from admission (when their nearest ED was not on diversion and when that same ED was exposed to less than 6, 6 to less than 12, and 12 or more hours of diversion out of 24 hours on the day of admission).
Between 2000 and 2006, the average daily diversion duration was 7.9 hours. The analysis included 11,625 patients, and among these patients, 3,541, 3,357, 2,667, and 2,060 were admitted for AMI when their closest ED was not exposed to diversion and was exposed to less than 6 hours, 6 to less than 12 hours, and 12 or more hours, respectively. There were 1,034 patients (29 percent) in the no diversion category who died within 1 year of ED admission, and the number of patients who died within 1 year of admission in the less than 6 hours, 6 to less than 12 hours, and 12 or more hours diversion categories were 1,028 (31 percent), 794 (30 percent), and 731 (35 percent), respectively.
There were differences in treatment patterns for patients once admitted: the number of patients receiving catheterization was 42 percent among those in the 12 hours or greater ED diversion exposure category vs. 49 percent in the no diversion category; and number of patients receiving percutaneous coronary intervention (procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries) was 24 percent in 12 hours or greater exposure category vs. 31 percent in the no diversion category.
Analysis of data indicated that there were no statistically significant differences in mortality rates between no diversion status and when the exposure to diversion was less than 12 hours. However, exposure to 12 or more hours of diversion, compared to no diversion, was associated with higher mortality rates at 30-days (19 percent vs. 15 percent); 90-days (26 percent vs. 22 percent); 9-months (33 percent vs. 28 percent); and 1-year (35 percent vs. 29 percent).
"These findings point to the need for more targeted interventions to appropriately distribute system-level resources in such a way to decrease crowding and diversion, so that patients with time-sensitive conditions such as AMI are not adversely affected. It is important to emphasize that while demand on emergency care is increasing as evidenced by increasing utilization, supply of emergency care is decreasing. If these issues are not addressed on a larger scale, ED conditions will deteriorate, having significant implications for all," the authors write.
They add that possible policy options to improve such care could include patient flow initiatives that have been implemented in many counties and states with success. "Diversion bans have been implemented in various regions, with the first statewide ban on diversion in Massachusetts in 2009. Early evaluation of this recent legislation has not revealed any negative outcomes for patients, at least when measured by waiting times. To prevent adverse consequences for patients, however, it is critical that such policies are implemented in conjunction with hospital-level changes beyond the ED that improve inpatient capacity and patient flow."
More information: JAMA. 2011;3052440-2447.
Provided by JAMA and Archives Journals
- Study shows emergency physicians have good first instincts in diagnosing heart attacks Jul 24, 2008 | not rated yet | 0
- Death rate decreases following hospitalization for heart attack Aug 18, 2009 | not rated yet | 0
- Fewer emergency patients seen within recommended time frame Nov 09, 2009 | not rated yet | 0
- Patients without health insurance more likely to delay seeking care for heart attack Apr 13, 2010 | not rated yet | 0
- Visits to emergency departments increases in recent years Aug 10, 2010 | not rated yet | 0
- Motion perception revisited: High Phi effect challenges established motion perception assumptions Apr 23, 2013 | 3 / 5 (2) | 2
- Anything you can do I can do better: Neuromolecular foundations of the superiority illusion (Update) Apr 02, 2013 | 4.5 / 5 (11) | 5
- The visual system as economist: Neural resource allocation in visual adaptation Mar 30, 2013 | 5 / 5 (2) | 9
- Separate lives: Neuronal and organismal lifespans decoupled Mar 27, 2013 | 4.9 / 5 (8) | 0
- Sizing things up: The evolutionary neurobiology of scale invariance Feb 28, 2013 | 4.8 / 5 (10) | 14
Classical and Quantum Mechanics via Lie algebras
Apr 15, 2011 I'd like to open a discussion thread for version 2 of the draft of my book ''Classical and Quantum Mechanics via Lie algebras'', available online at http://lanl.arxiv.org/abs/0810.1019 , and for the...
- More from Physics Forums - Independent Research
More news stories
Talking on a hands-free device while behind the wheel can lead to a sharp increase in errors that could imperil other drivers on the road, according to new research from the University of Alberta.
Health 3 hours ago | not rated yet | 0
(HealthDay)—More than one in four of those eligible for new premium assistance tax credits under the Affordable Care Act (ACA) do not have a checking account and will not be able to receive premiums from ...
Health 5 hours ago | not rated yet | 0
After studying noise in one French Quarter neighborhood of New Orleans to determine whether or not noise levels exceeded municipal ordinances, Annette Hurley, PhD, Assistant Professor of Audiology at LSU Health Sciences Center ...
Health 7 hours ago | not rated yet | 0
Young children who missed more than half of recommended well-child visits had up to twice the risk of hospitalization compared to children who attended most of their visits, according to a study published today in the American Jo ...
Health 7 hours ago | not rated yet | 0
The individualisation of drug treatments to support patients to self-manage their conditions is a concept that sits at the heart of policy, but a recent study in BMJ Open shows that there is no concrete defini ...
Health 9 hours ago | 3 / 5 (1) | 0
Two mutations central to the development of infantile myofibromatosis (IM)—a disorder characterized by multiple tumors involving the skin, bone, and soft tissue—may provide new therapeutic targets, according to researchers ...
4 hours ago | 5 / 5 (1) | 0 |
(Medical Xpress)—A new study by researchers in the US has shown that an ancient virus can be modified to help in the fight against the simian immunodeficiency virus SIV, which is the equivalent in monkeys ...
9 hours ago | 5 / 5 (3) | 0 |
Women at a particular stage in their monthly menstrual cycle may be more vulnerable to some of the psychological side-effects associated with stressful experiences, according to a study from UCL.
6 hours ago | 5 / 5 (1) | 0 |
Biological processes are generally based on events at the molecular and cellular level. To understand what happens in the course of infections, diseases or normal bodily functions, scientists would need to ...
7 hours ago | 5 / 5 (2) | 0 |
Kate O'Reilly's spring allergy survival kit includes the usual stuff - nasal sprays, allergy pills and a box of tissues. This season, she's added a new weapon to her line of defense: an app on her smartphone.
4 hours ago | not rated yet | 0