Some busy hospitals say they must turn away ambulances. Here's how one state banned the practice

A Journal Sentinel investigation found at least 21 deaths that came after patients were turned away from hospitals


This article originally appeared in the Milwaukee Journal Sentinel, and has been reprinted here with permission. 

By John Diedrich and Kevin Crowe
Milwaukee Journal Sentinel

Twelve years ago, Boston emergency room doctor Brien Barnewolt spent many days in frustration.

His hospital and others across Massachusetts often closed their doors to ambulances, sending paramedics scurrying to find an open ER. Every closure meant more time on the road for the ambulance and more risk to the patient in back.

The emergency department at Tufts Medical Center in Boston is centered around a hub, where the staff works to manage the flow of patients. (Rick Wood/Milwaukee Journal Sentinel)
The emergency department at Tufts Medical Center in Boston is centered around a hub, where the staff works to manage the flow of patients. (Rick Wood/Milwaukee Journal Sentinel)

He and others on a state committee studying the ambulance diversion problem had met time and again, but couldn’t find a solution. 

They posted hospital diversion hours online, hoping to shame officials into cutting back on the practice. They proposed limits on how often hospitals could close. They prodded hospital executives to improve admitting and discharge procedures to help relieve jammed ERs.

After one particularly trying meeting, Barnewolt was standing in the doorway chatting with other committee members when the state’s deputy health director walked up and offered an unexpected question: “Why don’t we just stop it?”

“I couldn’t believe what I was hearing,” Barnewolt said in a recent interview. 

Around the same time, Maryland health officials were contending with the same question: What should be done about busy hospitals that were routinely sending ambulances away? 

Massachusetts’ answer was to end the practice by state order — a step that a decade later is hailed for better serving those in danger and for forcing hospitals to own up to a long-standing problem and become more efficient at managing inpatient beds.

Maryland’s response was to stick with its alert system, which has no enforcement authority.

The state created a webpage that uses color-coded alerts to declare how busy emergency rooms are, leaving it up to ambulance drivers to decide if they should go elsewhere. Federal researchers once held up the system as a standard for others to follow.

But a Journal Sentinel examination found the alert hours reported by Maryland’s 53 hospitals in 2018 amounted to the equivalent of nearly 3,000 days — a 40% increase from 2017. The 2019 total is already higher than all of last year.

That means patients are not always going to the best, closest hospital.

Maryland's color-coded system has become a confusing tangle that sometimes prompts ambulances to go to more distant hospitals and other times sends out potentially dangerous noise that paramedics ignore.

Nick Duncan, left, director of emergency management at Tufts Medical Center, and Brien Barnewolt, chairman of the Department of Emergency Medicine. (Rick Wood/Milwaukee Journal Sentinel)
Nick Duncan, left, director of emergency management at Tufts Medical Center, and Brien Barnewolt, chairman of the Department of Emergency Medicine. (Rick Wood/Milwaukee Journal Sentinel)

With no standard definition of what merits an alert, officials say hospitals across the state are simply asked to keep the hours on alert down, but there is no evidence that is happening.

In Baltimore, a separate policy says hospitals may not be on yellow alert — the level signaling a swamped ER — for more than eight hours a day. But the Journal Sentinel found that rule is blatantly and frequently violated, with no action by the state.

Ambulance diversion is common in most of America’s largest cities, but is largely unknown by patients and overlooked by policymakers despite its potentially deadly consequences.

A Journal Sentinel investigation found at least 21 deaths that came after patients were turned away from hospitals — a number that likely vastly underestimates the total. Among the deaths: A 37-year-old woman from Milwaukee who had a stroke next door to the region’s top stroke center and a 4-week-old baby who lived five blocks from a hospital in Chicago.

Maryland officials told the Journal Sentinel they are committed to improving the system, but also are vowing to keep the alert system.

Reform advocates say that is a mistake. Maryland — and other states — should just get rid of diversion, they say.

“You are just moving around the pawns when you are color-coding,” said Mike Williams, president of the Abaris Group, a California health care consulting company. “It just gives the hospitals a comfort level that they have another out.

“They are really gnashing their teeth in places like Baltimore and the solution is so close to them but it is being obscured.”

The solution, experts say, lies about 400 miles to the north, where Massachusetts became the first — and so far only — state to ban the practice in 2009.

 

Boston: Chaos in the ERs

When diversion was bad in Boston, it was really bad.

When one hospital closed its emergency room, patients flooded other hospitals, which would then close their doors as well. Eventually, enough closed that the emergency dispatch center would order them all to reopen. 

Then the process would start over again. 

Sometimes, hospitals would game the system, going on diversion even when they weren’t that busy in a move to force others to reopen. 

Inside the hospitals, departments blamed each other for not doing enough to solve the problem. ER doctors pointed to surgeons scheduling operations only in the early part of the week. Surgeons said they were just following long-standing practice. 

Nurses in different departments pointed fingers at each other because they couldn’t get rooms filled and emptied fast enough.

Patients suffered. 

In November 2000, for example, a 55-year-old woman died of a heart attack after she was turned away from Mount Auburn Hospital in Cambridge, the closest, best-equipped hospital to treat cardiac emergencies. 

Shortly after the Mount Auburn incident, a man having a heart attack drove himself to Massachusetts General Hospital when he learned it was on diversion. He said, "Fine, I’ll drive myself there and then they can’t divert me," according to a study on diversion done by doctors in the state.

Paramedics lost precious minutes crisscrossing the city looking for open ERs.

“It was chaos,” said James Feldman, a longtime doctor in Boston Medical Center’s emergency room. “We knew it hurt people.”

For 10 years, a state committee, as well as individual hospitals, physician organizations and others, tried to find a solution. 

Nothing worked. 

“We were letting hospital and (emergency room) problems back up on the street,” said Alan Woodward, a doctor who was co-chair of the committee looking at the issue and is now retired. “Everyone realized what we were doing was not only unsafe but was the wrong thing to do for patients.”

In 2006, the Institute of Medicine, a federal nonprofit agency that advises Congress and the government on health care matters, wrote that diversions put patients at risk of dying because of delays and should be eliminated.

Many assumed the problem was because too many people were coming into the ER for bad colds, sprains and other minor issues — a misconception experts say remains today. 

Other studies determined that traffic to the emergency room — by ambulance, car or foot — was relatively predictable. As such, hospitals could staff for it. What threw things off was when hospitals went on diversion. Like a dam on a river, it created an unnatural flow of patients — one that could, in turn, flood nearby hospitals.

The problem, the studies showed, was that too many patients needing additional care would get stranded in the ER, waiting for a bed to open upstairs so they could be admitted. The urgency was felt in the ER, where patients might line the walls, but not in other parts of the hospital.

Going on diversion was the ultimate safety value — but it didn’t work.

A study found diversion had become a “psychological crutch.” The best way to address it, those pushing for changes felt, was to take diversion away as an option and force other changes to be made.

No law was passed. The state Department of Public Health simply decreed hospitals could not close their doors to ambulances except in the most extreme cases, such as a power outage or armed assailant in the building — a “Code Black.”

“It was a broad coalition of leadership that accepted the fact that diverting patients was harmful to patient care and the ultimate responsibility lies with the hospitals,” Feldman said. “That is the initial fix for ambulance diversion and (emergency room) crowding — hospitals actually have to own the problem.”

Often on alert in Baltimore 

When Maryland created its color-coded system, the idea was that hospitals going on alert would be a rare event. 

Three decades later, it’s a daily one.

Early on a Saturday evening in September, most of the two dozen hospitals in and around Baltimore were posting alerts of varying magnitude: Orange meant ambulances were backed up. Red meant there were no more monitored beds available for heart attacks and other severe cases. Yellow meant the ER was “overwhelmed.”

At 8:30 p.m. on Sept. 16, the statewide hospital alert web page showed only five of 23 hospitals in the Baltimore area were operating without any alerts.
At 8:30 p.m. on Sept. 16, the statewide hospital alert web page showed only five of 23 hospitals in the Baltimore area were operating without any alerts.

In the hours that followed, the warnings grew more intense, until the website looked like a gumball machine. A Journal Sentinel reporter and photographer visited the city’s ERs throughout the mid-September weekend and into the following week, stopping at the facilities only when alerts had been issued.

Here is what they found:

On Saturday night, the University of Maryland’s Midtown campus was on yellow alert for four hours, starting at 7 p.m. but shortly before midnight, the waiting room was empty except for two waiting patients. 

At Johns Hopkins Hospital that same night, the emergency room’s waiting area was three-quarters full while the hospital was in the midst of what would be a 22-hour yellow alert.

The following day, Sinai Hospital was on yellow alert for much of the day, yet the emergency room waiting area was largely empty. Officials later said that patients are kept in other areas and the waiting area is not necessarily a sign of how busy they are. 

By Monday, 18 of the area’s 23 hospitals were issuing an alert to ambulances. 

All told, between Saturday and Tuesday, two dozen hospitals went on more than 100 different alerts for a total of 760 hours. Several alerts lasted more than 24 hours straight.

The situation in Maryland mirrors that found by the Journal Sentinel in Illinois. In both cases, reporters found the most common days for alerts and diversions come early in the week. 

On Mondays, hospitals typically see intense demand for beds fueled by scheduled surgeries and seriously ill patients coming after visiting a clinic on the weekend. Alerts happen even more often on Tuesdays.

In Baltimore, when so many hospitals are on alert, ambulance drivers say it can make it harder — not easier — to decide where to take patients. Indeed, the drivers are more likely to ignore the alerts if the situation is urgent and the next available hospital is too far away.

When they do go to a hospital on alert, paramedics may face a long wait before they can get back on the road, which in turn can increase response times for other calls.

As in Chicago, a handful of Maryland hospitals — including some of the city's most prestigious — regularly employ the measures. 

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During one 96-hour stretch in September, Johns Hopkins — rated one of the top three hospitals in the nation by Newsweek — was on alert for 93 hours. In March, Hopkins was on alert for 93 hours straight twice. Last year, the hospital was on yellow alert for more than eight hours 181 times, in violation of a regional policy. 

Officials from Johns Hopkins said they only go on alert when their ER is saturated or they don’t have beds with heart monitors for critical care patients. They are not sure why their hours are so high but they said it appears to be connected to the kinds of cases in the hospital. 

“As the number of complex patient cases has increased at our hospital, our alert level has also increased,” a spokeswoman said in an emailed statement. 

Whatever the reason, the problem remains. 

“It’s like a game of whack-a-mole,” said Lisa Myers, a former official with the Maryland Institute for Emergency Medical Services Systems, the state agency that oversees paramedics statewide and the alert system. “You get one thing good and two more pop up.” 

Boston: How diversion was ended

In Massachusetts, officials knew ending diversion had to go hand-in-hand with improvements throughout hospitals. Otherwise, the move could be disastrous.

Hospitals were given six months to develop strategies to improve patient flow throughout the hospital to ease pressure in the ER. The state had to review and approve each “Code Help” plan. 

Going after spikes in the elective surgery cycle was key. 

Those surgeries tended to be on Monday and Tuesday, for the convenience of avoiding weekend work for doctors and their staff. But that created a fierce demand for beds in the early part of the week, as sick patients who waited for care over the weekend all converged on the ER. 

There were naysayers from the beginning. Feldman, the longtime doctor in Boston Medical Center’s ER who was among the group pushing for change, recalls other doctors warning that patients were going to die as a result of the ban. 

A two-week trial was done in southeast Massachusetts, a less-populated region of the state. It was deemed a success, though skepticism lingered. What about Boston?

The statewide ban went into effect Jan. 1, 2009. 

The ban worked well the first week, then the second. Hospital staffs found ways to live without diversion. When emergency rooms got crowded, officials activated their internal Code Help plans until the flow subsided.

James Feldman, longtime doctor in Boston Medical Center’s emergency room. (Rick Wood/Milwaukee Journal Sentinel)
James Feldman, longtime doctor in Boston Medical Center’s emergency room. (Rick Wood/Milwaukee Journal Sentinel)

Once the ban took hold, researchers examined whether there were consequences such as patient deaths while waiting in a crowded ER or paramedics out of service for a long time.

A 2013 study found no ERs studied had longer waits for patients even though volumes increased. In fact, the wait times dropped after the ban. 

Feldman and others worked separately on a study to find out how ER doctors and nurses felt about diversion before and after it was banned.

Their study showed just how much doctors and nurses disliked — even hated — diversion, but felt like it was the only thing they could do to relieve overcrowding.

“I think the mentality of an emergency department is that your doors are open — you want to take care of anybody who comes through the door, and the fact that you would shut your doors and turn people away is just abhorred by everyone,” one ER doctor told researchers.

“It’s a tragedy. It is a travesty.”

Massachusetts became the first — and still only — state to ban ambulance diversion in 2009, requiring hospitals to improve patient flow.

Baltimore: Confusing alert system 

Maryland’s alert system is hard for even medical professionals to understand.

Just ask Ted Delbridge who took over as director of Maryland’s emergency medical services agency earlier this year. A doctor specializing in emergency medicine, Delbridge had studied and worked in the field for decades. Yet, he had to have the color-coded system explained three or four times before he understood it.

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Green means stop — not go — because of a “mini-disaster,” such as a power outage.

Red doesn’t necessarily mean stop — just that there are no available beds with heart monitors. Yellow means paramedics shouldn’t even bring in patients in need of urgent care. 

Most important to understand, Delbridge said, is that the Maryland system is not ambulance diversion at all — at least not as it is practiced in other cities and states.

In other places, a hospital on diversion is essentially closed to patients coming in ambulances. Maryland regulations make clear paramedics have the authority to override alerts. As such, Delbridge said the alert system functions more as an advisory.

“The hospitals are saying, ‘This place is really busy, if there's another option, you might want to consider it,’ ” Delbridge said. 

There isn't reliable data about how often hospital alerts in Maryland are honored by paramedics. Delbridge said ambulances often go to hospitals on alert, though he notes the alerts “can and do” affect decisions.

He said that if ambulances go to hospitals with backed-up ERs, it often takes them off the street for longer periods.

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In 2018, paramedics spent 160,000 hours in Maryland ERs waiting, according to Delbridge. Maryland has the highest ER wait time of any state, trailing only Washington, D.C., and Puerto Rico, according to federal data on hospital wait-times analyzed by ProPublica, a nonprofit investigative journalism organization. 

In Maryland, patients who are not admitted spend, on average, just over three hours in the ER before going home. For more seriously ill patients, it took almost 6½ hours to be admitted. By comparison, the same average times in Wisconsin are two and 3½ hours, according to the data updated in September.

Yet Maryland residents use emergency rooms less often on average than people in other states.

An emergency medical technician who works in Baltimore told the Journal Sentinel the alert system sometimes leads to heated debates over the radio between paramedics and a Fire Department staffer who monitors the status of hospitals.

“They will say, ‘That hospital is on yellow. You can’t go there, go here,’ ” said the EMT, who asked not to be identified for fear of reprisals. “That’s another five minutes and my patient may not make it. (Expletive) it, I’m coming.”

Some paramedics are more willing to fight to go into a hospital on alert, the EMT said. But if they blatantly violate an order not to go to a hospital on alert, there could be disciplinary consequences.

“It’s a fear-based system,” the EMT said. “Some are worried about their patients and some are worried about their careers. You can make that call to go into (a hospital on alert), but you may very well end up on the hot seat.”

Deborah Hill learned firsthand about Maryland’s hospital alert system in 2016 when her 95-year-old mother was having stroke-like symptoms. 

She called an ambulance, figuring they would go to Anne Arundel Medical, a hospital less than 10 minutes away where her mother had been treated. Once her mother was loaded on the ambulance, paramedics were told that the hospital was on alert.

Instead, Hill’s mother was taken 45 minutes to Medstar Harbor Hospital in downtown Baltimore. As paramedics approached Medstar Harbor, that hospital went on alert and tried to turn away the ambulance. The paramedics said they were going in anyway, Hill said. 

“I just told everyone I knew that, ‘You probably don’t know about this but here is what I found out and here is what can happen,’ ” she said. “You need to know because nobody knows. You think you call 911 and an ambulance is going to transport you to your local hospital. 

“Not so. Not even close.”

The emergency department at Tufts is one of five Level 1 trauma centers in Boston, where ambulance diversion was ended 10 years ago. (Rick Wood/Milwaukee Journal Sentinel)
The emergency department at Tufts is one of five Level 1 trauma centers in Boston, where ambulance diversion was ended 10 years ago. (Rick Wood/Milwaukee Journal Sentinel)

Boston: A system without diversion 

On a recent Monday in Boston, some doctors and nurses in the emergency room at Tufts Medical Center studied computer screens, intensely focused, amid a hive of activity in the circle of rooms around them. 

The 36-bed ER was just about full.

Patients were lined up in beds in the hallways. Then a call came in that a seriously injured person was coming in and a room needed to be cleared. 

Nick Duncan, the hospital’s director of emergency management, got on the radio and dispatched a transport crew to move a patient out and a cleaning crew from upstairs to clean the room. Duncan also called for extra IV pumps for incoming patients. 

“We are a hospital,” he said. “The ER is the front door and we need to make it work.” 

Still, a decade after the ban, hospital officials in Massachusetts believe more could be done to improve efficiencies throughout hospitals.

Greg Volturo, ER doctor at the University of Massachusetts Medical Center in Worcester, called elective surgeries “moneymakers,” making them hard to move. Staffing schedules remain rigid. Much of the hospital’s blood work and other testing is still not done on the weekend, which pushes more cases to weekdays.

“There are multiple things in a health care system that are not conducive to a high-functioning industry,” Volturo said. “For a hospital to do all these things is very expensive. Bottom line, this all comes down to dollars.”

Laura Burke, an ER doctor at Boston’s Beth Israel Deaconess Medical Center. (Rick Wood/Milwaukee Journal Sentinel)
Laura Burke, an ER doctor at Boston’s Beth Israel Deaconess Medical Center. (Rick Wood/Milwaukee Journal Sentinel)

The architects of the ban wonder why more places haven’t done it. Hospitals in cities like Milwaukee, Seattle and Cleveland have voluntarily agreed to stop diverting, but there are no state bans or enforcement authority.

“If someone says diversion is necessary — that it is an intractable problem — I would say you haven’t tried everything,” said Laura Burke, an ER doctor at Boston’s Beth Israel Deaconess Medical Center and an assistant professor of emergency medicine at Harvard Medical School.

“Hospitals (in Massachusetts) that said it was an intractable problem stopped diverting.”

Burke said Massachusetts hospitals still have improvements to be made, “but the way to deal with that is not by turning away sick patients in need of emergency services.”

Terry Hudson-Jinks, Tufts’ chief nursing officer said operating without diversion takes a daily commitment to what she calls the “relentless, persistent pursuit of patient flow.”

“It is the right thing for nurses, doctors and patients. I would not have believed it until I lived it," Hudson-Jinks said. “I don’t think any hospital would vote to go back, ever.”

Emergency room personnel at Tufts Medical Center in Boston listen on a speaker to a call from an incoming ambulance. The driver gave an estimated time of arrival and details on the condition of the patient. (Rick Wood/Milwaukee Journal Sentinel)
Emergency room personnel at Tufts Medical Center in Boston listen on a speaker to a call from an incoming ambulance. The driver gave an estimated time of arrival and details on the condition of the patient. (Rick Wood/Milwaukee Journal Sentinel)

Baltimore: Paramedics would love no alerts

In Boston, paramedics are free to take all patients to the closest, best-equipped hospital for treatment.

Richard Schenning, EMS director for Baltimore County Fire Department, said his roughly 60 paramedics and EMTs would like a Massachusetts-style system.

“To be able to just say, ‘Hey, we're going to be able to go into each hospital’ and not have an alert system, paramedics would love that because it would make it much easier for their decision-making,” he said.

As it stands now, he said, his paramedics often don’t honor all the alerts; they couldn’t because there are too many. When asked to consider a recent weekend when many of the hospitals in his area wound up on bypass on Monday, he shrugged.

“If you would ask paramedics, ‘Are you surprised all these hospitals are on alert?’ They would say, ‘Nah, it’s just a Monday,’ he said. “They are numb to it. It’s every day. It’s the new norm.” 

Schenning said he is confident his paramedics would go to a hospital on alert if the patient’s condition were serious. But when the paramedics get in, they may get stuck there waiting. 

“It’s not that we can’t get in, it’s more that we can’t get out.” 

The Baltimore EMT who asked not to be named put the blame on hospital executives. It seems like something as fundamental as patient flow could be fixed, he said.

“You are a multibillion-dollar business with a lot of smart people. Figure it out.”

Those working inside Baltimore’s top hospitals say they are trying to do just that. 

At Johns Hopkins, officials created the Capacity Command Center a few years ago. It looks like a military operations nerve center, with employees studying analytical information to better move patients in and out of inpatient beds. 

The center has increased the occupancy rate for Hopkins’ most-in-demand beds, up to 95% at times, allowing Hopkins to reduce waiting time in the ER and accept more patients seeking the facility’s surgical expertise, said Jim Scheulen, Hopkins’ chief of emergency medicine.

“We have dedicated an enormous amount of resources to be able to run our hospital at an incredibly high occupancy rate,” Scheulen said. “All the efforts have been in the right direction and have done the right things for our patients.” 

At Sinai Hospital, the command center is smaller but has a worldwide reach. To speed the discharge of patients, Sinai uses nurses and physician assistants in Israel and the Philippines to review case files overnight, taking advantage of the time difference during lower-staffed overnight hours. The overseas nurses also help line up care for patients when discharged.

Despite the efforts, Sinai and Hopkins continue to be on alert for thousands of hours a year. 

Delbridge, the state EMS director, agreed the entire system needs to be reformed. A study on how to change it has begun, following a recent meeting with the leaders of Maryland’s hospitals.

Delbridge said hospital leaders have agreed to take steps to ensure everyone is using alerts for the same kinds of conditions. 

“I can just tell you that nobody is particularly happy with the alert status,” he said. 

Yet there is one thing he said that will remain as they consider reforms: The color-coded system.

This story was supported by the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems. Officials from the organization played no role in the reporting, editing or presentation of the project.

Contact John Diedrich at (414) 224-2408 or jdiedrich@journalsentinel.com. Follow him on Twitter at @john_diedrich, Instagram at @john_diedrichLinkedIn or Facebook.

Reprinted with permission of the Milwaukee Journal Sentinel, copyright 2019.

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