Shen says the report has important policy implications for emergency department managers and hospital executives.
"They should improve patient flow, and improve coordination between inpatient settings and the ED," Shen says. "But more importantly there's a broader message here. It's that when you have ambulance diversion at the ED, it's not an isolated incident, but a reflection of a larger access issue, and that you just can't take any more patients."
Hospitals with heart attack care capabilities in Los Angeles, Santa Clara, San Francisco and San Mateo counties were included in the report, about one-third of the state's population.
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When the nearest ED was on diversion on the day the patient was admitted, 30-day mortality was 19%, compared with 15% mortality if the nearest hospital was not on diversion. There also was higher 90-day and nine-month mortality for patients whose nearest hospitals were on diversion 12 hours or more.
Sandra Schneider, MD, president of the American College of Emergency Physicians, says the paper makes several critically important points about the way emergency departments are run today.
"You don't see this problem just with heart attack patients, but you would see it in patients with stroke and pneumonia, where it's important to get the treatment early," says Schneider, attending physician at Strong Memorial Hospital in Rochester, N.Y. When hospitals are crowded, door to balloon time is longer, time to pain medication is longer, and time to administer an antibiotic for a pneumonia patient is longer."