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Although the primary focus of an advanced EMS system is typically the patient care rendered in the field and during transport, the act of delivering the patient to the most appropriate facility, performing a safe transfer of care, and returning to service to await the next emergency call is an important and sometimes overlooked by EMS physicians as part of the “operational component.” Diversion and bypass may increase transport distance and delays in offload of patients in crowded emergency departments can cause EMS crews to be out of service for longer periods, reducing system efficiency. Clearly this component has a direct impact on patient care, both current and for those who have not yet dialed 9-1-1. Defining and understanding the different components and facets of this part of the medical operation is critical to medical directors seeking to ensure patient high-quality care.


  • Define terms ambulance diversion, hospital bypass, patient demand, ambulance offload delay, alternative destination, and emergency department crowding.

  • Discuss the historical and contemporary effects of ambulance diversion.

  • Describe the practice of hospital bypass and specialty hospital designations (eg, trauma, ACS/PCI, stroke).

  • Describe the NEDOCS scoring system and its potential use in EMS resource management.

  • Discuss state regulations, as well as legal, financial, and ethical implications of patient demand.

  • Discuss the use of alternative destinations, such as urgent care centers, psychiatric facilities, and doctors' offices.

  • Discuss the concept of “treatment, no transport” as an alternative to transport to the emergency department.

Emergency departments and EMS personal serve as the country's so-called medical safety net. As such, both are expected to be able to handle any and all patients at all times. The population within the United States continues to increase and as such, so do its medical need and the demands it places on the EMS system. Emergency department crowding and extended wait times have both become the norm and the focus of the press, legislature, and public.1,2 Several strategies have been implemented in an effort to decrease ED wait times and crowding. Prominent and controversial among these is ED diversion. Depending on the communities in which you serve, ED diversion may play a significant role in day-to-day EMS operations and present particular challenges to the prehospital provider.

Emergency medical personnel face many unique and challenging situations in the prehospital environment aside from that of direct patient care. Ideal patient management often requires careful consideration of the final destination for the patient and selection of a facility optimally equipped to deal with their particular emergency. For example, it may be appropriate to bypass the local community hospital in favor of the closest trauma center, focused pediatric emergency department, or high-risk labor and delivery hospital depending on the situation and the patient. Other decisions such as to potentially transport a patient by air as opposed to ground must also be considered and must factor ...

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