Ethics of ambulance diversion: "...from a moral viewpoint, the most important stakeholder is the individual patient..."

Am J Emerg Med. 2014 Dec 9. pii: S0735-6757(14)00895-X. doi: 10.1016/j.ajem.2014.12.002. [Epub ahead of print]

Ethics of ambulance diversion.

Geiderman JM1, Marco CA2, Moskop JC3, Adams J4, Derse AR5.

Author information

• 1Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; Cedars-Sinai Center for Healthcare Ethics, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: geiderman@cshs.org.
• 2Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH.
• 3Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
• 4Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
• 5Center for Bioethics and Medical Humanities (Institute for Health and Society) Medical College of Wisconsin, Milwaukee, WI; Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.

Abstract

Ambulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy, ambulances bound for one hospital are redirected to another, usually under policies established by regional emergency medical services systems. Other responses to this mismatch include maladaptive behaviors (such as "boarding" in "hallway beds") and the development of terminology intended to normalize these practices, all of which are reviewed in this article. We examine the history and causes of diversion as well as the ethical foundations and practical consequences of it. We contend that (1) from a moral viewpoint, the most important stakeholder is the individual patient because diversion decisions are usually relative rather than absolute; (2) decisions regarding ambulance diversion should be made with careful consideration of individual patient preferences, local and state emergency medical services laws, and institutional surge capacity; and (3) authorities should consider the potential positive effects of a regional or statewide ban on diversion.