Closed for Sat: Acting on the ED Diversion Dilemma

Marlene Vermeer

Marlene Vermeer , RN, BAN, CEN

Emergency Department Chair, Emergency Department Council
Efren Grospe

Efren Grospe , RN, BSN, CEN

Emergency Department Manager

Published September 03, 2015

Diversion isn't just costly for hospitals. The entire community is impacted when an emergency department (ED) closes to ambulance traffic. Here's how the ED team at Orange Coast Memorial Medical Center (OCMMC) in Fountain Valley, Calif., drastically reduced diversion hours by applying lean methodology while collaborating with colleagues across the hospital. The following is adapted from a poster presented at Vituity's 2014 annual conference.
Background ED overcrowding is a common problem across the United States. Results include ambulance diversion, prolonged wait times, suffering for patients as they wait, rushed and unpleasant treatment environments and delays in care.

The OCMMC ED has always scored well on measures of efficiency and quality, despite having only 16 beds. But in the past several years, patient census has risen steadily, creating a need for new solutions. Twenty years ago, our department treated 20 to 30 patients a day. Today, we treat an average of 96 in the same physical space.

Despite these challenges, our ED has maintained high quality scores, and turnaround times for discharged patients are below the national average. However, by late 2012, our ambulance diversion hours were exceeding 150 per month. This jeopardized our STEMI and Paramedic Receiving designations, increased the potential for negative patient outcomes and compromised access to the ED by the community.

Fortunately, our team had already begun embracing lean methodology, which provided tools for change. We decided to apply our learning to improve patient flow — both within our department and beyond.

Purpose and Objectives

The purpose of our project was to implement recommendations from two kaizen (lean) events, which focused on improving:
  • Front-end processes. This included work within the ED to update the triage process, improve communications and expand "virtual" capacity.
  • Throughput of admitted patients. Early in this change process, we realized that improving ED throughput alone would not solve the problem. We would also need to work with colleagues across the hospital, including our inpatient units, laboratory services, radiology and more.

Objectives for the project included:
  • Decrease and sustain ambulance diversion to ≤ 44 hours per month.
  • Reduce time between admit orders to "wheels out" (when patient leaves the ED for an inpatient unit) to ≤1 hour.
  • Sustain the number of patients who left without being seen (LWBS) below a benchmark of 2.6 percent.


To achieve our goals, our team implemented the following interventions:
  • Two-tier triage. As our census rose, it became difficult for a single triage nurse to keep track of the waiting patients. To enhance the process, we added a "greeter" RN to promptly assign emergency severity index (ESI) acuities and monitor the waiting room.
  • Crash bed. This is located near triage and open 24-7 to ensure capacity during serious emergencies.
  • Comprehensive pre-saturation plan. We developed a three-level alert system: green zone when there's plenty of capacity; yellow zone when the ED approaches saturation; and red zone when it's completely full. Moving into a higher zone triggers changes in patient flow and classification. To support this process, we implemented:
    • PerfectServe alerts. PerfectServe is an intelligent clinical communication system that transmits messages simultaneously to the entire care team via cell phone, email, pager and more. We use it to alert our team to zone changes and to inform hospital management of our ED diversion status.
    • Board rounds. When our ED hits the red zone, nurses and providers gather at the ED tracking board and engage in group problem-solving. Can we expedite an admission or discharge? Can a patient be moved to free up a bed?
  • Pulling (vs. pushing) patients from ED. When an inpatient bed is ready, the bedside nurse notifies the ED within 15 minutes, obtains a status reported on the patient and expedites the transfer.
  • Holding Unit. We worked with inpatient colleagues to designate and staff four telemetry "ready beds" that can hold ED patients until an inpatient room is available.
  • Standardized triage orders. We developed protocols that allow our triage RNs to implement lab, radiology and medication orders in routine cases.
  • Physicians and PA/NPs in the waiting room. One way to compensate for our limited physical space is to bring care directly to patients. Our providers now evaluate walk-in patients and order tests right in the waiting room. We worked closely with our lab and radiology colleagues to expedite imaging and make technicians available for point-of-care testing.
  • Selectively recruited ED volunteers. Process changes sometimes made it difficult to keep pace with "churn" in bed turnover, supplies and updates for patients and families. To help, we implemented a unique solution: volunteers. Prior to service, our ED volunteers receive over 12 hours of specialized training by EMTs, RNs and experienced volunteers.
  • Standardized work and staff education. Our leaders worked hard to build a culture of collaboration, innovation and openness to change within our department. The ED Council proved to be an excellent vehicle for change; staff engagement with the council increased throughout the project. Newly standardized processes were reinforced through daily emails and the intradepartmental website.


Since our first lean event in early 2013, our ED volume increased by an additional 12 percent. Despite this challenge, we've seen some real successes.

ED Diversion Hours decreased by 98.6 percent in the first 12 months (2013) as lean interventions were implemented. Diversion hours trended upward again in 2015 as patient census increased but generally remained at or below our benchmark of 44 hours. Further process work this period — including standardized triage orders and treating patients in the waiting room — may have helped to keep diversion times reasonable.

Though we didn't quite reach our goal of 60 minutes, time between admit orders and "wheels out" has also decreased significantly. The change process has raised a lot of awareness around this issue, and we are optimistic that this progress will continue.

Despite increased patient volumes, LWBS remained below benchmark in 8 out of 10 quarters.

Next Steps

Improving ED throughput is an ongoing process for our team. In the future, we plan to expand our standardized triage orders and implement Rapid Medical Evaluation (RME). We are also working on creative ways to communicate data in real-time, with a focus on LWBS rates. Finally, we hope to improve disposition of our psychiatric patients, who tend to have very long stays in the ED.

While we set out to reduce ambulance diversion hours, our efforts have benefited us in other ways. In particular, we were able to handle an unexpected rise in census this year without compromising efficiency or quality of care.

The OCMMC ED is now in the early stages of a renovation that will increase its physical space and add about 10 beds. However, we know that space isn't necessarily a cure all for throughput issues. We will continue to apply lean methodology and collaborate with other departments in order to enhance the flow of what is likely to be an even larger volume of patients.


  • Emergency Nurses Association (2014). Improving Flow/Throughput to Reduce Crowding in the Emergency Department.
  • Bellow Jr., Aaron A., MSN, APRN, CEN, FNP-BC, and Gordon Lee Gillespie, PhD, RN, PHCNS-BC, CEN, CPEN, FAEN. (2014). The Evolution of ED Crowding. Journal of Emergency Nursing. 40(2):153-160.
  • Viccellio, Peter, MD, FACEP. (2013). ED Crowding: Cause, Consequence, Fixes. Emergency Medicine and Acute Care: A Critical Appraisal. Produced by Center for Medical Education. 187-199.


We would like to thank these project leaders — and the entire OCMMC ED team — for making our work a success:
  • Jeff Lung, RN, BSN, CEN – Charge Nurse; Chair, Emergency Preparedness; ED Paramedic Liaison
  • Robert Realmuto, MD – ED Medical Director
  • Lynn Redwater, RN, MSN, NEA-BC – Executive Director, ED/CV/Pulmonary Services
  • Debbie Tracy, RN, MSN, NP-C, CNS – Director, Critical Care Services
  • Lynne Hart, RN, BSN, NP – Manager, PI/Patient Safety
  • Nika Carlson, RN, MSN – Manager, Clinical Practice Transformation
  • Sadeeka Al-Majid, RN, PhD – Nurse Research Scientist, and
  • Dale Vital, RN, BSN, MBA, NEA-BC, Chief Nursing Officer and Vice President of Patient Care Services for her vision and leadership

Partnering to improve patient lives

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