Since early December, with the exception of a few days, Indiana University Health has seen historically high rates of diversion. Many of its 16 hospitals are operating at up to 130% of capacity. (IBJ file photo)
Hospitals in central Indiana diverted ambulances for nearly 3,000 hours during a six-week period this fall, according to information IBJ received from the Indiana State Department of Health through an open-records request.
On some days during the covered period—which included the last two weeks of a surge in COVID-19 hospitalizations and the first four weeks of a decline—nearly every hospital in the region went on diversion status at once, as hospital emergency rooms were filled to capacity. That means the hospitals encouraged ambulances to take patients elsewhere.
The situation has only worsened in recent weeks, as the latest surge has packed emergency rooms and strained hospitals nearly to the breaking point.
“We’re seeing diversion unlike anything we’ve ever seen before,” said Dr. Dan O’Donnell, an emergency room physician at Eskenazi Health and chief of Indianapolis Emergency Medical Services, the largest provider of 911 ambulance services in the region.
State health department statistics covering September and early October—the most recent data available—provide the first detailed look here at hospital diversions, the practice of alerting ambulance teams that an emergency room is at capacity, so they should look for another hospital if possible.
The huge number of diversions is the latest sign the health care system is under extreme strain. In some cases, ambulances are traveling far out of their way to find a place to deliver patients. In other instances, ambulances are waiting for an hour or more in hospital parking lots, a practice known as “parking,” “ramping” or “off-load delaying.”
So far, there have been no reports of patients dying while waiting for care in the Indianapolis area. But health officials here warn the system is being stretched to the limit.
For years, hospitals held diversion figures under wraps, calling the information private and proprietary. They shared it only with ambulance companies and with one another. The public had no way to know how frequently each hospital went on diversion, or how often the regional health system was at full capacity.
Public health experts have criticized that secrecy, saying the public has a right to know how often hospitals are diverting ambulances and how that could affect patients who might be suffering from a heart attack or severe injury.
The secrecy has been loosening, perhaps temporarily, in recent months. In September, Gov. Eric Holcomb ordered all hospitals to begin reporting ambulance diversions to the health department, including the number of hours each hospital went on diversion each day.
The health department, however, has not posted the information on its dashboard nor made the figures easily accessible, requiring the submission of an open-records request to examine the data.
In response to an IBJ request, the department recently produced daily diversion records for 38 days, from Aug. 31 to Oct. 13, for hospitals in the Indianapolis area. However, the agency said in a letter to IBJ this week it would not compile such data for future public-records requests and argued that it is not required to do so.
Simultaneous diversions
The records show hospitals in the region diverted ambulances for a total of 2,891 hours during that period, with most hospitals going on diversion status at least a few hours every day.
On some days, the patient load grew so heavy that a dozen hospitals or more went on diversion simultaneously.
On one particularly busy day, Sept. 13, as a fall surge peaked, the emergency rooms at 13 hospitals went on diversion for a total of 147 hours. Two hospitals, Saxony Hospital in Fishers and Johnson Memorial Hospital in Franklin, went on diversion status for the entire day, while five others (Community North, Community South, Community East, Franciscan Health and Eskenazi Health, all in Indianapolis) went on diversion for at least 10 hours each.
The only area hospitals not listed on diversion that day were Riverview Health in Noblesville, Major Hospital in Shelbyville and Witham Health in Lebanon.
The same day, the Indiana Department of Homeland Security issued a bulletin reminding hospitals that diverting ambulances “delays patient care and further reduces our EMS system’s ability to respond to calls for emergency assistance in a timely fashion.”
“A hospital declaring diversionary status for EMS patients is simply a request for EMS to consider an alternate hospital destination,” the bulletin said. “The hospital may not refuse care for a patient presented to their facility.”
The guidance did not cause hospitals to pause their diversion practices. The very next day, 12 hospitals went on diversion for a total of 174 hours, an overnight increase in hours of 18%.
Only getting worse
Some health officials here say the problem has only intensified since the fall.
“It’s definitely worse right now than in September and October,” said Dr. David Dunkle, CEO of Johnson Memorial. “It’s worse than I can ever remember.”
Johnson Memorial ranked first among all local hospitals for number of hours on diversion, 510, during the 38-day period, according to the health department records. That included 16 days when the hospital was on diversion around the clock.
Dunkle attributed part of the problem to a cyberattack at the hospital in early October, which shut down the computer network and caused the hospital to divert ambulance traffic.
But the problem was exacerbated by staff shortages, often due to medical emergencies, including quarantining for COVID-19 exposure or infection. On a recent day, nearly 20 workers were out for medical reasons, Dunkle said.
When a nurse calls in sick at the last minute, he said, the hospital sometimes has to take the nurse’s beds out of service if it can’t find a staff replacement. That just adds to the bottleneck in the emergency room.
Dunkle said that, one day last week, his emergency room admitted so many patients that 17 had to wait in exam rooms, waiting rooms and hallways for inpatient beds.
In second place for the number of hours on diversion was Franciscan Health Indianapolis, with 396.
In a statement, Franciscan Health said it, like many hospitals, has been stressed with large numbers of patients seeking care.
“As a result, we have been forced to go on diversion throughout the long pandemic,” Franciscan Health said. “Unfortunately, diversion occurs frequently and continues to this day.”
Franciscan said it works closely with EMS teams to seek alternative medical sites, depending on the conditions of the patients they are transporting.
“However, we provide stabilizing care to any patient who personally shows up at our campuses,” the hospital system said. “We urge patients with lesser conditions, or who may simply need a COVID test, to seek treatment from their primary care providers or visit urgent care services such as Franciscan ExpressCare sites.”
‘Non-binding request’
Hospital officials attribute their frequent diversion status to the repeated surging and waning of the pandemic over the past year, a cycle that shows no signs of quitting and that has exhausted hospital workers and blasted a hole in workforce morale. In recent months, hundreds of nurses and other patient-care workers in central Indiana have retired, quit, taken overdue vacation time or accepted administrative jobs.
Across the state, hospitals are now seeing all-time-high daily census volumes of more than 12,000 patients, which include non-COVID patients. The ER often takes the brunt of that volume.
“Hospital emergency departments serve as the entry point to hospitalizations, so it is no surprise our emergency departments are seeing the same high level of patient volumes,” said Brian Tabor, president of the Indiana Hospital Association. “Hospitals use diversion as a non-binding request for EMS to seek alternative care sites if patient conditions allow. Unlike other industries that can close services to manage volume, hospitals must provide stabilizing care to every patient that presents to their campus.”
The Indiana Department of Homeland Security says on its website that ambulances should alert a hospital on diversion status of the condition of any arriving unstable patients.
Indiana University Health, the state’s largest hospital system, said patient volume has grown so heavy that the average length of stay in the ER at its largest location, Methodist Hospital, increased in 2021 by 50 minutes, to just under six hours.
Many of IU Health’s 16 hospitals are running at up to 130% of capacity, said Dr. Chris Weaver, the system’s chief clinical officer. He said the emergency rooms go on diversion only when the hospital has no open capacity.
“So, yes, across our health system, we are seeing patients waiting for beds in the emergency room,” Weaver told reporters during a media briefing on Dec. 23, as the U.S. Navy was arriving at Methodist Hospital with a 23-person team to help doctors and nurses. “We are seeing patients waiting to get into the hospital, but we’re doing the best we can to accommodate that.”
Since the beginning of December, with the exception of a few days, IU Health officials say they have seen unprecedented rates of diversion.
Nationwide backups
Across the country, the picture is much the same, say health experts who have followed the situation.
Part of the problem is that, not only are COVID-19 cases on the rise, but so are regular emergencies—from workplace accidents, highway crashes and other accidents—as the country has largely reopened since vaccines became widely available.
“That’s what is pushing a lot of hospitals over the brim,” said Dr. Ryan Overberger, an emergency medicine physician at the Einstein Medical Center in Philadelphia. “Once the system as a whole reaches a limit, there’s an exponential sort of breakdown.”
He added: “You can have the best 911 system in the world, but if they don’t have anywhere to bring patients to, it breaks down.”
Nearly every emergency room in the nation is operating at full capacity, said Dr. Megan Ranney, an emergency room physician and associate dean at the Brown University School of Public Health in Providence, Rhode Island.
“The original idea behind diversion is that it allows one hospital that is temporarily overwhelmed and has a lack of beds to divert patients to other hospitals with more capacity,” she said. “But given the current situation we’re in, nobody has capacity.”
She said the result isn’t just longer wait times; some acute problems, such as heart attacks or strokes, might get overlooked and not cared for quickly in the crush of patients.
“It’s a horrific situation for patients and for the health care providers alike,” she said.
Dr. James Feldman, professor of emergency medicine at Boston University School of Medicine, said the husband of a friend recently fell and broke five ribs. When he went to an emergency room for treatment, he was parked in a hallway for six hours before getting treatment.
“It still seems that the public is not really aware, or it has not penetrated, how much of a crisis emergency care is now,” Feldman said.
Indianapolis EMS, which transports thousands of patients a year to local hospitals, said having so many emergency rooms on diversion has caused it to suspend normal protocol and spread out runs to local hospitals, diversion or no diversion.
Still, with ERs packed, it takes longer to transfer patients from the back of the ambulance into an emergency room.
“Some of our ambulances spend a little more time waiting to hand the patient over, get the patient transitioned over to the hospital, because there are not as many beds in the emergency department,” said O’Donnell, chief of Indianapolis EMS.
He said the EMS team aims to transfer a patient within a few minutes of arriving at a hospital, but times have been creeping up to 20 to 30 minutes lately. “We’ve had a couple of instances where it has taken an hour to hand over the patient,” he said.
One day last month, every hospital in the region was on diversion in the afternoon, and three Indianapolis EMS ambulances “were hung up for over an hour,” O’Donnell said.
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