Ambulance diversions suspended amid Minnesota's COVID-19 crush

COVID-19 pressures have forced Twin Cities hospitals to suspend the longstanding practice of diverting ambulances from their emergency departments when they are too crowded.

ER closures to ambulances were so common during the latest COVID surge that drivers didn't know where to go and patients ended up getting delayed care at distant hospitals, said Dr. Aaron Burnett, chair of the East Metro Pre-Hospital Advisory Committee.

One ambulance diversion would prompt another and then another because they couldn't find ERs with space, said Burnett, an emergency physician at Regions Hospital in St. Paul.

"We weren't doing patients any benefit by taking them from one saturated hospital to another saturated hospital," he said.

The change, which took effect this month, reflects another pandemic stressor in Minnesota. In two years the state has reported 1.3 million confirmed coronavirus infections, 11,382 COVID deaths and 56,621 residents admitted to hospitals. The totals include 14,565 infections reported Friday and 43 deaths, including a Ramsey County resident in their middle to late 20s.

Patient demand and worker illnesses have kept pressure on hospitals, even though Minnesota has reached a peak in infections from the omicron variant of the coronavirus. The 1,502 COVID hospitalizations on Thursday were down from 1,575 a week ago. Only 34 of 1,013 staffed intensive care beds were open Thursday in Minnesota hospitals, but at one point last month that number had dropped to nine.

Gov. Tim Walz on Friday announced that a federal team of 23 doctors, nurses and others will boost staffing for the next month at Abbott Northwestern Hospital in Minneapolis. The state also has signed 201 contract nurses and respiratory therapists to work 60-hour weeks for 60 days and provide staffing relief at 32 hospitals.

Leaders of the west and east metro emergency medical advisory groups agreed to suspend diversions because transport times were increasing and ambulances were spending too much time out of service areas and unavailable for 911 calls. Central Minnesota hospitals around St. Cloud agreed to end diversions as well.

ERs are required under federal law to treat walk-in patients, but have long used cooperative diversion systems to protect each other from overcrowding and to reroute ambulances to hospitals with capacity. The idea is to backstop hospitals facing one-time surges in demand, or problems such as power outages.

But in the pandemic it became a race to see which ER would be the first to reach capacity and needed to divert incoming patients. Ambulances changed course multiple times during some transports because ER closures were so frequent, said Sam Erickson, a vice president of the Hennepin County Association of Paramedics and EMTs union.

"We often inform family members where a loved one is being transported while on scene," he said. "If we are rerouted in transit their family have no idea where the patient ended up."

ER closure orders in the Twin Cities soared from 37 in January 2021 to 334 in December. The rule in the Twin Cities was that a third diversion announcement at once forced all ERs to reopen to ambulance traffic. There were no forced re-openings last January, but there were 280 last month.

Hospitals had no rules for when they could close their ERs to ambulances, and some did so more than others. The University of Minnesota Medical Center closed its ER 284 times last year for a collective 559 hours, while United Hospital in St. Paul closed 450 times for 817 hours.

The M Health Fairview system voted against suspending ambulance diversions when it was proposed by West Metro EMS leaders.

"We believe the ability to divert patients from hospitals without capacity to nearby hospitals with capacity plays an important role in our ability to safely care for patients," said Fairview spokeswoman Aimee Jordan.

Full closures are still permitted when hospitals have emergency situations that require them to stop taking any patients in their ERs. However, Burnett said hospitals have learned to be creative and stretch capacity when forced to remain open to ambulances.

Solutions have included hospital-at-home programs in which stable COVID patients were discharged with oxygen support and monitoring, and regular calls from clinicians to make sure patient status wasn't deteriorating. Many ERs also began providing basic care in triage and waiting areas rather than having patients wait until beds opened.

"When we were told, 'You've got to get the job done, you're forced off divert,' we were able to get the job done as a system," Burnett said. "It was just that we had this crutch in our bag that people were relying on that was never intended for a crisis, where every hospital was equally affected. Every hospital is facing staffing shortages. Every hospital is getting flooded with patients."

EMS leaders will be reviewing ambulance data in February to see if suspending diversions had a more severe impact on some hospital ERs than others. The change was made specifically for the pandemic, but it could become permanent if hospitals find other long-term solutions for ER crowding.