Dear Hospital Administrator: Hospital ED Overcrowding

December 11, 2000

RE: Hospital ED Overcrowding

Dear Hospital Administrator:

The intent of this letter is to reaffirm for hospitals the obligations and responsibilities associated with responding to periods of emergency department overcrowding and ambulance diversion. Emergency Department overcrowding is emerging as a national and statewide health issue that requires your full attention.

Overcrowding and diversion can significantly impact ongoing service delivery and negatively impact the quality of patient care services. Diversion alone is not an effective solution to overcrowding. Hospitals must take steps to develop meaningful solutions to address these issues. Collaboration between hospitals and the pre–hospital providers is necessary. Our mutual goals must be to appropriately respond to community needs and ensure patient safety by promoting quality patient care services and protecting the rights of all patients. This can only be fully accomplished by working together. Each hospital should take immediate steps to devise and implement a current and appropriate plan for responding to emergency department overcrowding and ambulance diversion.

Hospital Obligations & Responsibilities:

  • Hospitals must assume the responsibility to move patients, who require admission, out of the emergency department. Hospitals must utilize all available inpatient beds in managing admissions from the emergency department. Maintaining admitted patients within the emergency department is not acceptable.
  • Ambulance diversion is a temporary accommodation for use on a time–limited basis to respond to periods of severe overcrowding. Hospital administration should monitor all diversion practices and decisions. Diversion may be requested only when the acceptance of another patient might endanger the life of that patient or another patient. Hospitals are expected to utilize all available inpatient resources prior to requesting diversion. Repeated or frequent diversion decisions must be carefully reviewed. Trauma centers in conjunction with hospitals, counties, and Regional Emergency Medical Advisory Committees, together assume the responsibility to meet to establish and/or assess the effectiveness of countywide policies and practices in regard to diversion. Strategies to accommodate regional or countywide diversion practices should be discussed, agreed upon and followed.
  • Emergency department overcrowding is a hospital–wide problem. Hospital administration must be proactive and accountable in addressing overcrowding situations. The hospital's Chief Executive Officer should frequently visit the emergency department particularly during peak periods to assess staffing levels, monitor patient care services and determine the facility's ability to appropriately respond to all patient care needs.
  • Plans to utilize facility–wide staffing resources, as in the case of disaster preparedness, should be in place to address periods of peak utilization. Emergency department utilization/volume and the number of admissions from the ED must be tracked to determine trends and identify necessary resources.
  • Hospitals must put in place monitoring protocols to track and identify length of stay patterns and deviations. Discharge planning activities and particularly patient placement efforts must be handled on a priority basis.
  • Hospitals should designate an individual(s) to act as a bed monitor to ensure that all available beds are promptly identified and made available for admissions from the emergency department. Such monitors would assume hospital–wide responsibility and facilitate moving patients from the ED to the floors. In periods of peak demand and ED overcrowding, the monitor(s) will coordinate the distribution of patients to the floors to reduce the ED census and provide for the even distribution of admitted patients throughout the hospital. All hospital beds, including all beds with monitors, should be identified and considered in determining bed assignments. As a temporary emergency measure, the use of beds in solariums and hallways near nursing stations should be considered consistent with a Facility–wide plan to alleviate ED overcrowding.
  • Hospitals must evaluate staffing levels on a hospital–wide basis. Regardless of where an admitted patient is located within a facility, staffing, services, privacy, infection control and confidentiality protections must be consistently in place.
  • To ensure optimal operations and respond to patient needs, emergency departments rely on the availability of staff and immediate access to ancillary support and transport services. Hospitals must assure that ancillary services are available to ED staff on a priority basis to allow for the prompt disposition of patient care needs. Transport services must be available 24 hours per day to meet patient needs and to allow for the timely transfer of admitted patients. Emergency department staffing needs must be assessed on a regular basis to address periods of peak demand and census.
  • Hospital ED staff should assess average length of time for EMS personnel to effect the transfer of patients arriving by ambulance to emergency department staff. EMS personnel should not be detained in a hospital ED, patient care responsibilities must be transferred promptly to ED staff, and patient care needs met by hospital staff.

Next Steps

In considering short–term and long–term solutions to this issue, Department staff will continue to work with hospitals and EMS providers to address emergency department volume and diversion practices. Greater attention will be given to identifying and analyzing ED volume, admissions from the ED, inpatient lengths of stay, discharge planning initiatives and quality indicators. In addition:

  • The Department will initiate efforts to monitor diversion practices including the number and frequency of diversion decisions to identify those hospitals and areas of the State which specifically require attention. EMS regional organizations and dispatch centers will be asked to develop a reporting system for the Department on the number and frequency of diversion requests. This information will serve to identify and target problem areas throughout the State for further review.
  • An industry workgroup will be convened to develop Best Practice Guidelines for hospitals to use to prevent and manage overcrowding and ambulance diversion.
  • Workgroup members will also seek to identify long–term solutions and recommendations to address some of the fundamental challenges faced by hospitals today, including staffing shortages, utilization trends and payment considerations.


The Department looks forward to working together on this important issue. I would encourage you to contact your regional or area office representatives to further discuss this issue and strategies for improvement. Should you have questions or need further information, please contact the Bureau of Hospital & Primary Care Services at (518) 402–1003, or the Bureau of Emergency Medical Services at (518) 402–0996, Extension 4.


Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner of Health