Ambulance Diversion (De Facto Emergency Department Closure) In Selangor May Harm Patients — Public Hospital Physician

Emergency Departments (ED) within Klang Valley public hospitals have been facing an acute shortage of capacity called “access block”. 

Access block occurs when an ED, which is required to keep its door open, faces an imbalance between ability to provide care and number of patients requiring care.

This imbalance phenomenon may be due to the following: 

1. ED has no physical room to place a patient.
2. No physical bed in the hospital to place a patient.
3. Not enough resources in the hospital to care for a patient.

If one remembers during the Covid-19 pandemic, Kuala Lumpur Hospital (HKL) and Hospital Tengku Ampuan Rahimah Klang Hospital (HTAR) faced all three situations.

In managing access block in ED since Covid-19, the Ministry of Health (MOH) has mandated hospitals to set up a Bed Management Unit (BMU) in all hospitals. MOH attributed access block in ED to a lack of beds in wards and the inefficient assignment of beds to patients by the wards.

This BMU has two simple tasks:

1. Ensure beds for patients from all parts of the hospital system are assigned a bed in a timely manner when needed.
2. Whenever needed, alert hospital administrators that capacity has been reached and subsequently activate the existing Hospital Business Continuity Plan (BCR) to ensure patient care is not compromised due to capacity issues.

However, the Selangor State Health Department (JKNS) did something that no one else does – they also established a State Bed Management Unit, an entity on behalf of the JKNS director that may overrule existing hospital policy to ensure that beds are managed efficiently.

JKNS, via its Selangor BMU, has a unique contingency plan called the Ambulance Diversion Order. 

What Is An Ambulance Diversion Order?

An ambulance diversion order is a command given by the State BMU to all ambulance operators as follows:

1. Emergency Department at Hospital A is full.
2. Do not send patients to them unless you can (kebolehlaksanaan).

This means that, if the general public calls 999 and a government ambulance arrives, that ambulance will not bring them to Emergency Department of Hospital A. Interestingly for Selangor, there is no standard operating procedure (SOP) to guide a paramedic in the ambulance on:

1. Where to send a patient.
2. How to do it safely.

The term “kebolehlaksanaan” is very loosely used.

What Does Medical Literature Say About Ambulance Diversion?

Ambulance Diversion simply means that an Emergency Department is closed. Don’t go there.

What Is The Impact Of Ambulance Diversion On The Emergency Department In Hospital A?

In theory, by controlling the ambulance and preventing them from entering the ED in Hospital A, it is hoped that the acute bed shortage in Hospital A will correct itself. Limit the input to Emergency Department and subsequently reduce output from ED or input into wards.

What Is The Impact Of Ambulance Diversion On A Patient?

The impact on the affected patient is:

1. You will be brought to another Emergency Department that may not be your usual hospital or the one closest to you.
2. The hospital is chosen on the pretext that “it is better than the one that is already full.”
3. The hospital may or may not be ready for you – be prepared for a canvas bed or even corridor nursing.
4. Your existing records are not in that hospital. 

Why Is This A Concern?

In recent days, all hospitals face ED overcrowding. There have been instances of Selangor BMU orders for diverted ambulance service from two hospitals within the same day. The affected hospitals are urban centre hospitals in the heart of Klang Valley.

There is a growing fear that the State Health Department does not monitor the utilisation of “Power to Divert Ambulance” by the State BMU. This power actually transfers a problem from one hospital to another if not monitored correctly.

Ambulance diversion is an attempt to manage what comes into the ED in the hope that the ED will be able to quickly turnaround from a disaster state to a non-disaster state. But it does not work that way. 

When treating patients, this is more complex than just input, throughput, and output perspective (divert when full). We have patient factor, disease factor, environment factors, nursing needs, and ratio between physical space, nursing, length of stay and care.

Ambulance Diversion is akin to closure of an Emergency Department. As MOH is the main provider of health care in Malaysia, who has the power to close an Emergency Department in a non-disaster scenario?

Is Ambulance Diversion An Evidence-Based Intervention?

Much literature on Ambulance Diversion comes from United States. Recently, many journal articles on this issue have also been published in Australia. The evidence says that:

1. There is limited evidence that it actually works to the benefit of patient. 
2. There is also limited evidence that it actually assists the health care system in facing ED overcrowding Issues.

Instead, there is a real concern that patient safety may be compromised and that it creates a vicious cycle of overcrowding in all hospitals within an area.

The majority of studies conclude that:

1. There is a need to ensure that this intervention associated with the closure of an Emergency Department should follow strict guidelines on when it can be activated, who should activate it, and how it should be monitored.
2. Systems that use Ambulance Diversion may be taking an easy way out to solve a complex issue, not fully understanding the complexity of patient care.

What Does MOH Say About Ambulance Diversion And Closing Of An ED?

There has not been any circular, directive, or guideline from the Director-General on Ambulance Diversion and closure of an ED. There is only a directive encouraging the formation of a BMU in hospitals to manage capacity more efficiently.

If There Is No Directive or Circular, Why Is Selangor Doing It?

Here is where the term “Only God knows” comes in, as there are no local publications yet to say that Ambulance Diversion solves the problem. 

What makes matters worse is the absence of guidelines on how to do this safely. 

So, back to MOH. Are you monitoring ED Access Block and use of Ambulance Diversion Orders by Selangor State BMU or individual hospitals? 

Countries that previously implemented Ambulance Diversion are moving away from it, as they understand that access block is a complex issue requiring multidisciplinary intervention, not just the ED.

The author is a physician at a public hospital in the Klang Valley. CodeBlue is giving the author anonymity because civil servants are prohibited from writing to the press.

• This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.