- Explore the benefits of the continuity
of hospital care.
- Understand the rules and regulations
behind triage and hospital choice decisions by emergency medical
services (EMS) providers, and the roles of ambulance diversion and
federal Emergency Medical Treatment and Active Labor Act (EMTALA)
- Identify ways to improve continuity of
A 74-year-old man had a long history of coronary
artery disease requiring coronary artery bypass grafting as well as
placement of an automated internal cardioverter-defibrillator
(AICD) for ventricular arrhythmias. His AICD was almost 10 years
old, and his cardiologist had found minor lead displacement (one of
the wires to his heart had moved over time). Admitted to Hospital X
(less than 1 mile from his house), he underwent the placement of a
new AICD—a minor surgical procedure, which was uncomplicated.
The patient was discharged 2 days later.
Within hours after arriving home from the
hospital, the patient's newly placed AICD began
"firing"—shocking his heart with large amounts of energy and
causing considerable pain. As the AICD fired more than 15 times in
the course of minutes, his wife called 911.
Emergency medical services (EMS) arrived and
found him lying on the couch, awake and alert, but in discomfort.
His heart rate and blood pressure were normal. Because of repeated
AICD firings and concern for a heart attack, he was taken in the
The patient told paramedics that he had received
all of his care at Hospital X and had just been discharged from
there. However, they took him to Hospital Y, a few miles away.
In the emergency department (ED) of Hospital Y,
the patient's AICD continued to fire shocks. The defibrillation
stopped after the patient was treated with amiodarone and
supportive care. He was then admitted to cardiology at Hospital Y
for ongoing management. The next day, when the patient was
clinically stable, the cardiologist considered transferring him
back to Hospital X but decided to keep him at Hospital Y.
Unfortunately, the patient continued to have more
ventricular arrhythmias and firings of his AICD even with medical
treatment. Despite maximal efforts, the patient eventually died
from a cardiac arrest.
It was unclear whether the patient's death could
have been prevented had he been taken to Hospital X. However, one
could argue that he may have received better informed care had he
been admitted to his original hospital.
1. Pham JC, Patel R, Millin MG, Kirsch TD,
Chanmugam A. The effects of ambulance diversion: a comprehensive
review. Acad Emerg Med. 2006;13:1220-1227. [go to
2. Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 1-concept, causes, and moral consequences. Ann Emerg Med. 2009;53:605-611. [go to
3. Sun BC, Mohanty SA, Weiss R, et al. Effects of
hospital closures and hospital characteristics on emergency
department ambulance diversion, Los Angeles County, 1998 to 2004.
Ann Emerg Med. 2006;47:309-316. [go to
4. Pines JM, Heckman JD. Emergency department boarding and profit maximization for high-capacity hospitals: challenging conventional wisdom. Ann Emerg Med. 2009;53:256-258. [go to
5. Hartocollis A. City pushes cooling therapy for
cardiac arrest. The New York Times. December 3, 2008. [Available at]
6. Emergency Medical Treatment and Active Labor
Act (EMTALA). [Available at]
7. Hayes CM. New EMTALA ruling makes ambulance
diversion rules more confusing. EMSVillage.com. [Available at]
8. Dean S. The origins of system status
management. Emerg Med Serv. 2004;33:116-118. [Available at] [go to