title: Impact of an emergency department closure on the local emergency medical services system.
abstract: BACKGROUND
  On July 12, 2010, Boston Medical Center (BMC), the busiest emergency department (ED) in Massachusetts, with more than 100,000 adult patient visits per year, consolidated its two fully functional EDs into one. In preparation for this consolidation, BMC implemented systems changes to mitigate potential negative effects on both BMC and emergency medical services (EMS) providers, including Boston Emergency Medical Services (Boston EMS), the provider of 9-1-1 EMS to the City of Boston.
  
  
  OBJECTIVE
  To examine the impact of the closure of an ED on an urban EMS system in a setting where ambulance diversion is not allowed.
  
  
  METHODS
  We performed a before-and-after study that examined the effects of an ED closure on BMC and Boston EMS. We examined ED and Boston EMS volumes and ambulance turnaround intervals from June 1, 2010, to July 11, 2010 (preclosure) as compared with July 12, 2010, to August 26, 2010 (postclosure). Mean ED and Boston EMS volumes and Boston EMS turnaround intervals were calculated in four-hour shifts. We used multivariate analysis to analyze electronic medical systems data from BMC and Boston EMS and linear regression. We used autoregressive integrated moving average (ARIMA) models to determine the effect of the ED closure on turnaround intervals, ED volumes, and transport volumes. All analyses were adjusted for shift, ED volume, day of the week, and citywide EMS transport volumes.
  
  
  RESULTS
  After ED closure, there was a statistically significant increase of 0.89 minutes (p = 0.02) in the mean EMS turnaround intervals. Additionally, the total ED volume decreased by 3.67 visits per shift (p < 0.001). The ratio of patients transported by Boston EMS to BMC remained unchanged (p = 0.11) for two weeks before and two weeks after the closure.
  
  
  CONCLUSIONS
  The closure of one ED resulted in a statistically significant increase in turnaround intervals and a significant decrease in ED volume independent of EMS volumes. In the absence of ambulance diversion, ratios of EMS turnaround intervals and EMS volumes according to hospital destination can be used as alternatives to ambulance diversion times to examine the effects of system-level changes such as closure of an ED on an urban EMS system.
authors.affiliation: Department of Emergency Medicine, Boston University, Boston, Massachusetts 02118, USA. mj sayed@hotmail.com
authors.forename: Mazen
authors.initials: M
authors.lastname: El Sayed
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Mitchell
authors.forename: Laura F
authors.initials: LF
authors.lastname: White
authors.forename: Julia E
authors.initials: JE
authors.lastname: Rubin-Smith
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maciejko
authors.forename: Daniel T
authors.initials: DT
authors.lastname: Obendorfer
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Ulrich
authors.forename: Sophia
authors.initials: S
authors.lastname: Dyer
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Olshaker
mesh_terms: D000046:Academic Medical Centers / Q000600:supply & distribution; D000552:Ambulances / Q000458:organization & administration*; D001900:Boston; D016001:Confidence Intervals; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data* / Q000600:supply & distribution*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008404:Massachusetts; D020380:Needs Assessment; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D018570:Risk Assessment; D013997:Time Factors; D014187:Transportation of Patients / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000600:supply & distribution; D014505:Urban Population