title: Ambulance diversion reduction and elimination: the 3-2-1 plan.
abstract: BACKGROUND
  The diversion of ambulances from their intended emergency departments (EDs) occurs frequently, compromising patient care. Previously, we reduced ambulance diversion (AD) by 74% in a large urban area with 17 EDs.
  
  
  OBJECTIVE
  In this follow-up program, we sought to further reduce and eliminate AD by progressively reducing the duration of each AD event.
  
  
  METHODS
  Using tight diversion criteria, AD at each ED was limited by protocol to 3h at a stretch, after which incoming ambulances had to be accepted at that ED for at least 1h. After 6 months, AD was limited to 2h per diversion event; after another 6 months, AD was limited to 1h. The monitoring for AD was programmed into a region-wide, Internet-based Emergency Medical Services (EMS) program.
  
  
  RESULTS
  Total annual AD decreased from 8469 h in 2006 (pre-implementation) to 4592 h in 2007 (during implementation), and finally to 2439 h and 2306 h in 2008 and 2009 (post-implementation), respectively, an 87.4% (95% confidence interval 64.6-95.5%) reduction, and one county within the region eliminated AD altogether. From 2006 to 2009, overall increases were noted in EMS arrivals (7.8%), ED census (13.0%), hospital admissions (6.6%), Intensive Care Unit admissions (17.1%), and overall Sacramento population (1.9%).
  
  
  CONCLUSIONS
  By limiting the duration of AD events to progressively shorter periods of time using a region-wide, Internet-based EMS program, we reduced AD hours in 17 EDs by 87.4% and eliminated AD in one entire county. This original, collaborative 3-2-1 Plan may be readily reproduced across the country to progressively reduce and eliminate AD.
authors.affiliation: Department of Emergency Medicine, The Permanente Medical Group, Kaiser Permanente Medical Centers, Sacramento and Roseville, California 95661, USA.
authors.forename: Pankaj B
authors.initials: PB
authors.lastname: Patel
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
mesh_terms: D000552:Ambulances / Q000458:organization & administration* / Q000600:supply & distribution; D002140:California; D003441:Crowding; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D017146:Models, Organizational; D015397:Program Evaluation; D019037:Urban Health Services / Q000458:organization & administration* / Q000600:supply & distribution