title: "No diversion": a qualitative study of emergency medicine leaders in Boston, MA, and the effects of a statewide diversion ban policy.
abstract: OBJECTIVE
  We examine the attitudes of emergency department (ED) key informants about the perceived effects of a statewide ban on ambulance diversion on patients, providers, and working relationships in a large urban emergency medical system.
  
  
  METHODS
  We performed a qualitative study to examine the effects of a diversion ban on Boston area hospitals. Key informants at each site completed semistructured interviews that explored relevant domains pre- and postban. Interviews were deidentified, transcribed, coded, and analyzed with grounded theory for emerging themes. We identified important themes focused on patient safety, quality of care, and relationships before and after implementation of the diversion ban.
  
  
  RESULTS
  Nine of 9 eligible sites participated. Eighteen interviews were completed: 7 MD ED directors, 2 MD designees, and 9 registered nurse leaders. Although most participants had negative opinions about diversion, some had considered diversion a useful procedure. Key themes associated with diversion were adverse effects on patient care quality, patient satisfaction, and a source of conflict among ED staff and with emergency medical services (EMS). All key informants described some positive effect of the ban, including those who reported that the ban had no direct effect on their individual hospital. Although the period preceding the ban was reported to be a source of apprehension about its effects, most key informants believed the ban had improved quality of care and relationships between hospital staff and EMS.
  
  
  CONCLUSIONS
  Key informants considered the diversion ban to have had a favorable effect on emergency medical care in Boston. These results may inform the discussion in other states considering a diversion ban.
authors.affiliation: Division of Emergency Medicine, Harborview Hospital, University of Washington School of Medicine, Seattle, WA.
authors.forename: Shannon D
authors.initials: SD
authors.lastname: O'Keefe
authors.affiliation: University of California Berkeley School of Public Health, Berkeley, CA.
authors.forename: Salma
authors.initials: S
authors.lastname: Bibi
authors.affiliation: Ben-Gurion University of the Negev, Israel.
authors.forename: Julia E
authors.initials: JE
authors.lastname: Rubin-Smith
authors.affiliation: Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address: jfeldma@bu.edu.
authors.forename: James
authors.initials: J
authors.lastname: Feldman
mesh_terms: D064422:Ambulance Diversion / Q000331:legislation & jurisprudence*; D001291:Attitude of Health Personnel; D001900:Boston; D004632:Emergency Medical Services / Q000458:organization & administration; D006291:Health Policy / Q000331:legislation & jurisprudence; D006801:Humans; D007407:Interviews as Topic; D008404:Massachusetts; D061214:Patient Safety; D010360:Patient Transfer / Q000331:legislation & jurisprudence*; D011787:Quality of Health Care