How a data-driven story on ambulance diversion revealed a deeper story of health inequities in L.A.

When I began researching ambulance diversion — when an ambulance reaches the ER with a patient and gets rerouted to a different hospital — I already knew about the racial and class divides in quality of care, worsened by hospital overcrowding and inflated wait times. I also knew, to some extent, that unequal care happens more often in communities of color. 

Months before I applied for the Data Fellowship, I submitted public records requests to police and fire agencies in Los Angeles County for ambulance dispatch records. I repeatedly got no response or was passed from one person to another. No one could or would tell me where or from whom I could get the data I wanted, or even which department might have what I needed. 

I applied to the fellowship because I was hopeful that data analysis resources and tools like R, coupled with the invaluable support of mentors familiar with ambulance service agencies, would help me formulate records requests and analyze data I needed to ground my reporting. Ultimately, the reporting lessons I learned had more to do with the value of finding key sources to help track down and decipher this type of health data.

What began as a story purely about diversion and COVID-era delays grew into something much bigger: a deep dive into how systemic overcrowding, ambulance wait times and ambulance diversion contribute to understaffed and under-resourced hospitals and create delays in care.

Ambulance patient offload time, known as APOT, is the time between a patient’s arrival outside the emergency department doors and the time that patient is transferred to an emergency department’s care. Patients may be moved to a gurney, bed, chair or other licensed location. At the hospital, paramedics and EMTs relinquish control of patient care by handing over a care report detailing where the patient is coming from, their injury or complaint, demographic information, and the time that they were handed over to the hospital.

For months, I made records requests to city and county fire departments, private ambulance companies, and county EMS agencies on patient care reports and ambulance transfer records, with little to no response. I circled back with EMT, fire department and health department sources who were able to help me narrow my requests. I was also able to leverage these relationships to finally connect with L.A. County Fire Department administrators who connected me with data analysts at Falck and McCormick, two of the three private ambulance companies contracted by Los Angeles County.

During the reporting process, we discovered that each ambulance company records their ambulance offload times differently. Some companies put emphasis on the loss of productivity from long wait times while others emphasize the number of calls in relation to those wait times. Not only do private, city, county and state EMS agencies keep their records differently, they also seem to rarely communicate with one another about the data they have, even when they have the common goal of reducing ambulance offload times.

When I set out to write about the impacts of ambulance diversion rates on communities of color in Los Angeles, I knew diversion and wait time were only symptoms of larger problems within the system. 

From 1993 to 2003, there was a 44% increase in emergency department visits nationally, according to a 2016 study. In 2020, the height of the COVID pandemic, the rate of emergency visits of Black people was the highest of all racial group, according to the Centers for Disease Control. This story provided vital information for and about Black and Latino people across Los Angeles County who sought medical care daily and were being rerouted to under-resourced hospitals, or not being seen at all due to overcrowding or extended wait times.

I realized that there was much more to this story by the end of my initial interviews. EMTs were scrambling to do what they could to help patients amidst growing obstacles from the private ambulance companies, and the county fire administration. I interviewed at least a half dozen EMTs and health care workers willing to go on the record, and they all told me variations of the same thing: the system itself prevents them from helping patients. 

In an effort to fact-check these sources, I contacted a fire department official who was able to explain to me exactly what happens when you call 911, and who is in charge of deciding when someone goes to the hospital. 

That answer was not simple.

Can the system be fixed?

I asked a variety of professionals with expertise from across the healthcare system about how the problems that stem from ambulance diversion might be fixed.

Clayton Kazan, incoming president of California's chapter of the National Association of EMS Physicians (Cal-NAEMSP) explained: 

“Dispatching alternative response units such as community paramedics, response units staffed with a nurse practitioner or physician assistant, or mental health units are other strategies that could be implemented,” he said.

When the needs of patients can’t be met in the field, Kazan said transporting them to destinations other than the emergency room — like psychiatric urgent care centers or sobering centers — can save much needed ER capacity. 

“Diverting people who don’t need a hospital in the first place, who have less severe injuries or conditions, could also ease the strain on an overwhelmed system. We need to improve access to urgent care centers and awareness of their capabilities,” Kazan continued. “Many people aren’t aware they can use an urgent care center, even with Medi-Cal.”

Glendale Battalion Chief Todd Tucker said he holds regular meetings with his staff to review the data on long wait times and brainstorm ways to curb those outcomes. On the ground, as an EMT, the realities are often much different than policies.  

“The intent with these policies is to process EMS patients at receiving facilities as soon as possible in order to release the EMS resources back into the community to be available to respond to 911 calls,” said Tucker. Sometimes, however, the system just gets overloaded, and we get stuck holding the wall”

EMT Katrina Slye recalled when a paramedic on her team got stuck holding the wall for over 40 minutes with a patient who demonstrated signs of a severe heart attack. “He said, ‘This is insane. Heart tissue is dying, and we’re still holding the wall’”, she said. 

May Noor, director of the UCLA Mobile Stroke Center, said units like hers are only dispatched where the fire department tells them they need to go. “When somebody calls 911 and describes the event they're having, the 911 call taker has 60 seconds to decide what to dispatch that call type as right… And so mislabeling that call prohibits the unit from knowing about that patient so the unit doesn't dispatch that patient,” Noor said. 

Ultimately, there are too many disparate systems within L.A. County to come up with a sweeping solution to the problem. 

“The current situation is so bad that ambulances are held at the hospitals, sometimes for hours, waiting to offload their patients, and the result can be prolonged response times for EMS 

patients with critical needs,” said Kazan. “Emergency rooms are drowning under the burden of filling in all of the gaps in the healthcare system, in addition to caring for the critically ill patients that they were intended for.”

There is a body of research to describe disparities and inequity stemming from ambulance diversion at a national level, but far less (and none since 2009) to identify problems specifically seen in California or Los Angeles. 

One researcher’s answer surprised me. “The underlying root of the problem has not changed,” said David Tan, professor of emergency medicine at Washington University in St. Louis, “So, nobody feels the need to update research when the original problem remains, which is not emergency department overcrowding, but more honestly, hospital overcrowding. ERs cannot get patients out of the back and upstairs to inpatient services, which makes getting patients through the front door of the ER next to impossible. Many ERs are on ‘disaster’ status as a matter of routine which is why so many go on diversion. Hospitals have no incentive to rapidly discharge patients who are ready to go, clean rooms, and get patients up from the ER as soon as possible. So, it becomes an ER problem.” 

As a result, the “ER problem” falls squarely on those who need care the most, in areas like South Los Angeles. Hospitals here, serving predominantly Blacks and Latinos are more likely to go on diversion – where ambulances are forced to go to another hospital when one hospital is overcrowded which is more likely to be under-resourced or understaffed. In community listening sessions, we heard from people who experienced this firsthand, and often paid with their health as a consequence. 

My biggest reporting lessons from this series ultimately apply to data projects more broadly: 

1. Seek data early, and check in often. In my experience, county health officials rerouted requests to the same people over and over.  No one knows everything about the system, so you will need to leave time for back and forth until you find the right person for what you need. 

2. Be specific in data requests, and background with sources to get to know the terms you need to use for those requests. If you aren’t using their lingo, you won’t get anything useful. For example, when I originally submitted my records requests to the L.A. County Department of Health Services, I mistitled my requests. I asked for “dispatch records” which was too general. When I requested the data using their terms, as “patient care reports /patient run reports,” the agency provided me with the specific reports filled out by ambulance staff as they transferred patients. 

3. Ask for conversations until you get to the right people to give the answers you need. In my case, that meant corroborating information about ambulance diversion with multiple sources from hospitals, EMTs and fire departments.

4. Build strong relationships with the communications leads at the agencies involved in your reporting, who can get you to the right people for the info you need. 

5. Researchers are your best friends. They can provide expert context, help you understand complex data, and contextualize what on-the-ground sources are telling you.