Massachussetts "No Diversion" ambulance / ER policy works

[IzzyEng4 427]

The Boston Globe

State’s ER policy passes checkup

Hospitals accept ambulance rule; Wait times don’t spike for patients

A new state policy requiring crowded hospital emergency rooms to accept all patients delivered by ambulance has not worsened conditions, as some doctors had feared.

According to an analysis by state public health officials, the average time patients spent in 75 of the state’s emergency rooms remained about the same since the rules went into effect in January. Patients who were admitted to the hospital spent between 5 and 5 1/2 hours in the emergency room, while patients who were sent home spent about 2 1/2 hours.

“This policy was a risk,’’ said Alice Bonner, director of health care safety and quality for the state Department of Public Health. “We wanted to be sure there was no spike in waiting time or any unintended consequences. It’s been a success.’’

http://www.boston.com/news/health/articles/2009/12/14/states_er_policy_passes_checkup/

[WAS967 97]

I personally, think hospitals should not go on diversion unless there is some major internal disaster (someone holding up the ER with a gun, fire, etc). What they SHOULD have is advisories. If an ER is overwhelmed with patients and truly feel that bringing more will be detrimental to care, then send out an advisory to EMS in the field so they can take that under advisement and make a more informed transportation decision. Ive actually been in overly crowded and hopping ERs and nexteled my coworkers to advise them that that particular ER is jammed and they might be interested in going to the next available ER if they can.

Too many hospitals drop the diversion word and expect it to be the solution to all their crowding problems, then get mad when we show up yelling that they're on diversion without realizing the policies that EMS crews follow.

Just a thought.

[SageVigiles 1,194]

What happens when you get an MCI?

[WAS967 97]

Same you do with any MCI. Transportation officer should be reaching out to the area hospitals to see how many criticals and stables they can take and dole them out appropriately. Other units coming from separate incidents could then be notified like always if the ER finds themselves in the thick.

Just like the EMS system in the field, the EMS system in the ER should be able to handle swells in activity. Call in additional units (floaters from other floors, on call staff, supervisors, etc) and handle the volume until it subsides. Ambulances don't get to go on diversion, why should receiving facilities?

Maybe we can have hospitals post a DEFCON status. The worse they get the lower the number goes.

[ny10570 745]

Just about any time an ER is diversion there's a doc or triage nurse we have to remind that diversion is a courtesy. If your burn beds are occupied, CT is down, or power is out thats a reason to go to a different hospital. Otherwise they're gonna have to deal. One interesting policy FDNY instituted is redirection. If there is 1 ambulance at an ER for more than 1 hr or multiple for more than 40 minutes the ER gets shuttered to any 911 ambulance without approval from medical control. At most hospitals this lit a fire under administrators to ensure units are triaged quickly and ushered out the door. To get units out more stretchers have to be available. More stretchers means clearing patients faster. Since the policy ER turnaround times have dropped somewhat, but unexpectedly ER diversions dropped too.

[helicopper 1,050]

Same you do with any MCI. Transportation officer should be reaching out to the area hospitals to see how many criticals and stables they can take and dole them out appropriately. Other units coming from separate incidents could then be notified like always if the ER finds themselves in the thick.

Just like the EMS system in the field, the EMS system in the ER should be able to handle swells in activity. Call in additional units (floaters from other floors, on call staff, supervisors, etc) and handle the volume until it subsides. Ambulances don't get to go on diversion, why should receiving facilities?

Maybe we can have hospitals post a DEFCON status. The worse they get the lower the number goes.

This would be true if an MCI was actually managed and didn't manage the responders. How many times have you walked up to the "Transport Officer" only to find out that they have no idea who went where or in what condition? I've seen it at both incidents and exercises alike. Sometimes all we do is relocate the incident from the street to the hospital. We all know how many patients it takes to overwhelm a facility.

Hospitals do have to have some surge capacity but it isn't like EMS mutual aid. You can't just ring a bell and have "extra" people respond from other floors or units. Hospitals have no extra people anymore; they're doing more with less also. Patient to RN ratios are already obscenely high, most facilities have done away with support staff so there aren't the extra people in house that can be drawn from. So "calling in" additional staff can be done but takes time. Surge capacities and call-ins aren't intended to be instant mutual aid and we have to be realistic in our expectations.

Just about any time an ER is diversion there's a doc or triage nurse we have to remind that diversion is a courtesy. If your burn beds are occupied, CT is down, or power is out thats a reason to go to a different hospital. Otherwise they're gonna have to deal. One interesting policy FDNY instituted is redirection. If there is 1 ambulance at an ER for more than 1 hr or multiple for more than 40 minutes the ER gets shuttered to any 911 ambulance without approval from medical control. At most hospitals this lit a fire under administrators to ensure units are triaged quickly and ushered out the door. To get units out more stretchers have to be available. More stretchers means clearing patients faster. Since the policy ER turnaround times have dropped somewhat, but unexpectedly ER diversions dropped too.

Too bad it took the threat of fiscal implications to get them to do this. It's just going to mean unattended patients in hallways again though because hospitals may have extra beds lying around but no staff to care for their occupants. Diversion is only a courtesy and it would be nice if the staff remembered that instead of abusing the EMS crews.

[IzzyEng4 427]

When I worked for C-MED New Haven, the hospitals in our region could go on diversion regardless of the reason. However, we could end a hospital's diversion in a crisis such as an MCI or if we felt that the hospital was abusing the policy, which occurred a few times while I was there. Also in CT, if a hospital was to go on diversion, another hospital much be able / willing to accept the diversion patients at their facility. If no hospital accepts the diversion, there is no diversion place in effect. If the receiving hospital ends the diversion on their end, then the diversion is over. If the original hospital still needs to have the diversion, then they have to find another receiving hospital otherwise the diversion is no longer in effect. Also diversions are check upon every 1 to 2 hours by C-MED.

Also too, certain medical emergencies such as cardiac arrests, traumatic arrests or any transport where a patient need immediate attention and cannot go to a further out hospital, the hospital that is closest has to take the patient for stabilization regardless of the diversion. Usually diversion status allowed up in my region are usually for psych / ETOH, telemetry, equipment failures and rarely, full no acceptance diversions.

[Guest alsfirefighter]

I personally, think hospitals should not go on diversion unless there is some major internal disaster (someone holding up the ER with a gun, fire, etc). What they SHOULD have is advisories. If an ER is overwhelmed with patients and truly feel that bringing more will be detrimental to care, then send out an advisory to EMS in the field so they can take that under advisement and make a more informed transportation decision. Ive actually been in overly crowded and hopping ERs and nexteled my coworkers to advise them that that particular ER is jammed and they might be interested in going to the next available ER if they can.

Too many hospitals drop the diversion word and expect it to be the solution to all their crowding problems, then get mad when we show up yelling that they're on diversion without realizing the policies that EMS crews follow.

Well in all actuality that is what diversion in an essence truly is...an advisory to not bring patients there. The problem with it is often in the area where I work (and you know this well) is that the BLS agencies and one in particular disregard it and add to the problem only further pushing the clear time back by adding more to the mix. I've never had an issue when I've called any facility on diversion with either a very simple need or one in which the added transport time to me could have been detrimental to the patient or I didn't want the added risk when the patient was deteriorating despite actions I've already taken.

Additionally I have always found it trivial as how even some fellow ALS providers when faced with a medical patient in severe distress or decompensation of the present medical issue get the thought of closest facility in their head and can't deviate from that...however when faced with a just as critical or unstable trauma patient (with a managed or manageable airway) have no issue transporting by ground to the trauma center. There are local hospitals just as close or slightly closer then WMC in my area. If anything with the addition of Etomidate I have found being able to facilitate conscious sedation for intubation much much easier then just with straight narcotics a plus. Add in CPAP and a good ALS provider should be able to manage many of the issues (respiratory seems to be the flair of conditions leading to wanting to bring them in to the facility on diversion) that causes the lock onto the "closest facility" syndrome. Not to mention that when involved in the QA/QI process there were many cases where providers didn't even dig deeper in the tool chest for management.

The bottom line is that whatever ones opinion on diversion is..or as I often hear from some in one agency "its not my problem its theirs"...it is really your patients problem. Its about explaining to them the issue at hand and that they may not receive prompt treatment, may have an extended ER wait and sit time and may not get the same level of care that they would normally or need/deserve. I really could give a crap when my local facility goes on diversion...I have no place else I can go when at work so I deal with it. What is a shame is how local agencies still have no SOP's to deal with it appropriately and how mutual aid goes up when the word gets out and that every agency still seems like to be on a island when they are all dealing with the same issues. Get friggin crews in there on standby. Make it worthwhile...feed them...give them things to stay busy and share resources so calls get covered in your region not just your little island.

[rutola413 5]

Were I am from in western MA (Granville), we have 2 hospitals we traansport to. Noble has a basic ER, which is in Westfield MA. Baystate has a Trauma ER which is in Springfield. For me in my POV, it takes 30-45 minutes normal driving to get to Baystate, and 10 to get to Noble. If Noble goes on diversion, they HAVE to accept our patient. Even if it is to stabalize them before we go to Baystate. And the same with Baystate. They have to accept a Trauma patient.

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