Ambulance Diversion

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joeDO2

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So I was reading the article in annals last month about the results of the statewide ban on ambulance diversion in the state of massachusetts. It appears the problems anticipated (overcrowding, boarding, slower ambulance turnaround) were not realized in the end. Your thoughts? Should this become a national trend?

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In my mind, there are two reasons why EDs go on divert. The first is when the ED becomes a bottleneck for patients due to a lack of inpatient beds. The staff isn't really overwhelmed, there just isn't any room for new patients and there are a ton of people to watch over in the ED. This is why many Massachusetts hospitals were going on divert and when the DPH banned diverts, hospitals were forced to streamline inpatient processes to prevent ED bottlenecking.

The other reason EDs go on divert is when the staff is truly overwhelmed from a sudden, large influx of high-acuity patients. In the 3 years that I worked ED, this happened a handful of times and I really think that going on divert saved our butts a few times. Then again, I also I know how frustrating it is for pre-hospital providers when EDs go on divert. Luckily, where I live, there are two trauma centers within a few blocks of each other, so one ED going on divert doesn't really affect the ambulances.

It's a tricky issue. I think it's great to encourage efficiency for hospitals to prevent unnecessary diverts, but I'm hesitant to support a ban on diversion because I think it can be a useful tool under the right conditions.
 
In my mind, there are two reasons why EDs go on divert. The first is when the ED becomes a bottleneck for patients due to a lack of inpatient beds. The staff isn't really overwhelmed, there just isn't any room for new patients and there are a ton of people to watch over in the ED. This is why many Massachusetts hospitals were going on divert and when the DPH banned diverts, hospitals were forced to streamline inpatient processes to prevent ED bottlenecking.

The other reason EDs go on divert is when the staff is truly overwhelmed from a sudden, large influx of high-acuity patients. In the 3 years that I worked ED, this happened a handful of times and I really think that going on divert saved our butts a few times. Then again, I also I know how frustrating it is for pre-hospital providers when EDs go on divert. Luckily, where I live, there are two trauma centers within a few blocks of each other, so one ED going on divert doesn't really affect the ambulances.

It's a tricky issue. I think it's great to encourage efficiency for hospitals to prevent unnecessary diverts, but I'm hesitant to support a ban on diversion because I think it can be a useful tool under the right conditions.

I see your points but I disagree on some of the subtleties. When the ED is holding a lot of patients the staff is overwhelmed. From a nursing perspective few patients are simply being "watched over" any more. Inpatient stays are short and intense due to financial necessity and nurses are expected to push events and get the patients out. An ER nurse with 4 inpatients is still busy and even more so if any of those holds are unit players.

You mention "encouraging efficiency for hospitals" which is a good point. ED holds is an IN HOUSE problem that disproportionally affects the ED. We need to find a way to force hospitals to staff adequately so the holds don't happen. If all we do is eliminate divert then we are just allowing the ED to be overwhelmed which doesn't affect the in house side or motivate administrators. It's similar to Medicaid programs that are trying to stop patients from abusing the ED for non-emergent visits by not paying the bills (e.g. WA). It only hurts the ED, not the entity causing the problem.

One idea would be to have CMS refuse to allow a facility charge until the patient is physically out of the ED. That would work but again it pits the ED against the rest of the hospital.
 
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I see your points but I disagree on some of the subtleties. When the ED is holding a lot of patients the staff is overwhelmed. From a nursing perspective few patients are simply being "watched over" any more. Inpatient stays are short and intense due to financial necessity and nurses are expected to push events and get the patients out. An ER nurse with 4 inpatients is still busy and even more so if any of those holds are unit players.

I can agree to that. My idea of a truly overwhelmed ED is still more along the lines of a rapid inrush of high-acuity patients, but you're right - nurses who are holding a lot of patients can be overwhelmed and it's a pretty big stress on the ED.

I'm curious docB - would you be okay knowing that your ED was unable to go on divert? (due to a statewide ban like in Massachusetts) Do you think that going on divert makes a significant difference to your ED?
 
I work at a few places that have a no divert policy. one is rural so there is really nowhere else for folks to go. the other is a busy trauma ctr.
their version of "no divert" basically means low acuity ambulance pts wait in the waiting room and to make it to the back you need to have a level 1 or 2 complaint. there are MANY other hospitals in the area so I think they just went to this policy to assure themselves more income honestly. it doesn't improve care, it just makes everyone's wait longer.
 
You mention "encouraging efficiency for hospitals" which is a good point. ED holds is an IN HOUSE problem that disproportionally affects the ED. We need to find a way to force hospitals to staff adequately so the holds don't happen. If all we do is eliminate divert then we are just allowing the ED to be overwhelmed which doesn't affect the in house side or motivate administrators. It's similar to Medicaid programs that are trying to stop patients from abusing the ED for non-emergent visits by not paying the bills (e.g. WA). It only hurts the ED, not the entity causing the problem.

One idea would be to have CMS refuse to allow a facility charge until the patient is physically out of the ED. That would work but again it pits the ED against the rest of the hospital.

This is the crux of the matter, as others have pointed out. The longer the "boarding" time, the more backlogged you get in triage, until you reach the point where the only patients getting back are the level I/II, and the lower acuity patients are being passed over, with no real way to work them in due to bed space and staff resources. Then you get the LWBS numbers increasing, satisfaction scores decreasing, etc.

The patients get the short end of the stick, with EMS being a close second. My experience has been that once the initial divert domino falls, other facilities begin to follow. I always found it ironic that the hospital could turn EMS away over the radio, but if the ambulance dropped the patient off 1 foot from the door, and the patient simply took a single step forward, the facility would be obligated to treat them, regardless of resource availability.

One of the biggest problems at the hospitals I have worked at is the floor dragging its feet. I know when the ED is busy, everyone is busy, but when you are trying to transfer a patient and the charge nurse says it is going to have to wait because they just got two or three admissions, you just want to bang your head on the table as you look into the waiting room that is currently 100 patients deep.

Parkland initiated a rapid admission process where they have an internist in the ED, who immediately assumes care for the patient once the admit order is given by the ED physician. Prior to that, you had to wait for the floor orders to be completed by the hospitalist, then wait for nurse to nurse, then transfer the patient. Basically, once the ED physician pulls the trigger on admission, the patient goes into the "transitional" period where they are the responsibility of the floor they have been admitted to, and on the internal medicine service while they make their way up there. Facilities have also created transfer RNs who basically relieve the ED staff of patient care duties once the admit order is placed, and the boarding time has been reduced by up to 25% in some cases.

Just some food for thought. For me, one of the most frustrating situations in healthcare (EM anyway) is when you can't move patients out, and you can't move patients in. You are in healthcare purgatory.
 
their version of "no divert" basically means low acuity ambulance pts wait in the waiting room and to make it to the back you need to have a level 1 or 2 complaint.

isn't this essentially just triage??
 
One of the biggest problems at the hospitals I have worked at is the floor dragging its feet. I know when the ED is busy, everyone is busy, but when you are trying to transfer a patient and the charge nurse says it is going to have to wait because they just got two or three admissions, you just want to bang your head on the table as you look into the waiting room that is currently 100 patients deep.

I think it might be helpful to investigate why patients are not moving. When I worked in pt transport at a hospital I realized the causes of delay were more variable that you might expect. For instance, is it: 1. truly no beds available because the floors are full, 2. no nursing staff available, 3. transport backup to bring pt to the floor, 4. housekeeping needs to clean the room, 5. mr. jones is sitting in a wheelchair in his room waiting for his family to arrive and take him

Many of the above problems (esp 3-5) have immediate solutions. Sometimes it helps to know what you're dealing with and make the appropriate calls.
 
I'm curious docB - would you be okay knowing that your ED was unable to go on divert? (due to a statewide ban like in Massachusetts) Do you think that going on divert makes a significant difference to your ED?
We only go on divert rarely but when we need it we need it. We're not kidding when we use it. When EMS chooses to ignore it we wind up coding patients in the hallway.
This is the crux of the matter, as others have pointed out. The longer the "boarding" time, the more backlogged you get in triage, until you reach the point where the only patients getting back are the level I/II, and the lower acuity patients are being passed over, with no real way to work them in due to bed space and staff resources. Then you get the LWBS numbers increasing, satisfaction scores decreasing, etc.

The patients get the short end of the stick, with EMS being a close second. My experience has been that once the initial divert domino falls, other facilities begin to follow. I always found it ironic that the hospital could turn EMS away over the radio, but if the ambulance dropped the patient off 1 foot from the door, and the patient simply took a single step forward, the facility would be obligated to treat them, regardless of resource availability.

One of the biggest problems at the hospitals I have worked at is the floor dragging its feet. I know when the ED is busy, everyone is busy, but when you are trying to transfer a patient and the charge nurse says it is going to have to wait because they just got two or three admissions, you just want to bang your head on the table as you look into the waiting room that is currently 100 patients deep.

Parkland initiated a rapid admission process where they have an internist in the ED, who immediately assumes care for the patient once the admit order is given by the ED physician. Prior to that, you had to wait for the floor orders to be completed by the hospitalist, then wait for nurse to nurse, then transfer the patient. Basically, once the ED physician pulls the trigger on admission, the patient goes into the "transitional" period where they are the responsibility of the floor they have been admitted to, and on the internal medicine service while they make their way up there. Facilities have also created transfer RNs who basically relieve the ED staff of patient care duties once the admit order is placed, and the boarding time has been reduced by up to 25% in some cases.

Just some food for thought. For me, one of the most frustrating situations in healthcare (EM anyway) is when you can't move patients out, and you can't move patients in. You are in healthcare purgatory.
Remember that the ironly you point out is due to a poorly conceived federal mandate. Those are frequent sources of irony.

About the system you mention at Parkland, in my shops the holds have nothing to do with the internists. We write orders on every patient and they go to the floor as soon as there's a bed whether they've been seen by an inpatient doc or not. We are stuck because there's no bed. So that while that system may have fixed their problem it would not be universally applicable.
I think it might be helpful to investigate why patients are not moving. When I worked in pt transport at a hospital I realized the causes of delay were more variable that you might expect. For instance, is it: 1. truly no beds available because the floors are full, 2. no nursing staff available, 3. transport backup to bring pt to the floor, 4. housekeeping needs to clean the room, 5. mr. jones is sitting in a wheelchair in his room waiting for his family to arrive and take him

Many of the above problems (esp 3-5) have immediate solutions. Sometimes it helps to know what you're dealing with and make the appropriate calls.
Ultimately all the situations you mention are due to money. Space, enough nurses, enough housekeepers, enough transporters, etc. It's all about money.

For example, in my shops they staff nurses for the NEXT shift based on the census. If we get backed up at 9 am they start staffing for the night shift at 7 pm. So we're stuck until then. It's too expensive to have nurses on call so we wait.
 
isn't this essentially just triage??
yup. but as a pt if you called 911 for what you thought was a reasonable complaint( and let's assume for a moment that it is, say abd pain) you won't be pleased with a facility that takes you off the ambulance gurney and (holding your iv bag over your head) tells you to wait in line to check in to see a triage nurse. then you wait for 3 hrs in a lobby full of folks with dental pain and chronic low back pain. when you get to the back you eventually get your ct scan showing a ruptured appy.....and later you get your 2000 dollar ambulance bill which just ended up being a taxi ride and some iv fluids...
 
For example, in my shops they staff nurses for the NEXT shift based on the census. If we get backed up at 9 am they start staffing for the night shift at 7 pm. So we're stuck until then. It's too expensive to have nurses on call so we wait.
we take this to the next level. if it's slow for a few hrs they send nurses home as "low census" and start closing parts of the dept like fast track. of course the minute half your nurses leave you get 20 pts in the waiting room....frickin ridiculous. they need to staff for an avg day every day with a contingency to have surge capacity. they require us ( docs/PAs) to have a surge capacity plan but they don't have one for techs and nurses.
 
we take this to the next level. if it's slow for a few hrs they send nurses home as "low census" and start closing parts of the dept like fast track. of course the minute half your nurses leave you get 20 pts in the waiting room....frickin ridiculous. they need to staff for an avg day every day with a contingency to have surge capacity. they require us ( docs/PAs) to have a surge capacity plan but they don't have one for techs and nurses.

Excellent point. We do that too. I call it flipping off God. It invariably results in a huge influx as soon as the leaving nurse's tail lights disappear. I think if you're going to send nurses home you should send them all home.

You mention that the hospitals demand that their contractors (us) maintain surge capacity but they won't pay for it themselves in the form of nursing care. That is absolutely true. It also points out that we need to make sure that we don't punish the ER for nursing/financial policies made at the institutional level.
 
I think it might be helpful to investigate why patients are not moving. When I worked in pt transport at a hospital I realized the causes of delay were more variable that you might expect. For instance, is it: 1. truly no beds available because the floors are full, 2. no nursing staff available, 3. transport backup to bring pt to the floor, 4. housekeeping needs to clean the room, 5. mr. jones is sitting in a wheelchair in his room waiting for his family to arrive and take him

Many of the above problems (esp 3-5) have immediate solutions. Sometimes it helps to know what you're dealing with and make the appropriate calls.

add on:

6. Hospitalists not starting their day soon enough up on the floor to dispo their patients
Them rolling in at 0900 to eat breakfast first, will screw the ED, who is holding admits
 
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