Diversion…

[NYEMMED]

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Let’s talk about Diversion.
Does anybody find it helpful?

I feel anytime the ED is out of control (which is always lately) the requests for diversion go out and are quickly stamped down by some admin.

Several hospitals in the area made a “pact” that they will never go on diversion at their facilities.

How does that help, if one facility is actually overburdened?

 

[southerndoc]

Diversion is related to capacity, but you can be overly saturated and not capable of treating further patients without being on diversion.

Diversion is a courtesy notification to EMS that you are overly saturated. It does not mean they cannot bring you patients. If they choose to bring you patients, then you must accept them per EMTALA. Some EMS agencies have protocols in place to avoid facilities on diversion. Most, however, do not.

A facility does NOT need to be on diversion to not have the capacity to accept a transfer. Again, diversion does not have any relationship to a transfer process other than communicating to everyone that you're over capacity.

Some states (MA) have state laws that prevent facilities from going on diversion. Some states (GA) post NEDOCS scores status to a website to allow EMS to gauge how bad an ER is.

Hospitals going on "diversion" status really doesn't mean anything and I wish every hospital in America would stop.

 

[GonnaBeADoc2222]

Trauma and Stroke are huge money makers. Even if there's no acute CVA needing tpa / thrombectomy, the ability to roll a few more stroke alerts in for "95 yo seems more confused than usual" is not something the leeches upstairs will be willing to pass up in order to make things safer for the patients / nurses / physicians in the department.

 

[Rekt]

Diversion is related to capacity, but you can be overly saturated and not capable of treating further patients without being on diversion.

Diversion is a courtesy notification to EMS that you are overly saturated. It does not mean they cannot bring you patients. If they choose to bring you patients, then you must accept them per EMTALA. Some EMS agencies have protocols in place to avoid facilities on diversion. Most, however, do not.

A facility does NOT need to be on diversion to not have the capacity to accept a transfer. Again, diversion does not have any relationship to a transfer process other than communicating to everyone that you're over capacity.

Some states (MA) have state laws that prevent facilities from going on diversion. Some states (GA) post NEDOCS scores status to a website to allow EMS to gauge how bad an ER is.

Hospitals going on "diversion" status really doesn't mean anything and I wish every hospital in America would stop.

View attachment 359173

Yep. Diversion is pointless. Was always funny to hear the charge nurse let EMS on the radio know that we're on diversion and EMS essentially say neat, we'll see you in five!

As for the capacity argument, I've been on both sides. Very much sucks being at a critical access hospital with a patient that needs to be transferred asap with true need for higher level of care but is being refused due to capacity and we're stuck holding the bag. We need a better system. They'd probably still have better outcomes laying on the floor with a monitor in your tertiary center than my Ed.

 

[southerndoc]

Yep. Diversion is pointless. Was always funny to hear the charge nurse let EMS on the radio know that we're on diversion and EMS essentially say neat, we'll see you in five!

As for the capacity argument, I've been on both sides. Very much sucks being at a critical access hospital with a patient that needs to be transferred asap with true need for higher level of care but is being refused due to capacity and we're stuck holding the bag. We need a better system. They'd probably still have better outcomes laying on the floor with a monitor in your tertiary center than my Ed.

Sure, perhaps we could work out a swap system or the sending facility could send a nurse to take care of the patient since the receiving facility's nurses are overstretched to unsafe conditions as it is.

You send your aortic dissection, I send you a social admit plus a stroke outside the window for treatment who now must sit in the hospital for weeks waiting on SAR placement.

 

[RustedFox]

Sure, perhaps we could work out a swap system or the sending facility could send a nurse to take care of the patient since the receiving facility's nurses are overstretched to unsafe conditions as it is.

You send your aortic dissection, I send you a social admit plus a stroke outside the window for treatment who now must sit in the hospital for weeks waiting on SAR placement.

Sweet! It's like trading baseball players.
I'm in; I'm good at this game.

 

[southerndoc]

Sweet! It's like trading baseball players.
I'm in; I'm good at this game.

In all seriousness, it does get frustrating when we have a ton of patients just waiting for SAR placement taking up inpatient beds, which clogs up the ER with people waiting on beds, which keeps us from accepting transfers that need to come to us. Not every head bleed needs to be transferred (brush up on BIG criteria), an elderly lady with 3 rib fractures needing pain control does not need a trauma center, etc. When people flood a tertiary referral center with that non-sense then no, we won't have room to take your stroke with 12 hours of symptoms who needs a thrombectomy, your subdural with impending herniation needing a crani, or your young person needing ECMO.

It drives me crazy to accept a trace subarachnoid hemorrhage from a trauma only to repeat their CT and discharge them from the ER without a neurosurgeon ever seeing them. This should be done by the transferring facility without ever involving me or my neurosurgeon, but you can't get some of them to man up. This literally happened the other day, and unfortunately, while the patient was sitting in the ER we became quite saturated and I had to turn down 2 transfers for things that needed to come here.

 

[NYEMMED]

Yep. Diversion is pointless. Was always funny to hear the charge nurse let EMS on the radio know that we're on diversion and EMS essentially say neat, we'll see you in five!

As for the capacity argument, I've been on both sides. Very much sucks being at a critical access hospital with a patient that needs to be transferred asap with true need for higher level of care but is being refused due to capacity and we're stuck holding the bag. We need a better system. They'd probably still have better outcomes laying on the floor with a monitor in your tertiary center than my Ed.

Technically the charge nurse “discouraging a EMS patient” is a EMTALA violation. Even worse if it’s on a recorded radio transmission

 

[southerndoc]

Technically the charge nurse “discouraging a EMS patient” is a EMTALA violation. Even worse if it’s on a recorded radio transmission

Not an EMTALA violation unless the ambulance goes elsewhere.

 

[thegenius]

What we really should do is summarily discharge all people who don't have a medical emergency, immediately.

And the hospitals need to back us up on that.

Your UTI, cough, desire for STD testing, mild cellulitis, migraine HA, chronic ortho pain, LBP, slightly worsening COPD and CHF, and about 84 other complaints should be shown the door after their 1-2 minute MSE that doesn't require any labs or imaging.

 

[The Knife & Gun Club]

Diversion is related to capacity, but you can be overly saturated and not capable of treating further patients without being on diversion.

Diversion is a courtesy notification to EMS that you are overly saturated. It does not mean they cannot bring you patients. If they choose to bring you patients, then you must accept them per EMTALA. Some EMS agencies have protocols in place to avoid facilities on diversion. Most, however, do not.

A facility does NOT need to be on diversion to not have the capacity to accept a transfer. Again, diversion does not have any relationship to a transfer process other than communicating to everyone that you're over capacity.

Some states (MA) have state laws that prevent facilities from going on diversion. Some states (GA) post NEDOCS scores status to a website to allow EMS to gauge how bad an ER is.

Hospitals going on "diversion" status really doesn't mean anything and I wish every hospital in America would stop.

View attachment 359173

I see Atlanta hasn’t changed since I moved away 7 years ago 😂

 

[WilcoWorld]

What we really should do is summarily discharge all people who don't have a medical emergency, immediately.

And the hospitals need to back us up on that.

Your UTI, cough, desire for STD testing, mild cellulitis, migraine HA, chronic ortho pain, LBP, slightly worsening COPD and CHF, and about 84 other complaints should be shown the door after their 1-2 minute MSE that doesn't require any labs or imaging.

Whoah whoah whoah...are you suggesting that the Emergency Department should focus on emergencies?!

Somebody loan me some pearls so that I can clutch them.

 

[NITRAS]

In all seriousness, it does get frustrating when we have a ton of patients just waiting for placement taking up inpatient SAR beds, which clogs up the ER with people waiting on beds, which keeps us from accepting transfers that need to come to us. Not every head bleed needs to be transferred (brush up on BIG criteria), an elderly lady with 3 rib fractures needing pain control does not need a trauma center, etc. When people flood a tertiary referral center with that non-sense then no, we won't have room to take your stroke with 12 hours of symptoms who needs a thrombectomy, your subdural with impending herniation needing a crani, or your young person needing ECMO.

It drives me crazy to accept a trace subarachnoid hemorrhage from a trauma only to repeat their CT and discharge them from the ER without a neurosurgeon ever seeing them. This should be done by the transferring facility without ever involving me or my neurosurgeon, but you can't get some of them to man up. This literally happened the other day, and unfortunately, while the patient was sitting in the ER we became quite saturated and I had to turn down 2 transfers for things that needed to come here.

You know how many calls I get to transfer that are completely stupid? This crazy lady who had a completely negative stroke workup last week is presenting the exactly the same way and needs a continuous EEG. . . . Um you have have neurology, you have an MRI machine, you have an EEG machine and you don’t have capacity to take this patient?

Or the lady who got a biliary stent who had AST/ALT’s in the 20,000 range now down to 1000’s with some belly pain. The following day, her numbers were still better and seh was feeling better. . . But we still need to transfer her because our GI doc who does ERCP’s doesn’t feel comfortable with it.

Gosh darn it I really hate it when we have new people in the admissions taking calls. I get some really stupid or inappropriate calls.

 

[RustedFox]

In all seriousness, it does get frustrating when we have a ton of patients just waiting for placement taking up inpatient SAR beds, which clogs up the ER with people waiting on beds, which keeps us from accepting transfers that need to come to us. Not every head bleed needs to be transferred (brush up on BIG criteria), an elderly lady with 3 rib fractures needing pain control does not need a trauma center, etc. When people flood a tertiary referral center with that non-sense then no, we won't have room to take your stroke with 12 hours of symptoms who needs a thrombectomy, your subdural with impending herniation needing a crani, or your young person needing ECMO.

It drives me crazy to accept a trace subarachnoid hemorrhage from a trauma only to repeat their CT and discharge them from the ER without a neurosurgeon ever seeing them. This should be done by the transferring facility without ever involving me or my neurosurgeon, but you can't get some of them to man up. This literally happened the other day, and unfortunately, while the patient was sitting in the ER we became quite saturated and I had to turn down 2 transfers for things that needed to come here.

I hear you, bro.
From the community doc's perspective: the problem (99% of the time) is that we can't get IM to take the patient.

Ground level fall with (whatever fractured) and the old lady owns a pair of roller skates from her days as a drive-in waitress at a 50s sock-hop? IM will refuse, INSISTING that it's "trauma".

 

[NITRAS]

I hear you, bro.
From the community doc's perspective: the problem (99% of the time) is that we can't get IM to take the patient.

Ground level fall with (whatever fractured) and the old lady owns a pair of roller skates from her days as a drive-in waitress? IM will refuse, INSISTING that it's "trauma".

That’s a problem with your surgery/IM/EM leadership. They should make clear guidelines. Shoot, they activate so many “traumas” where I work, but our trauma service doesn’t admit most of them. It isn’t a big deal.

 

[southerndoc]

It's an EMTALA violation to unnecessarily transfer a patient. If the hospitalist refuses to admit a patient with rib fractures for pain control (with no surgical issue), it's an EMTALA violation for the patient to be transferred (unless the patient requested it). Likewise, a GI patient who needs an ERCP who has a GI doc that does ERCP's at the sending facility, it's an EMTALA violation for that doc not to do it. If patient has surgery at hospital A, presents to hospital B with a complication, it's an EMTALA violation for hospital B to send to hospital A just because hospital B's surgeon doesn't want to deal with somebody else's complication.

There are a ton of EMTALA violations that occur by the sending facilities. Most receiving facilities don't report them because they just don't feel like messing with it. However, now that patients can report issues to CMS directly, it's very likely we will see the unnecessary transfers reported more when the receiving doc slips up and tells the patient "not sure why they transferred you 100 miles away because they could have handled this."

 

[RustedFox]

That’s a problem with your surgery/IM/EM leadership. They should make clear guidelines. Shoot, they activate so many “traumas” where I work, but our trauma service doesn’t admit most of them. It isn’t a big deal.

Yeah; not so much at my new gig that has more robust services, but at the last place that I quit it was a huge battle.

I remember saying to IM once: "No, his grandson doesn't own a skateboard, so it's not a trauma and it can stay here."

At NewJob, we have N.surg and CT surg, and IM still tries to punt occasionally.

 

[thegenius]

Whoah whoah whoah...are you suggesting that the Emergency Department should focus on emergencies?!

Somebody loan me some pearls so that I can clutch them.

LMAO

problem is ERs will be stuck with psych and weak old men and women that we can't just discharge.

What I really want to do is have a single sheet of paper of all the free clinics and urgent cares in our community, COLOR PRINTED, both sides of the paper...and just give it to people when the doctor in triage does their MSE.

"We only permit access to doctors here to those people who have critical illnesses that can result in death or permanent severe bodily damage"
"Here is a sheet of all the urgent cares and free clinics in the community you can go do almost anytime you want."
"KThxBye"

 

[thegenius]

It's an EMTALA violation to unnecessarily transfer a patient. If the hospitalist refuses to admit a patient with rib fractures for pain control (with no surgical issue), it's an EMTALA violation for the patient to be transferred (unless the patient requested it). Likewise, a GI patient who needs an ERCP who has a GI doc that does ERCP's at the sending facility, it's an EMTALA violation for that doc not to do it. If patient has surgery at hospital A, presents to hospital B with a complication, it's an EMTALA violation for hospital B to send to hospital A just because hospital B's surgeon doesn't want to deal with somebody else's complication.

There are a ton of EMTALA violations that occur by the sending facilities. Most receiving facilities don't report them because they just don't feel like messing with it. However, now that patients can report issues to CMS directly, it's very likely we will see the unnecessary transfers reported more when the receiving doc slips up and tells the patient "not sure why they transferred you 100 miles away because they could have handled this."

You make it seem so black and white yet I suspect it's rarely like that.

I'm trying to think of an example but it's eluding me right now. It would have to do with a specialty not trained to deal with other specialty's realm of interest. Broken ribs could be construed as that as internal medicine never spends 1 minute of training in internal medicine dealing with broken ribs. Even though it's just pain control (98% of the time)

 

[miacomet]

Let’s talk about Diversion.
Does anybody find it helpful?

I feel anytime the ED is out of control (which is always lately) the requests for diversion go out and are quickly stamped down by some admin.

Several hospitals in the area made a “pact” that they will never go on diversion at their facilities.

How does that help, if one facility is actually overburdened?

I've worked in multiple states and ERs, rarely see this anywhere else.

 

[Groove]

What we really should do is summarily discharge all people who don't have a medical emergency, immediately.

And the hospitals need to back us up on that.

Your UTI, cough, desire for STD testing, mild cellulitis, migraine HA, chronic ortho pain, LBP, slightly worsening COPD and CHF, and about 84 other complaints should be shown the door after their 1-2 minute MSE that doesn't require any labs or imaging.

The funny thing is that hospital admin wants to have their cake and eat it too. We are constantly barraged with pressure to reduce LOS and improve our metrics yet they also send out an average charge per encounter insinuating that they want us to work on maximizing our charging/documentation per pt so we can bill more for each encounter. I was like..."You guys can't have both. You can either have really low LOS with reduced charges or you can bill more per encounter at the cost of LOS." I mean, WTF? How is that a difficult concept to grasp? It's not the pts that give me ulcers...it's the suits.

 

[thegenius]

The funny thing is that hospital admin wants to have their cake and eat it too. We are constantly barraged with pressure to reduce LOS and improve our metrics yet they also send out an average charge per encounter insinuating that they want us to work on maximizing our charging/documentation per pt so we can bill more for each encounter. I was like..."You guys can't have both. You can either have really low LOS with reduced charges or you can bill more per encounter at the cost of LOS." I mean, WTF? How is that a difficult concept to grasp? It's not the pts that give me ulcers...it's the suits.

I know it's f'ing terrible. they love these easy visits. Cough and tooth itching and about 40% of all patient encounters because it's easy, low risk money. They don't give a shiiit about anything else.

 

[RustedFox]

The funny thing is that hospital admin wants to have their cake and eat it too. We are constantly barraged with pressure to reduce LOS and improve our metrics yet they also send out an average charge per encounter insinuating that they want us to work on maximizing our charging/documentation per pt so we can bill more for each encounter. I was like..."You guys can't have both. You can either have really low LOS with reduced charges or you can bill more per encounter at the cost of LOS." I mean, WTF? How is that a difficult concept to grasp? It's not the pts that give me ulcers...it's the suits.

Yet, God Forbid they should do anything themselves to try to achieve this goal. Oh, no. Stepping out of their offices and interacting with patients is so pedestrian.

 

[southerndoc]

You make it seem so black and white yet I suspect it's rarely like that.

I'm trying to think of an example but it's eluding me right now. It would have to do with a specialty not trained to deal with other specialty's realm of interest. Broken ribs could be construed as that as internal medicine never spends 1 minute of training in internal medicine dealing with broken ribs. Even though it's just pain control (98% of the time)

IM doesn't know how to treat pain?

It's one thing for a pneumothorax or hemothorax, but a few broken ribs they can treat. They admit hip fractures at most places. That's a traumatic injury. They can admit a hip fracture for ortho but can't admit a little old lady with 2 rib fractures who has a sat of 89% because she's gotten morphine? CT doesn't show pulmonary contusion, pneumothorax, or hemothorax. C'mon, what's a trauma surgeon going to do with that for it to need a trauma center? The same thing that a hospitalist can do. In fact, when we do have capacity and take some of these type transfers, our hospitalists admit them and not our trauma surgery service. Trauma surgery sees them once and signs off.

 

[RustedFox]

IM doesn't know how to treat pain?

It's one thing for a pneumothorax or hemothorax, but a few broken ribs they can treat. They admit hip fractures at most places. That's a traumatic injury. They can admit a hip fracture for ortho but can't admit a little old lady with 2 rib fractures who has a sat of 89% because she's gotten morphine? CT doesn't show pulmonary contusion, pneumothorax, or hemothorax. C'mon, what's a trauma surgeon going to do with that for it to need a trauma center? The same thing that a hospitalist can do. In fact, when we do have capacity and take some of these type transfers, our hospitalists admit them and not our trauma surgery service. Trauma surgery sees them once and signs off.

- and in the academic world that you work in.... sure. I'm not being adversarial or snarky. I'm even agreeing with you contextually and practically. The excuse commonly given is/was: "well, what if a complication arises from [injury] and our services won't manage it here?" (Like; what if a [vascular] complication arises during orthopedic repair of [injury] and we don't have [vascular] on-call that day?)

Is it a lame excuse? You bet. I will also submit that NewJob is FAR better about this than OldJob; but I'm willing to bet that more community shops out there are more like OldJob than NewJob.

I'm on your side, bro. I even listed the examples of me openly mocking the IM mouthbreathers when they protest the admission.

 

[southerndoc]

- and in the academic world that you work in.... sure. I'm not being adversarial or snarky. I'm even agreeing with you contextually and practically. The excuse commonly given is/was: "well, what if a complication arises from [injury] and our services won't manage it here?" (Like; what if a [vascular] complication arises during orthopedic repair of [injury] and we don't have [vascular] on-call that day?)

Is it a lame excuse? You bet. I will also submit that NewJob is FAR better about this than OldJob; but I'm willing to bet that more community shops out there are more like OldJob than NewJob.

I'm on your side, bro. I even listed the examples of me openly mocking the IM mouthbreathers when they protest the admission.

You act like I've only ever worked in academics. We were not always an academic place, nor have I always worked where I am. My hospitalists at other facilities did not have issue with admitting these kind of things. We can all play the what if game. Why send home the biliary colic just because it might become cholecystitis?

 

[RustedFox]

You act like I've only ever worked in academics. We were not always an academic place, nor have I always worked where I am. My hospitalists at other facilities did not have issue with admitting these kind of things. We can all play the what if game. Why send home the biliary colic just because it might become cholecystitis?

Your hospitalists must not have sucked as much as mine have. I'm 10 years out of residency.
No joke: OldJob was a nightmare trying to get these cases admitted, and I suspect that my situation wasn't unique.

Honest question: How long have you been in the academic world?

 

[turkeyjerky]

You act like I've only ever worked in academics. We were not always an academic place, nor have I always worked where I am. My hospitalists at other facilities did not have issue with admitting these kind of things. We can all play the what if game. Why send home the biliary colic just because it might become cholecystitis?

I wonder if some of this stuff is more common w/ younger IM attendings. One of our night hospitalists is really bad about this sort of stuff. I called him about an admission the other night (can't remember what) and he tried to push back. I told him, "dude, everyone else would admit this no problem. There's literally no reason to transfer. You just need to this-and-that." He relented but asked me to hold off on the bed request until an hour until shift change, so that he wouldn't have to manage the patient at all.

In defense of diversion--I think it's occasionally necessary. If a place is so chaotic and overwhelmed, is it really unreasonable to request an ambulance bring a patient to a hospital 5 min farther away? What if critical equipment, eg CT, is down for a few hours? My old shop, due a mix of location and demographics, would occasionally get slammed w/ 8-10 runs in an hour at 2ish in the morning. We'd be single coverage at that time, typically w/ a backlogged WR. Now, that place was a dumpster fire for a whole host of reasons, but I think arguing for bypass in a situation where staff is unable to even keep track of patients, much offer them care, is reasonable.

I have to say, though, that going on bypass for the typical reasons, ie not enough tele beds, is generally BS.

 

[southerndoc]

Honest question: How long have you been in the academic world?

Currently in my fifth year (we just graduated our second class).

 

[RustedFox]

Currently in my fifth year (we just graduated our second class).

I think turkeyjerky is on to something with "young IM attendings are skerred". OldJob was full of young attendings and their nonsense.

 

[thegenius]

IM doesn't know how to treat pain?

It's one thing for a pneumothorax or hemothorax, but a few broken ribs they can treat. They admit hip fractures at most places. That's a traumatic injury. They can admit a hip fracture for ortho but can't admit a little old lady with 2 rib fractures who has a sat of 89% because she's gotten morphine? CT doesn't show pulmonary contusion, pneumothorax, or hemothorax. C'mon, what's a trauma surgeon going to do with that for it to need a trauma center? The same thing that a hospitalist can do. In fact, when we do have capacity and take some of these type transfers, our hospitalists admit them and not our trauma surgery service. Trauma surgery sees them once and signs off.

You don't need to convince me. A lot of hip fractures go to medicine because they have more medical problems than the problem at large (the hip). Where I work most hip fractures go to medicine but I have admitted hip fractures to Ortho when it's a young 37 yo guy with some weird traumatic hip fx. Medicine refused and rightly so.

 

[bravotwozero]

I think diversion is of some help. Here in houston, my shop is about 7 miles away from the texas medical center. We are always the last to go on divert. So, when everyone else goes on divert, which is always together for some reason, guess who gets hit with all the freakin ambulances at the same time?

Eventually, we go on divert too if this keeps up for an hour or two, at which point i feel like I can breathe again. When that happens, EMS will still bring us patients, but it's more round robin, where they'll give each hospital a turn, instead of slamming one place for dear life because 'everyone else is on divert'.

 

[Rekt]

I wonder if some of this stuff is more common w/ younger IM attendings. One of our night hospitalists is really bad about this sort of stuff. I called him about an admission the other night (can't remember what) and he tried to push back. I told him, "dude, everyone else would admit this no problem. There's literally no reason to transfer. You just need to this-and-that." He relented but asked me to hold off on the bed request until an hour until shift change, so that he wouldn't have to manage the patient at all.

In defense of diversion--I think it's occasionally necessary. If a place is so chaotic and overwhelmed, is it really unreasonable to request an ambulance bring a patient to a hospital 5 min farther away? What if critical equipment, eg CT, is down for a few hours? My old shop, due a mix of location and demographics, would occasionally get slammed w/ 8-10 runs in an hour at 2ish in the morning. We'd be single coverage at that time, typically w/ a backlogged WR. Now, that place was a dumpster fire for a whole host of reasons, but I think arguing for bypass in a situation where staff is unable to even keep track of patients, much offer them care, is reasonable.

I have to say, though, that going on bypass for the typical reasons, ie not enough tele beds, is generally BS.

I think turkeyjerky is on to something with "young IM attendings are skerred". OldJob was full of young attendings and their nonsense.

Interesting. Since starting my new job these past two months, I was theorizing this to myself as well. The new attendings give the most pushback and want the most consults before accepting and try to push a patient into to ICU instead of admitting. Worse at night.

 

[RustedFox]

Interesting. Since starting my new job these past two months, I was theorizing this to myself as well. The new attendings give the most pushback and want the most consults before accepting and try to push a patient into to ICU instead of admitting. Worse at night.

This actually happened at OldJob: Young IM attending was refusing HIV+ altered mental status admit until LP was done because she was "afraid of cryptococcus meningitis" and wouldn't accept because "the workup wasn't done". Infectious disease actually happened to be in the department at the time and said: "You don't need an LP to know that this isn't crypto." He said some other things that I can't type here before laughing.

It was like that, a lot.

 

[RustedFox]

I think diversion is of some help. Here in houston, my shop is about 7 miles away from the texas medical center. We are always the last to go on divert. So, when everyone else goes on divert, which is always together for some reason, guess who gets hit with all the freakin ambulances at the same time?

Eventually, we go on divert too if this keeps up for an hour or two, at which point i feel like I can breathe again. When that happens, EMS will still bring us patients, but it's more round robin, where they'll give each hospital a turn, instead of slamming one place for dear life because 'everyone else is on divert'.

Diversion is always of some help to me for this exact same reason. You know what the real problem is? Lack of inpatient beds. I'm looking at you, admins...

 

[thegenius]

Diversion is always of some help to me for this exact same reason. You know what the real problem is? Lack of inpatient beds. I'm looking at you, admins...

They are all taken up by admissions from the ER!
Real problem is people who can't take care of themselves and they are sick enough that they need to be admitted for 1-2 days, just so they can repeat the continued self-negligence.

Cats have nine lives. people should too. On the tenth you should go POOF

 

[RustedFox]

They are all taken up by admission from the ER!
Real problem is people who can't take care of themselves and they are sick enough that they need to be admitted for 1-2 days, just so they can repeat the continued self-negligence.

Cats have nine lives. people should too. On the tenth you should go POOF

I know, right?

Grandma's 900th COPD exacerbation. Grandpa's 4000th CHF exacerbation.

They listen to absolutely nothing that they are told and just go out and eat cigarettes and lick salt shakers.

I tested this theory once. I said this to patient:

Me: "So, pay attention - because this is important. What causes diverticulitis?
Patient: "I don't know."
Me: "Diverticulitis happens when a diverticula; a pocket of colon, becomes infected."
Patient: "Okay."
Me: "So we're going to use these medications to treat it. Wait... what causes diverticulitis?"
Patient: "I don't know."

They really have no idea what it is that they're even saying most of the time. Completely hapless and hopeless creatures.

...

Who reminds them to breathe?

 

[xaelia]

I know, right?

Grandma's 900th COPD exacerbation. Grandpa's 4000th CHF exacerbation.

They listen to absolutely nothing that they are told and just go out and eat cigarettes and lick salt shakers.

The most interesting thing I've encountered over here – and the most disorienting for new Fellows who come over from the U.S. for a bit – is how liberally they apply the concept of a "ward-based ceiling of care".

Such and such with 900 COPD exacerbations is put on a palliative pathway that does not include intubations or ICU, and the treating physician has fairly wide discretion to determine certain patients are poor candidates for critical care procedures.

 

[turkeyjerky]

Who reminds them to breathe?

Recently I've had a handful of patients who come in with transient nocturnal dyspnea, concerned about not being able to use their CPAP machines due to allergies/URIs/malfunction, etc. I get the feeling they think that they're just gonna die during sleep w/o it.

In the realm of unnecessary ER visits leading to ultimately unnecessary but logistically unavoidable admissions, I've had:
1) Guy w/ about a second of chest pain, but had a recent outpatient cath showing an LAD stenosis (itself done for dubious purposes, after an outpatient stress test which was done for "screening, b/c my brother had a heart attack")
2) Old lady brought in by daughter, straight from being moved from out of state, b/c 02 concentrator stopped working. No established outpt care in this area.
3)Old decrepit guy goes home after week-long admission for COPD. Refused rehab placement. As soon as he gets home realizes he can't take care of himself (which was ultimately the reason for admission in the first place) and comes right back.

In the realm of medically necessary but avoidable admissions, I've got:
1) Otherwise healthy lady w/ severe hyperglycemia after dexamethasone for covid. Never had hypoxia or other indication for steroid. Evidently always gets hyperglycemic w/ steroids. This time worse than most, glucose w/ 700 and had severe hypokalemia as well.
2) Old guy w/ cancer and CHF. Oncologist (who works in another system 100 miles away) takes him off lasix a week ago b/c he CXR was clear, without talking to his cardiologist. Now he's here in CHF.

edit--just wanted to clarify that these were all on one shift last night

 

[RustedFox]

The most interesting thing I've encountered over here – and the most disorienting for new Fellows who come over from the U.S. for a bit – is how liberally they apply the concept of a "ward-based ceiling of care".

Such and such with 900 COPD exacerbations is put on a palliative pathway that does not include intubations or ICU, and the treating physician has fairly wide discretion to determine certain patients are poor candidates for critical care procedures.

The Land of No Lawyers?

 

[emergentmd]

When I were MD at my site, this was just a game that hospitals played and pissed off the other hospitals. One would go divert, overburden others, then the others would play the same game. EMS got sick of this and told all sites if they go on divert, they would send someone over to confirm then shut down all elective procedures.

Guess what happened when they threatened this? No hospital went on EMS divert after this happened no matter if they were holding 100% ER inpatients.

 

[southerndoc]

When I were MD at my site, this was just a game that hospitals played and pissed off the other hospitals. One would go divert, overburden others, then the others would play the same game. EMS got sick of this and told all sites if they go on divert, they would send someone over to confirm then shut down all elective procedures.

Guess what happened when they threatened this? No hospital went on EMS divert after this happened no matter if they were holding 100% ER inpatients.

How can EMS shut down elective procedures?!?

 

[NYEMMED]

EMS got sick of this and told all sites if they go on divert, they would send someone over to confirm then shut down all elective procedures.

Guess what happened when they threatened this? No hospital went on EMS divert after this happened no matter if they were holding 100% ER inpatients.

I assume you meant state department of health? Not sure EMS can control elective surgeries

 

[NYEMMED]

In my state when you are on diversion the state department of health makes you cancel all elective surgeries while you are on diversion.

I think it’s a good policy, it made sure hospitals weren’t doing money making care while ignoring their EDs.

However a few went on diversion at 5pm, and came off at 5am everyday to avoid canceling surgeries

 

[emergentmd]

How can EMS shut down elective procedures?!?

I didn't go into the weeds but that is what admin passed down to the dept heads. I believe our ER nurse director tried to go on divert, and it was quickly squashed by admin. I have no idea where there authority came from, maybe the local health dept, but anyone going on divert had to cancel all elective procedures to ensure any open beds were to go first to ER holds and not elective procedure pts.

Makes complete logical sense to me. A hospital can not say they have no beds for EMS traffic, go on divert, but then have 20 elective surgeries that would need a bed. Also, the abuse were obvious when the charge nurse can call divert any time they wanted just because they had a prolonged waiting room.

 

[southerndoc]

I didn't go into the weeds but that is what admin passed down to the dept heads. I believe our ER nurse director tried to go on divert, and it was quickly squashed by admin. I have no idea where there authority came from, maybe the local health dept, but anyone going on divert had to cancel all elective procedures to ensure any open beds were to go first to ER holds and not elective procedure pts.

Makes complete logical sense to me. A hospital can not say they have no beds for EMS traffic, go on divert, but then have 20 elective surgeries that would need a bed. Also, the abuse were obvious when the charge nurse can call divert any time they wanted just because they had a prolonged waiting room.

I get it. It makes sense. Just not sure they have the authority to force hospitals to cancel surgeries. Are all elective surgeries canceled or only those that require admission after surgery? An elective gallbladder getting canceled isn't going to help anything.

 

[EctopicFetus]

In all seriousness, it does get frustrating when we have a ton of patients just waiting for SAR placement taking up inpatient beds, which clogs up the ER with people waiting on beds, which keeps us from accepting transfers that need to come to us. Not every head bleed needs to be transferred (brush up on BIG criteria), an elderly lady with 3 rib fractures needing pain control does not need a trauma center, etc. When people flood a tertiary referral center with that non-sense then no, we won't have room to take your stroke with 12 hours of symptoms who needs a thrombectomy, your subdural with impending herniation needing a crani, or your young person needing ECMO.

It drives me crazy to accept a trace subarachnoid hemorrhage from a trauma only to repeat their CT and discharge them from the ER without a neurosurgeon ever seeing them. This should be done by the transferring facility without ever involving me or my neurosurgeon, but you can't get some of them to man up. This literally happened the other day, and unfortunately, while the patient was sitting in the ER we became quite saturated and I had to turn down 2 transfers for things that needed to come here.

Med mal dude.. med mal. while you may be up to date on all the latest research and such those docs in smaller facilities dont know. The risk is real and lets also be real you can also "man up" and tell them how they should manage it and not accept them. Of course EMtala is a thing and most hospitals want the inpatient business. It goes both ways.

I say this as someone who works in both a well resourced hospital and others with little to no resources.

 

[southerndoc]

Med mal dude.. med mal. while you may be up to date on all the latest research and such those docs in smaller facilities dont know. The risk is real and lets also be real you can also "man up" and tell them how they should manage it and not accept them. Of course EMtala is a thing and most hospitals want the inpatient business. It goes both ways.

I say this as someone who works in both a well resourced hospital and others with little to no resources.

Unfortunately, I cannot tell them how they should manage and not accept them. EMTALA allows three options: accept, deny due to not having the needed services, or deny due to lack of capacity. If they call saying "I'd like to transfer" then I can't offer advice. I can only give one of those three answers. If they call asking for advice, then I can say that the patient doesn't need to be transferred.

 

[emergentmd]

I get it. It makes sense. Just not sure they have the authority to force hospitals to cancel surgeries. Are all elective surgeries canceled or only those that require admission after surgery? An elective gallbladder getting canceled isn't going to help anything.

All elective surgery gets cancelled. An EMS guy actually goes to the hospital and meets with admin, ensure elective cases cancelled before they put EMS on diversion.

Maybe they didn't have authority to cancel elective cases, but if the EMS commander showed up and they were doing elective cases, he likely would have walked out and radioed "Send this hospital all the EMS traffic b/c they are full of $hit".

elective gallbladder could very well turn into someone that needs a bed. Rare, but could happen. Thus all electives had to be cancelled until EMS diverts traffic.

As you can see, and EMS knew this, diversion was just a tool b/c hospital were understaffed, lazy, or just didn't want to work hard. Needless to say, we never went on divert when the cash cow was threatened.

 

[EctopicFetus]

Unfortunately, I cannot tell them how they should manage and not accept them. EMTALA allows three options: accept, deny due to not having the needed services, or deny due to lack of capacity. If they call saying "I'd like to transfer" then I can't offer advice. I can only give one of those three answers. If they call asking for advice, then I can say that the patient doesn't need to be transferred.

you can offer advice. They can choose not to transfer based on your discussion. now if they insist, sure. Or perhaps you can offer them an educational lecture afterwards to solve this problem for the future.