Massachusetts orders hospital ERs to halt diversions

[J-Rad]

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http://www.boston.com/news/local/articles/2008/09/13/state_orders_hospital_ers_to_halt_diversions/

I'm not an EM doc, so my reading of ED lit extends mostly to where EM intersects with my field (peds), but not to issues of (emergency) medical economics or logistics. But we all have the potential to be on the receiving end of emergency care and given this and my role as physician I find the above article interesting (but having nothing but minimal background in EM, I have no solid frame of reference with which to discuss this from a professional perspective). I am curious what the thoughts of the EM folks are on this (even if those thoughts are "this is a snore, we've been talking about this for ages in the EM community and everyone knew it was going to happen..." I know as well as anyone that the lay media often makes medical "news" out of non-news)

 

[GeneralVeers]

The system is broken from two ends. On one end the Hospital and ED usually lack sufficient nurses to meet the patient volume. On the other is an EMS system that allows patients with even minor complaints to overload the EMS system. Probably 50-60% of people who come in by ambulance have no "emergency".

Sure ending diversion will mean patients can go to the hospital they want, but if they get put out in triage for 6-8 hours, is it really going to improve patient care?

 

[Hallm_7]

In my very limited two months in EDs I came to the realization that this isn't a problem that can be solved in the ED. It's a problem upstairs. The only time our hospital goes on diversion is if there are no beds available in the hospital, which happens fairly often. It may be a different story at other hospitals, but that's the way it is at our hospital. On a "normal" day (late afternoon and evening) when our hospital isn't absolutely full, our ED has 25%-40% of its beds used by people who are just waiting to be moved upstairs.

Ultimately, there are too few beds in today's hospitals. During the 90s there was very little bed expansion despite an aging population. The managed care movement of the 90s really negated any increase in admissions due to the aging population. However, the population continues to age, and overtaken any decrease in admissions due to managed care practices. The result is total admissions have increased.

The ultimate solution, in my opinion, is that the number of beds must increase. In the short term getting patients out sooner in the day must happen, and soft admissions and unneeded nights in the hospital have to stop. I know we've all seen patients who have stayed extra nights because they couldn't get a ride home. These aren't hotels, and people can't just stay because it's more convenient for them.

 

[Station51]

So I was told that no ED in the city I work in goes on diversion for the reason that diversions just causes another ED to take on a massive load and exacerbates the problem in another ED. It seems that diversions just promote a vicious cycle.

 

[GeneralVeers]

The ultimate solution, in my opinion, is that the number of beds must increase. In the short term getting patients out sooner in the day must happen, and soft admissions and unneeded nights in the hospital have to stop. I know we've all seen patients who have stayed extra nights because they couldn't get a ride home. These aren't hotels, and people can't just stay because it's more convenient for them.

Most hospitals are not running at their "capacity" in terms of number of beds. The reason is a nursing shortage. Hospitals are unable to open entire wards because they don't have enough staff.

Example: My hospital in Corpus Christi had 500+ licensed beds and space for that many. On a good day they operated 250-300 depending on staffing levels.

 

[keeping-it-real]

Nothing out of the ordinary here... bureaucrats handing down rules that make no sense and most likely negatively impacting care. The ongoing healthcare debacle is like watching a giant circus charade except nobody is aware that it is a charade.

There is a massive shortage of healthcare personnel. So far their strategies for solving this problem have involved cutting physician pay, increasing the workload for each provider while simultaneous increasing punishment for errors, and mandating that every person that comes to the ER gets seen regardless of their complaint.

Doesn't take a genuis to figure out the endpoint of this story.

 

[jbar]

I also noticed that the article says some hospitals are going to start doing blood tests at 5am to get results back earlier. Might help flow, but if I was a patient I wouldn't be happy getting woken up at 5am to have a really tired person stick me with a needle. Bad enough coming in and asking people if they've passed gas at that hour. And I believe that making patients tired and cranky doesn't help healing.

 

[diphenyl]

With the reactive type society we live in, its only going to take one incident, such as a famous person dying because they couldn't receive emergency treatment in time because the county system was over run with ambulances and ED's handling sprained ankles, while a person w/ a STEMI dies. there has been talk for years about the need for advanced training for EMS to be able to refuse transport to people w/o life threatening emergencies. I love the guy who comes in for a broken finger that comes in an ambulance, but his family drives in right behind him. WTF?
Having EMS crews able to turn away non emergents is a double edged sword because there will be costly mistakes made on a few occasions. I had an old lady w/ decreased appetite over 1 day turn into a STEMI. So who knows, i guess someone much wiser than I could ever be.

 

[EMmedic]

there has been talk for years about the need for advanced training for EMS to be able to refuse transport to people w/o life threatening emergencies. I love the guy who comes in for a broken finger that comes in an ambulance, but his family drives in right behind him. WTF?
Having EMS crews able to turn away non emergents is a double edged sword because there will be costly mistakes made on a few occasions. I had an old lady w/ decreased appetite over 1 day turn into a STEMI. So who knows, i guess someone much wiser than I could ever be.

This is wishful thinking, at least for the state of Massachusetts. We aren't trusted to selectively backboard patients let alone decide who needs an ambulance. At my company we aren't even trusted to make the decision about who can walk to the ambulance and who cannot (we must carry everyone). We are scrutinized daily about who we do and do not triage down to BLS. Unfortunately, I don't ever foresee medics being allowed to refuse transport.

This article was written about my EMS area. I think getting rid of the diversion is a terrible idea. Its existence does not delay care - the sick patients go to the hospitals they need to be at regardless of diversion status. There are times when the hospitals are too overwhelmed - you can't just keep bringing them all the patients. In this area another hospital is always a stones throw away.

While Mass General has the highest rate of diversions, they are actually one of the best hospitals in the area in terms of executing it. If you have a sick patient and bring them to MGH anyway...they don't say a word...they don't criticize...they just treat the patient. Unfortunately this is not what happens everywhere in the greater Boston area. Some of the smaller hospitals actually had "scheduled diversion" on a rotating schedule. Certain hours during the day were assigned to different hospitals for diversion regardless how busy they were. So, you would bring a sick patient in and they would yell that they were on divert...but half the beds were empty. Things like this did not work. But, diversion is necessary at times - I don't see how some of these hospitals will be able to treat patients well without it.

 

[Hallm_7]

I also noticed that the article says some hospitals are going to start doing blood tests at 5am to get results back earlier. Might help flow, but if I was a patient I wouldn't be happy getting woken up at 5am to have a really tired person stick me with a needle. Bad enough coming in and asking people if they've passed gas at that hour. And I believe that making patients tired and cranky doesn't help healing.

My hospital starts around 4:30AM with blood draws. Of course that's just when they start, so most patients are still getting drawn around 5:00, but if you're in the SICU or on one of the surgery floors you're getting poked early. In the majority of the time all the labs are back in time for surgical rounds that start at 6:00AM.

If I were a patient I would beg for them to put in an IV or PICC just so they wouldn't have to wake me up that early to draw my blood.

 

[GeneralVeers]

If I were a patient I would beg for them to put in an IV or PICC just so they wouldn't have to wake me up that early to draw my blood.

I was always amazed on medicine rounds that they expected us to wake up patients at 5 AM to annoy them. If I was a patient I'd be pissed. Not only is it rude, but it probably doesn't do a bit for the healing process.

 

[spyderdoc]

I personally wouldn't mind this law here in CA. In my experience, the cycle usually starts when the county hospital goes on diversion, loading all the surrounding EDs with the not so desirable patients. We then get busy with all the psychos and drunks, then end up having to go on diversion to clear out the mess, and then the cycle comes back around....

If there were no diversions allowed, I sure would not miss getting slammed with the county patients while our good paying customers sit out in the waiting room waiting for us to clear out the psychos and drunks.....

 

[met19]

I personally wouldn't mind this law here in CA. In my experience, the cycle usually starts when the county hospital goes on diversion, loading all the surrounding EDs with the not so desirable patients. We then get busy with all the psychos and drunks, then end up having to go on diversion to clear out the mess, and then the cycle comes back around....

If there were no diversions allowed, I sure would not miss getting slammed with the county patients while our good paying customers sit out in the waiting room waiting for us to clear out the psychos and drunks.....

worried more about the dollar thank getting some undersirables?

county hosp cleans up the pt's your hospital doesnt want. the drunks, psychos, bad trauma, the uninsured (whether trauma or medical), med refills, etc.

county osp dont go on diversion due to drunks, med refills, etc. they go on diversion due to serious admissions (e.g. no more critical care beds after the labor day weekend shootout). sorry if you get a few bs cases when we get swamped with mult MIs, traumas and septic uninsured pts!

 

[GeneralVeers]

worried more about the dollar thank getting some undersirables?

county hosp cleans up the pt's your hospital doesnt want. the drunks, psychos, bad trauma, the uninsured (whether trauma or medical), med refills, etc.

county osp dont go on diversion due to drunks, med refills, etc. they go on diversion due to serious admissions (e.g. no more critical care beds after the labor day weekend shootout). sorry if you get a few bs cases when we get swamped with mult MIs, traumas and septic uninsured pts!

That is true. In LA County we used to go on diversion when the hospital was full, not the ED. Typically the drunks and crazies don't occupy inpatient hospital beds.

 

[spyderdoc]

worried more about the dollar thank getting some undersirables?

Why don't you refer back to your thought after you are out of residency and in private practice someday my friend....

Not that I don't appreciate what the county hospitals do, but you (well, not you yet, since you are a resident) choose your path, and if you choose to work in a county-type of facility, then you are pretty much knowing what your patient population will be.

Believe me, we get our fair share of self pay and medicaid (over 40% of our patient population), both walk-in, and brought in by EMS, so I think we are doing our part to stamp out disease in this population, thank you very much.

 

[emtcsmith]

Change EMTALA so that you don't evaluate everyone, which can lead to a EMS initated 'refusal for transport' and preventing unnecessary transports.