Little Rock Plan Looks to End Patient Diversions from Crowded Hospitals


Carolyne Park | | Wednesday, April 16, 2008

LITTLE ROCK, Ark. -- Little Rock area hospitals no longer would be able to automatically divert ambulances from crowded emergency rooms under an ordinance before the city's Board of Directors tonight.

In a move approved by hospital administrators, Metropolitan Emergency Medical Services wants to eliminate diversions from hospitals in the four-county area it serves to ensure patients aren't turned away from their hospital of choice. The city board will vote on whether to repeal the code requiring the ambulance service to honor diversions.

"The main concern from the medical perspective is that we get the wrong patients to the wrong hospitals," said Dr. Marvin Leibovich, chairman of the department of emergency medicine at the University of Arkansas for Medical Sciences. "It's in the patient's best interest not to be diverted." Currently, hospitals can divert ambulances if their emergency departments are over capacity or don't have specialists available to treat certain injuries or conditions.

Diversions have become all too common because of crowded emergency rooms. At any given time, 12-18 hospitals in the Little Rock area are on diversion status.

Diversions cause problems when patients can't go to their regular hospitals, which have their medical histories, said Jon Swanson, executive director of the Little Rock-based ambulance service. Federal rules prohibit hospitals from selectively accepting some patients while diverting others.

In some instances, patients needing emergency attention refuse ambulance transport and risk driving themselves to the hospital, Swanson said. Eliminating diversions would remove that risk and allowMetropolitan Emergency Medical Service to better coordinate with area hospitals, he said. Hospitals still would inform the ambulance service when they are crowded, but that fact alone wouldn't prevent them from getting patients.

"We want to make certain that we are able to take patients to the most appropriate hospital to deal with especially the most critically ill and critically injured people, so that there's not a delay or a question about which hospital we can go to." Hospitals and ambulance services across the United States face the same problem, said Caroline Steinberg, vice president for trends analysis with the American Hospital Association.

"The issue of emergency department capacity and diversion is a huge issue nationally," she said. "Hospitals are facing rising demand for emergency care and falling capacity." Because of medical advances, patients spend less time in the hospital. Many services, as a result, are provided on an outpatient basis, causing hospitals nationwide to close their doors, Steinberg said.

Meanwhile, the remaining hospitals are left sharing the burden of an ever-growing demand for emergency-room care. The number of ER visits at hospitals nationwide increased 49 percent between 1991 and 2006, according to the American Hospital Association.

While he hasn't seen the problem in Little Rock, Swanson said he's heard of emergency rooms in other cities refusing to accept patients and leaving "the [ambulance] crew on the side of the road with nowhere to take the patient." If too many hospitals declare diversion status in the Little Rock metropolitan area, city policy allows Metropolitan Emergency Medical Service to use its "override protocol," which requires hospitals to accept patients.

"We're never without a facility to go to," he said.

Leibovich, a member of the service's medical oversight committee, said the change would force Little Rock-area hospitals to be more efficient and find ways to accommodate patients.

At UAMS, emergency department beds, both in rooms and in hallways, are filled on a daily basis, Leibovich said. Hospital officials are meeting regularly to discuss ways to move patients out of hospitals or into inpatient care more quickly.

"It is a community issue, and everyone's working hard to come up with a community solution," said Scott Gordon, chief operating officer of Arkansas Children's Hospital. Children's, which has about 42,000 emergency department visits annually, doesn't go on diversion status, he said.

When hospitals divert patients, paramedics are left having to navigate a complex system.

"These people are out there working hard - there's a bad accident, critical injuries, and next thing you know they're having to find a hospital, literally beg for a place that can take that patient," Leibovich said. "At any one point in time, Baptist may be on diversion, University may be on diversion, St. Vincent may be on diversion, and that patient may wind up going to a hospital where optimal care for critically injured patients is really not delivered."

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