Administration and Leadership, Patient Care

Always Open: Study finds no adverse effects from stopping ambulance diversion

Issue 10 and Volume 34.

Ambulance diversion is a frustrating fact of life for most EMS providers, but that may not always be the case. In 2006, emergency physician Franklin Friedman, MD, of Tufts Medical Center, led a team of researchers that looked at what happened when a group of Boston teaching hospitals stopped diverting ambulances for two weeks.„

When the team compared efficiency during this period without diversion versus the two weeks prior, they discovered no significant differences. The same number of patients received care in the emergency departments (EDs), and EMS crews had to wait the same amount of time for ED staff to take over care of the patients. Even more interesting, admitted patients waited in the ED for a hospital bed about 18 minutes less.

What does this mean?
Franklin says the backup problem “isn_t ED overcrowding; it_s hospital overcrowding.” He also says that when hospitals discharge patients at noon, rather than later in the day, there_s less ED crowding.

Franklin is reluctant to attribute too much weight to the report, because “it was a very brief time and everyone knew it was coming.” Further, the sample isn_t large enough to draw many conclusions. But in January 2009, Massachusetts ended ambulance diversion throughout the state, noting the study_s findings. The state hasn_t released numbers yet, so it_s not clear how it has impacted EMS.„

Las Vegas EMS went through a period of increased diversion several years ago as the population boomed there, says Chad Henry, BS, NREMT-P, American Medical Response_s manager of operations in that city. Waiting times at Las Vegas hospitals were so long, sometimes a crew could only transport one patient per shift. More than once, they spent six to eight hours waiting for their patient to be admitted. At shift change, EMTs and paramedics went straight to the hospital to relieve a crew.

It was clear something had to be done. Several new hospitals opened in 2005, but that didn_t solve the problem. The Nevada legislature meets only every two years, so relief took time. In 2007, the legislature passed a bill stating that Nevada hospitals must ensure that patients in need of EMS are transferred to a “bed, chair, gurney or other appropriate place” within 30 minutes of arrival.

Henry says since they have fully automated their computer input of the required times, among other measures, they have achieved 98% compliance with the new law.

If hospitals know they can_t hand off patients, there are ways to improve protocols and streamline operations. With diversion now an archaic practice in two states, could others be far behind?
ƒAnn-Marie Lindstrom„

For more, read “On Diversion”

System Offers
100% Full Spectrum Biologic Kill
A new system could significantly change the way EMS conducts vehicle and equipment decontamination. On Friday, Aug. 7, AeroClave introduced a process that offers a safe and cost-effective way to decontaminate public safety, commercial and military vehicles and aircraft of all bacteria and viruses, including anthrax, MRSA, C. difficile, SARS, smallpox and avian influenza.„

Ronald D. Brown, MD, MBA, AeroClave_s founder and managing partner, introduced the Portable Asset Decontamination System (PADS), a totally enclosed structure that uses STERIS Corporation_s patented vaporized hydrogen peroxide (VHP) process to treat multiple vehicles and associated equipment in less than 90 minutes, for less than $100 per application, and realize a 6-log reduction of all pathogens.

AeroClave delivers biocidal VHP concentrations to all internal and external vehicle surfaces and equipment and extinguishes such difficult-to-kill spore-forming agents as anthrax with no residual odor or damage to vehicles or equipment. The„system offers a 100% full-spectrum kill, preventing the 0.1% that other systems miss from causing mutations and drug-resistant viruses.

The PADS unit not only decreases the spread of prehospital or hospital-acquired infections, but also the risk for claims by patients, EMS crews and other health-care workers because of suspected exposure to contaminated vehicles and equipment. It also allows for the rapid recovery of ambulances and other critical transportation assets after an exposure, or in the wake of a bioterrorist attack or global pandemic event.

Pro Bono
What_s My Overtime Rate?
Career EMS personnel sometimes receive different rates of pay for different types of jobs or for working different types of shifts. For example, an EMT may be paid one hourly rate for work as an EMT, and then get paid a different rate if they also work as a telecommunicator. Plus, some EMS agencies may pay a higher hourly rate for working night shifts or weekends.„

Employees who are covered by the Fair Labor Standards Act (FLSA) must ordinarily be paid one-and-a-half times their “regular rate” of pay for all overtime hours worked in a given workweek. (Overtime hours are typically any hours worked over 40 hours in that week, unless you_re employed by a fire department where special overtime rules, such as the “7k” exemption, may apply.)„

As a general rule, the regular rate of pay for calculating„overtimewhen an employee has two (or more) different hourly rates must be based upon a “weighted„average”

A weighted average is calculated by totaling an employee_s full pay (all compensation received) for the workweek and dividing it by the number of hours actually worked.„

For example, EMT Smith works a total of 50 hours during a workweek. Smith earns $10 per hour during day shifts and $12 per hour during night/weekend shifts. Let_s say she worked 35 hours of day shift and 15 hours of night/weekend shift during one workweek. The total wages for the workweek would be $530 (35 hours at $10 = $350 plus 15 hours at $12 = $180).„

To calculate Smith_s regular rate, the employer divides $530 by the number of hours worked during the weekƒ50. That results in a regular rate of $10.60 per hour. Smith is entitled to one-and-a-half times that regular rate, so her overtime rate for the 10 hours of overtime is $15.90 ($10.60 x 1.5).„

Keep in mind that, as with many labor rules, there may be exceptions to the general rule and calculating overtime can be a complicated process. But knowing the basic rules can help you understand how your employer calculates your overtime rate.„

Pro Bono is written by attorneysDoug WolfbergandSteve WirthofPage,Wolfberg & Wirth LLC,a national EMS-industry law firm. Visit the firm_s Web site atwww.pwwemslaw.comfor more EMS law information.„

Quick Take
N95 Alternatives
With H1N1 at pandemic status and expectations that the flu strain will become more virulent this fall, some regions face shortages of N95 masks as providers and civilians alike race to stock up. But there are other options if your medical supplier runs out. Try your local hardware store, megastore or industrial safety supplier. Also, don_t get hung up on that number: Although 95s are the standard recommendation, N99s, N99.97s (N100s), R95s and P95s actually provide more protection, because they block out varying degrees of particulates above 95%. Another option, especially when providers see multiple respiratory illness patients each shift (requiring them to repeatedly replace their mask), is the P95 T-5000 respirator manufactured by Union Springs Pharmaceuticals. Although more expensive than a single mask, the T-5000 is impregnated with an antimicrobial solution to allow repeated use of a single mask during a shift as opposed to replacing it after every patient contact.

Shawnee County (Kan.) commissioners voted in July to increase AMR rates to transport the severely obese (i.e., patients who weigh 350 lbs. or more). For these patients, a ride to the hospital will increase from $629 to $1,172, and the per-mile rate will go from $11.09 to $16. Larger patients certainly take more resources, but where do we draw the line? Does you agency charge more for bariatric patients or would it consider doing so? Tell us at and we_ll publish the results in an upcoming issue ofJEMS.

Names in the News
Gregg S. Margolis, PhD, NREMT-P, will be taking a one-year leave of absence from his position as the associate director of the National Registry of EMTs (NREMT) in order to complete a Robert Wood Johnson Health Policy Fellowship. Margolis is the first paramedic to be selected for this fellowship and sees this as an extraordinary opportunity for the entire EMS community. He says, “It_s exciting to think that EMS will be represented in the health-care reform conversations occurring in Washington, D.C., but more importantly, I hope to learn how the federal policy process works and how to ensure that EMS can participate effectively for many years to come.JEMS

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