On Diversion’

We all look for that ideal world where our emergency departments would be ready, willing, able and even happy to receive new arrivals from EMS 24 hours a day, seven days a week, with EMS turn-around times of five minutes or less. And we all know the real world we face: Emergency department (ED) overcrowding is increasing at the national level, EMS crews “park” at EDs for hours to unload patients, and local crises happen daily in the delivery of emergency care.

This is because of three problems, which are inter-related:

• EMS delays in turning over care to EDs,
• ED overcrowding, and
• Hospital requests for diversion of EMS transports to other hospitals.

The critical bottom line is the health and safety of our patients. We must put the best interests of the patient first, EMS second and hospitals third.

The topic of hospital diversion, also called bypass or closure, often draws a heated reaction from EMS. It evokes images of EMS bypassing multiple EDs with a critical patient to find one that is open. This is obviously an unacceptably high-risk practice and one that shouldn’t happen in a structured bypass plan. Most prehospital providers believe that a patient is always better off in an ED — any ED — than in the back of a rescue truck or ambulance, but most ED providers would disagree if an alternative is less than five minutes away.

EMS systems across the country handle this problem in widely different ways, ranging from totally ignoring hospital requests for diversion to accepting whatever hospitals ask for. What works in one system may not be practical for another. Refusing to allow any hospital bypass at all often results in significantly longer delays in turning over patients to an ED, called turnaround times or TATs. This in turn lengthens response times to the next 9-1-1 caller.

For Miami Fire Rescue, diversion times once increased to an unacceptably high level when EMS didn’t police the system, but a series of steps worked for us. We

• Re-defined the rules (see below),
• Met with senior hospital administrators individually,
• Met with area hospitals periodically as a group to provide data and discuss problems, _ Tracked and distributed diversion data to all hospitals, and _ Enforced the rules.

In fact, based on the push from EMS, several EDs got hospital support to streamline systems to stay open. Diversion times dropped from 15,000 “diversion hours” per year (all hospitals combined) to 900, which were easily dealt with by EMS. In addition, our relationship with local EDs grew stronger. During quarterly group meetings with hospitals today, we rarely need to discuss diversion, which allows us to focus on other issues, such as communicating new EMS protocols and MCI planning.

Let’s look at the problem and potential ways to handle diversion requests.

From the EMS Perspective
EMS operates under protocols designed to transport each patient to the nearest capable hospital, with goals of optimizing patient safety and minimizing TATs. The underlying concept is that the patient is best treated in an ED rather than in the back of the EMS vehicle. Patient preferences are accommodated when possible, but within limits on acceptable distance to the hospital of choice and specific hospital capabilities.

A variety of differences among EMS providers, their medical directors and local systems may affect EMS transport and diversion policies. They include,

• Autonomy:Most EMS medical directors and providers have the autonomy to set their own policies, but some function under a local or regional governing board while others are owned and operated by a specific hospital.
• State regulations:EMS policy and/or hospital diversions may be governed by state regulations.
• Field supervision:Most providers have a field supervisor who can visit or call the “problem hospital” as the problem is happening.
• Geography:Most importantly, local geography varies in terms of distances to and numbers of receiving hospitals. In an urban setting with multiple hospitals that are concentrically located around a central urban core, hospital diversion requests are easier to accommodate. In a larger metropolitan setting, suburban hospitals may be located far apart in a linear pattern, so diverting to the next closest hospital may require an additional 15 minutes or more. And in a rural setting, there may only be one choice.
• Computer system:The EMS provider’s computer system is also a critical component of successful diversion systems. If the dispatch center can easily track current hospital status, every EMS crew is aware of their best options before leaving the scene. EMS providers can relay accurate data to hospital administrators. If the provider can do real-time tracking of TATs at its local EDs, it can easily see when one hospital is overwhelmed. In some systems, such as Houston, EMS can be fully in control of hospital bypass — dispatchers and supervisors can see where the gridlocks are and put a specific ED on diversion if TATs are too long.

Attitude and relationships with hospitals also vary, and there are individual personalities to consider. Many EMS providers believe the ED must just tough it out no matter what, or that diversion requests are due to ED staff laziness. It’s very frustrating to transport a patient with lights and sirens only to find that patient still waiting to be seen in the gridlocked ED upon your return. Likewise, ED staff often believes EMS is “dumping” on them, or goes out “trolling” for less-than-desirable patients — and EMS sometimes threatens to do just that.

All too often, EMS and ED personnel end up as adversaries, especially when EMS personnel are greeted with hostile and unprofessional comments from receiving staff. Every EMS crew knows when a problem ED staff member is on duty. It could be “that nurse,” who won’t make eye contact to acknowledge a new arrival or “that doctor” whom EMS tries to avoid on behalf of their patients’ best interests. EMS crews often give up confronting or reporting such situations, since it’s much easier to just go elsewhere for the rest of the shift. This is a different type of diversion work-around.

From the Hospital and ED Perspectives
Hospital diversion is primarily a consequence of ED overcrowding, a real-time “capacity” crisis that’s likely to worsen as the American healthcare crisis worsens. ED gridlock is multifactorial, but overwhelmingly ED overcrowding is due to overall hospital overcrowding — whether because of high volume/high acuity of patients or cumbersome systems that fail to efficiently move admitted patients through care and discharge.

Most often, EDs are overcrowded because admitted patients are stuck there with no staffed upstairs beds to accept them. Our county hospital ED frequently has more than 50 admitted patients occupying ED space and nursing time. This results in the following:

• High risk to the safety and care of new ED arrivals;
• Long waiting times;
• ED staff burnout, and
• ED frustrations, which are inappropriately vented on EMS and newly arriving patients.

Inpatient beds, including ICU beds, are often closed to new patients when staffing is inadequate (a common ICU ratio is one nurse for every two ICU patients) but not ED space (where often one nurse may have four or more critical care patients to manage). Although ED administration and staff push their hospital for solutions, there are many roadblocks.

Most ED gridlock situations are beyond the control of the ED staff, and they see EMS diversion as the only safety net for their patients. For the most part, ED physicians and nurses are on the same “side” as EMS — working hard in the trenches despite obstacles to provide the best patient care. Obviously, EMS diversion shouldn’t be the only safety net for an ED, but in reality it may be. In fact, ED overcrowding and lack of hospital support has led many ED physicians and nurses to feel more allied with EMS than the rest of their hospital, and most ED staff take issue with the EMS mantra that a critical patient is safer in an overcrowded ED than in the back of the ambulance.

On the other hand, some hospitals want to go on diversion to EMS when the ED itself is empty but the ICUs upstairs are full or when certain equipment, such as a CT scan, is down. Although it makes sense to avoid bringing an obvious acute stroke patient needing tPA to an ED with no CT scan, the ED often also balks at accepting even a BLS patient, such as one with a bump on the head and no reported loss of consciousness.

Before we policed our diversion system, some hospital diversions were called in while the laboratory technician or doctor took a dinner break, and other EDs remained on diversion long after their crunch time was over “to give the staff a breather.” These situations are obviously unacceptable, and ED directors and chief executive officers generally fix them rather quickly when EMS brings up the issue accompanied with documentation.

Hospitals also make requests that don’t translate to the EMS realm. An example is to request diversion because they don’t have an orthopedic surgeon after a certain time. Since those EDs definitely have an emergency physician on duty who is expected to be capable of handling the initial care of orthopedic emergencies, such statements are irrelevant to EMS decisions and shouldn’t be accepted. EMS personnel aren’t geared to figure out which patient with a limb injury can be treated by an emergency medical (EM) physician or needs a specialist immediately. Although lack of an orthopedist might imply diverting patients with open femur fractures or mangled hands, the hospital often means they want all ankle sprains and minor hand lacerations diverted. The latter are all cases that fall within the capability of any EM physician in any ED.

In any case, it’s the hospital’s legal responsibility to set up systems to deal with these types of issues. They shouldn’t shift the burden to EMS.

Especially in these economic times, the hospital business world is a cut-throat one governed by financial and regulatory bureaucracies. Hospital financial status is the bottom line, and EDs are often “loss leaders” for the hospital. This means the ED is kept open because it’s vital to the hospital’s overall service and attractiveness to its paying patients as well as a good community standing. But it also opens the door to the uninsured, which may cost the hospital a great deal of non-recoverable money.

On the other hand, most CEOs view ED diversion times as unprofitable (although a recent study showed just the opposite) and want to keep their ED open, sometimes even refusing to allow their ED the safety valve of diversion. A hospital policy that requires high-level approval prior to requesting diversion usually limits requests.

Again, EMS created none of the above issues, but crews and patients and caught in the middle.

From the Patient’s Perspective
Most patients have very little understanding of EMS systems and policies. They rarely understand the consequences of their demands to go to a particular hospital. These consequences include:

• Longer transport times with risk of deteriorating en route,
• Poor choices, such as demanding a non-STEMI center in the middle of an acute massive myocardial infarction (MI), and
• Safety risk and physical discomfort in gridlocked EDs.

There’s a major advantage for patients with complex conditions to return to the hospital with all of their medical records. In the middle of a medical crisis, most patients and their families are unlikely to understand what it means to them if their choice hospital is “on diversion.” Few realize they can be stabilized at the nearest hospital and then transferred to their choice hospital later, or that their doctor or insurance plan usually covers multiple hospitals.

Legal Issues
The federal Emergency Medical Treatment and Active Labor Act (EMTALA) statute and policies are strict and carry significant penalties for hospitals and physicians, as do state laws. EMS personnel aren’t under EMTALA requirements, just hospitals with an ED. Once a patient arrives on hospital grounds, the ED must take over care of that patient, providing a medical screening examination and treating emergency conditions within a reasonable period of time.

EMTALA doesn’t spell out what a “reasonable” period of time is for transfer of care, although 30 minutes is frequently stated for stable patients. Thus, if EMS mistakenly brings a patient to an ED on diversion, or overrides a hospital’s request for diversion, the ED is still fully responsible for that patient, and EMS should report apparent EMTALA violations. However, recognize that when a hospital has exceeded its capacity, the law makes allowances for longer times to evaluate a new arrival, so that a reported violation may not be upheld if the ED has good documentation of its overload at the time.

Regardless, the investigative process is so onerous to any hospital that EMTALA provides a very strong measure of support for EMS. Also, as in Florida, once many state regulatory authorities for EMTALA have received a violation, they’re not limited to investigate that complaint alone and are free to search for other types of violations as well.

Guidelines for Successful Diversion Policies
A successful diversion plan puts patient safety first but considers the local emergency system as a whole. Systems with successful plans generally have simple ground rules with EMS in charge. EMS must be the controlling and policing agency in a local or regional diversion plan, with rules developed by the EMS medical director and provider.

Diversion policies may be written and formalized (de jure). Or they may be unwritten and more covert (de facto), such as if an EMS crew waited too long at one overcrowded ED, then EMS spreads the word to avoid that hospital for a few hours. Although the latter is much simpler, it carries a greater liability risk to EMS and medics for making their own independent and subjective determinations of ED status. In general, it’s more appropriate to track and document diversion status via a formalized approach.

EMS may let each hospital designate its status or be the agency that determines when to put a hospital on bypass, either by tracking EMS TATs or inspecting an ED when a crew or ED reports delays. Hospital requests for diversion should be just that — requests rather than orders. They must be based on actual ED status, meaning the ED itself must be overwhelmed and not simply that all ICU beds are full while the ED is empty.

Consider the following scenario: Hospital A is gridlocked and requests EMS diversion, then EMS should go to Hospital B. But if that second hospital is also asking for diversion, EMS must use transport times to determine whether there’s a third close enough and, if not, whether to override Hospital A’s request. If all hospitals are closed at the same time, then all are considered open to EMS — pick one and rotate the next runs around. No diversion requests are practical in a true MCI, and hopefully EMS and hospitals have done local planning for reasonable patient distribution plans.

EMS can and should override diversion status for necessary situations:

• Patient where EMS can’t intubate or ventilate
• Patient discharged within seven days from a specific hospital and now has a related condition
• Specially designated hospitals (STEMI, stroke or trauma centers are usually expected to accept patients 24 hours a day, seven days a week for 365 days a year, year round)
• Hospitals with a special capability (e.g., handles complex transplants or amputation reimplantation)
• Patient demands transport to hospital that’s on diversion, despite EMS explanation
• Mass casualty incidents. Next closest hospital is also on diversion, or transport time exceeds a set threshold
• Paramedic judgment that next closest open hospital is too far for a critical patient

Keep diversion plans simple. Consider each hospital as either open or closed to all ALS and/or all BLS. Avoid a detailed set of criteria that EMS crews won’t remember. Determine which categories to divert: Since BLS patients can often safely wait a long time for definitive ED care, a local EMS system with several nearby hospitals may decide to divert only the ALS patients who need ED care faster. Alternatively, some EMS plans never divert critically ill patients because the travel time to the next closest ED is too long. Diversion requests must be short (e.g., one-to-two hours), and must automatically expire unless the hospital calls in to renew its request. At the time an ED calls in a diversion request, they may still receive patients already en route. This means they can’t hear a radio call, deem the run undesirable and go on diversion.

Once EMS has determined its plan, officials should meet with area hospitals (both ED and hospital management) individually. They should then meet periodically as a group in meetings chaired by EMS. Emphasize that EMS can and will override diversion if needed. Hospitals must be required to have an internal plan for dealing with ED overcrowding, such as letting admissions go upstairs to hallways, and an internal policy that spells out steps to be taken prior to requesting EMS diversion, including notification of a high-level administrator. ED managers must make sure their staff knows and follows the rules, and that unprofessional behavior is unacceptable.

Make sure EMS dispatch and field personnel understand the ground rules, and encourage them to report problems. Policing the system doesn’t need to be complex. Track the data on diversion hours and distribute to ED and hospital management. Remind the hospitals that diversion data is potentially public record and will be released to the media if requested. Importantly, let all hospitals know the diversion data on each other in spreadsheet tallies. Designate a 24/7 EMS supervisor to intervene as problems occur and drop in occasionally to verify that EDs on diversion actually need it, plus a hospital liaison person who will follow up as needed. The EMS medical director and provider need to review the data periodically and intervene as needed when problems occur.

If more than one EMS agency transports to a hospital, it’s also useful to have those agencies meet to try to coordinate their diversion policies. It can become quite confusing to hospital staff when one agency recognizes the hospital request for diversion but another agency is still transporting. Also, there should be a clear line of communication between the EMS provider and the hospital as to the person responsible within the hospital to make the call to EMS, and who within EMS will handle requests, such as dispatch or a field supervisor.

Summary
ED overcrowding has a major impact on EMS providers and is likely to increase. EMS systems for bypassing gridlocked EDs can work effectively and safely to mitigate delays in patient care and to decrease EMS TATs when transferring care at the ED. City of Miami Fire Rescue developed a straightforward written plan that works well in our community, now requiring minimal enforcement and upkeep, and we rarely see prolonged TATs at our receiving EDs.

But each local provider must consider multiple local factors in developing an optimal plan — one plan does not fit all. Close communication between EMS and hospital management is essential, whether or not an EMS provider allows a bypass or diversion plan.

Kathleen Schrank, MD, FACEP, FACP,is a professor at the University of Miami Miller School of Medicine, chief of the UM Division of Emergency Medicine and an EM physician at Jackson Memorial Hospital. She has served as the EMS medical director for City of Miami Fire Rescue since 1988 and for the Village of Key Biscayne Fire Rescue since 1994. She can be contacted atkschrank@med.miami.edu.

Marc Grossman, MD, FACEP,is a voluntary assistant professor at UMMSM and an EM physician at Jackson Memorial Hospital. He is the associate EMS Medical Director for City of Miami and the EMS medical director for Coral Gables Fire Rescue. He can be contacted atmgrossman@miamigov.com.

Resources

1. Brennan JA, Allin DM, Calkins AM, et al: “Guidelines for ambulance diversion.” Annals of Emergency Medicine. 36(4):376-377, 2000.
2. Burt CW, McCaig LF: “Staffing, capacity and ambulance diversion in emergency departments: US 2003-04.” Advance Data. (376):1-23, 2006.
3. Handel DA, McConnell KJ: “Diversion and bypass,” chapter 51 in Emergency Medical Services: Clinical Practice and Systems Oversight, Cone D, O’Connor R, Fowler R (Eds). National Association of EMS Physicians. Kendall Hunt Professional, Dubuque, Iowa. 604-608, 2009.
4. Vilke GM, Castillo EM, Metz MA, et al: “Community trial to decrease ambulance diversion hours: The San Diego County patient destination trial.” Annals of Emergency Medicine. 44(4):295-303, 2004.