Ending Ambulance Diversion

“Central Hospital from Medic 22, en route with one BLS trauma on board. ETA seven minutes.”

“Medic 22 from Central, negative. We are on BLS divert.”

“Medic 22, copy that.” New traffic: “Southside Hospital from Medic 22, en route with one BLS trauma on board, ETA 22 minutes.”

Hospital diversion—the practice of effectively “closing” an emergency department to area EMS agencies—occurs on a daily basis throughout the United States. While it tends to occur more frequently in urban areas with higher populations, diversion is no stranger to suburban and even rural hospitals.

In recent years, as hospital leaders started analyzing their surge capacity, a stark reality stood out. With emergency departments running at or near capacity on a regular basis, how could the hospitals possibly step up to a terrorist act or pandemic?

In spring of 2007, current Airlift Northwest Executive Director Chris Martin was well into her 23-year career as administrative director for emergency services at Harborview Medical Center in Seattle, WA. She recalls sitting with a handful of people at a Starbucks coffee shop in Seattle’s University District looking to brainstorm surge capacity ideas.

“What we quickly realized was, how could we do surge when we can’t even do our normal daily load?” Martin recalls. The group shifted to brainstorming how emergency department (ED) throughput could be improved, which led to the idea of becoming efficient enough to end ambulance diversion.

Coincidentally, concerns from the area EMS community to the Regional EMS & Trauma Council about diversions at all 18 hospitals in Seattle and King County were increasing. Some complaints included transporting units being diverted with critical patients on board and families ending up at different hospitals than their patients. The timing was ripe for a new way of doing business.

Diversion Consequences to EMS Agencies

Hospitals can call divert (close their EDs to EMS) at a number of status levels (see Table I), and EMS agencies are not always given a clear understanding of why an ED closed. All they know is the hospital is on divert. To them it means the ED is not available, when in reality it may only be a BLS divert, or an ALS divert, or some particular subspecialty care that is not available.

Seattle Fire Department Assistant Chief A.D. Vickery says diversion impacts his agency’s ability to function at peak performance. “Our EMS system in Seattle is fire-based, utilizing all SFD apparatus in a layered response system, with the closest fire apparatus dispatched to the scene,” he says. Vickery says all Seattle firefighters are EMT-certified as a condition of employment. Because all on-duty apparatus is available for any type of call, delays encountered on an EMS call could impact response to a subsequent EMS call, structure fire, motor vehicle accident or some other emergency. “Any delay in patient delivery impacts the entire fire/rescue/EMS response system negatively, delaying our service delivery,” Vickery concludes.

American Medical Response (AMR) is responsible for the majority of BLS patient transports in King County. AMR’s operations manager for King and Snohomish Counties, Kaylee Garrett, says diversion affects her crews’ abilities to provide the best service to their patients and also impacts AMR’s ability to meet its contractual obligations for emergency and interfacility transports.

Garrett was concerned about making ambulance crews find the “next best” destination for their patients while en route. AMR crews are also limited to a 20-minute window from arrival at a hospital until they are back in service. ED backups and diversion to another hospital that is backing up due to someone else’s divert status makes that standard hard to meet. When the crews are backed up at hospitals or finding alternatives they are not available for the next emergency call or interfacility transport.