EMS on the Outside Looking In
The running joke in Las Vegas while a pair of new hospitals were being built, was how long it would take the ambulance diversions to begin. The punch line, when it came, didn't make anyone laugh.
That leads to an important truth about the diversion/delay conundrum: There's only so much EMS can do about the phenomenon of ED saturation. Issues like patient throughput and the "boarding" of admitted patients in EDs are up to the hospitals to fix. Other contributors, like a paucity of nurses and some specialists and what ED observers say is the increasing acuity of patients' conditions, must be addressed by the healthcare community at large. Still others, like the large number of Americans without health insurance, are complex social issues demanding multifaceted solutions at high levels of government.
So to a certain extent, all EMS can do is roll with the punches. In Vegas, that has entailed creative solutions like leaving a single crew or supervisor at the hospital to watch over multiple patients until ED staff can assume care, which at least frees up other crews to get back in service.
Even this, however, wasn't enough to keep things working at last year's holiday crunch. Things got so bad then that EMS was driven to a somewhat desperate gambit.
"Just before New Year's, we actually didn't have any units available to respond," says Chetelat. "So we decided that if things got desperate enough, at 30 minutes, our crews could just offload patients without the hospital necessarily accepting them. We just felt 30 minutes was long enough. It caused a bit of an uproar, obviously. We did set some criteria that they had to be on hospital equipment, a hospital bed, that kind of thing. But if a crew absolutely had to go, they could go. We started doing that, and amazingly, the hospitals started finding ways to deal with the patients."
Sacramento: In Synch
In California's capital, things were deteriorating at an alarming pace. In 1999, area hospitals were on diversion for a cumulative total of 4,131 hours. By 2001, that jumped to 23,785--an increase of 476%.
"It was really warping the system," says Williams, whose company was asked to tackle the problem.
The first thing Williams discovered was that different hospitals had different criteria for going on and coming off diversion. This was remedied by a standardized policy imposed on all of them. By mid 2002, everyone was playing by the same rules.
In addition, the region's hospitals were divided into geographic zones, much as Las Vegas had done, with a policy that the minute every hospital in a zone was on diversion, all would come off. Two hospitals in a three-hospital zone could be on diversion simultaneously, but not all three. A widely used Internet-based monitoring/tracking system, EMSystem, was installed at every hospital and the EMS dispatch center to keep EMS crews updated about ED statuses. Finally, a committee was created to hold the hospitals accountable to the changes. If they were out of compliance too much, they had to explain why and provide a plan for improvement.
Internally, hospitals were asked to analyze the causes of their diversions and draft plans to address them. They developed pre-diversion avoidance processes by which they could ramp up resources and capabilities or take other steps to avoid diversion when it appeared imminent. And diversions were limited to three hours in length. After that, an ED had to reopen for at least an hour.
"Probably the most important step was to get all the diversion policies to synch up," says Williams. "Now everybody goes on and off for the same reasons. And you can't go on diversion unless you get the highest administrative authority in the hospital to approve it. The idea is that they're supposed to be asking for more help and resources before they go on diversion. And that's worked wonderfully."
By 2003, total diversion hours dropped to 7,143--a 70% reduction over two years before.
Area hospitals employed other tactics as well. If an ED bogs down, for instance, a physician might leave the back and come to the front to do preliminary screening of incoming patients, weeding out those who can be seen or treated elsewhere.
"With a simple three- or four-minute check," Williams says, "some hospitals have experienced a 30% discharge rate right from the front door. We build all these barriers to getting the patient to the back. If an emergency physician's not busy because all the ED beds are paralyzed--they're all filled with patients waiting for tests or patient beds--why not move that physician up front until they clear the queue?"
As well, basic tests can be started in backed-up EDs upon a patient's arrival. Then, by the time he gets to a bed, the results are on hand, saving valuable time.
