"Everybody gets a look every day at what's going on," says Ron Lagoe, PhD, the council's executive director. "We put a big priority on getting these data to people and making that an incentive. And it's interesting, in a four-hospital system, there's always one that wants to improve the situation. You'd like to have it with all four, but there's usually somebody cracking down on the diversion hours. And it's visible every day. Right now we have one that's really stepped up. This used to be the hospital where we'd [accept] the third-largest number of ambulances in the community, and all of a sudden it's number one. You don't think that gets people's attention?"
The hospitals did their part as well. The senior administrative staffers who must approve diversions got tough. In one case that meant demanding a plan for reopening before granting approval. In another it meant requiring notification when certain thresholds were exceeded that made diversion likely, thus allowing countermeasures to be taken before the fact. In a third, it meant approving diversions for an hour, but mandating reauthorization each hour thereafter.
Other tactics included staffing up during periods when overcrowding was expected; imposing standing orders for some testing so that results could get to physicians sooner; adding resources like cardiac monitors and telemetry beds; fast-tracking certain patients for speedier transfer and discharge; and faster turnaround of patients upstairs to free up beds.
Denver: Fewer Choices
Painting diversion as a serious step--one to be avoided if possible and never to be undertaken lightly--was also a strategy used in Denver.
"We used to have eight or nine [categories of] diverts," says James Cusick, MD, longtime EMS director for the Rocky Mountain region of Kaiser Permanente and now national medical director for AMR, as well as a member of the American College of Emergency Physicians' EMS Committee. "We had psych diverts, OR diverts, pediatric diverts, ICU diverts--a whole host of diverts. People could select what divert they wanted to be on, so everybody was always on some kind of divert."
The strategy here was to go to a single whole-hospital divert centered in the ED.
"We got rid of all the other categories. You were either open or closed, and that started solving the problem right there," Cusick says. "It put you on whole-hospital divert, and that meant you couldn't take anything. So it forced the EDs to stay open longer and try to fix their issues."
The system did retain certain advisory categories--critical care, psych, O/B, trauma/OR and CT--that EMS was asked to observe if it could. But if the EMS situation were dire enough, those could be ignored.
"On a good day in EMS," Cusick explains, "we'd say, 'Try to work with the hospitals and pay attention to the advisories.' On a bad day in EMS, if the system was overloaded, they'd mean nothing. We'd go back to just open or closed."
Denver also employed zones and utilized EMSystem to share information. And independently, a pair of its hospitals went even further: They began screening patients coming into the EDs and referring some to clinics elsewhere.
Denver isn't the only city where this has been tried, and it is controversial. But studies suggest that a third of the care provided in U.S. EDs could be more appropriately obtained elsewhere. According to a Washington Post account from April 2004, ambulances had, in the preceding six months, delivered three patients to one of these EDs for hangnails. "That kind of behavior wrecks the system," a doc there told the paper.
ED visits at that hospital dropped by 20% once the "rational rationing" began.
The long-term issues, Cusick says, are more staffed beds and better throughput.
"All these things, in a way, are a just a Band-Aid," he says. "We're lucky they're succeeding, but we're not sure for how long. We need more staffed beds, and we need flowthrough efficiency throughout the whole hospital. Getting patients upstairs quicker, getting patients discharged quicker--it's all part of the puzzle."