Ambulance Diversion Project Comes to Successful End

Nearly a year after the end of a 90-day pilot project aimed at ending ambulance diversion in King County, Wash., hospitals, all 18 hospitals continue at or near zero-divert status.

“I think King County is off divert for good,” says David Carlbom, MD, associate director of emergency services at Harborview Medical Center, the Level 1 trauma center in Seattle. “There have been times when it would have been convenient to go on divert, but we haven’t; we worked through the challenges instead.”

The pilot project was the culmination of 18 months of preparation by the hospitals, private and public EMS agencies, and the Central Region EMS Council (see “Ending Ambulance Diversion,” EMS World, April 2011). During the March through May 2011 pilot period, divert hours declined to less than 6 total per month for all 18 hospitals. Since the pilot ended, ED diversions hours in King County have remained between 11 and zero hours per month, including zero for both November and December 2011.

EMS agencies operating in King County have all noticed and appreciated the move toward zero diversion. Kaylee Garrett, operations manager for American Medical Response (AMR) in King and Snohomish Counties, reports: “We at AMR have been ecstatic with the work King County hospitals have done to make these changes, because we see they do work.”

Eastside Fire and Rescue (EF&R) serves a population of 120,000 in 193 square miles of urban, suburban, rural, wilderness and mountainous areas. In 2010 it logged more than 5,000 EMS responses. Transport times in such a large and diverse geographic area always factor into EMS operations. Deputy Chief Wesley Collins appreciates how zero diversion has helped solve some of their transport issues. “In general, the improvement is being able to go to the hospital that is the most appropriate for the patient, meets the patient’s wishes, and does not cause confusion for the family members who may end up at a different hospital than the patient due to diversion,” Collins says.

Pilot Kick-off

Merrili Owens, executive director of the Central Region EMS & Trauma Council in Seattle, described the reason to engage hospitals in the 90-day pilot program as, “We needed to dip their toes in the water.” In other words, just do it.  By the end of the second month of the three-month test, the hospitals had met both primary goals:

1. Will it work?
2. Can everyone do it?

Pilot project manager Clark Hartley said no critical issues occurred to compromise operations or patient care. Anticipated problems were addressed by prepared work-arounds already in place, with no unpleasant surprises. According to Hartley, most problems were related to timely and accurate data reporting, which continued to suffer from lack of up-to-date training due to turnover.

There were minimal hitches along the way, Hartley said, but they were mostly hospital-specific, where pilot project procedures were not followed, rather than system-wide issues. Busy hospital EDs faced a new reality: We’re saturated, we can’t divert, now what do we do? Hartley said managers dealt with problems by using existing but little-used policies, rather than defaulting to diversion.

Zero diversion has been sustained because everyone understands it has become the new norm. Hartley recalls an example of the new paradigm: “One evening a supervisor in one hospital announced they were no longer participating and placed their ED on divert. The next morning the supervisor’s manager was horrified to find this out, solved the problem, and that hospital has never gone on divert since.”

Carlbom said that at Harborview initially there was some concern from front-line staff, but once they experienced no-divert, they recognized they really could do it. He says, “It turned into more of a pride issue for staff, as in, ‘Look what we did!’”