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Don't Come Around Here

      The flu outbreak has kept EMS services and emergency departments in the region busy, and in the early evening hours, Attack One is dispatched to another call for a "person ill." But the elderly gentleman they find at his home is not ill with influenza. He has had a progressive onset of shortness of breath throughout the day, and is having chest discomfort. He notes his urine output has been less than usual, and his weight was up 5 lbs. over his baseline when he got on his bathroom scale today. A call by his wife to his physician resulted in the doctor's office calling EMS for transport to the hospital. He is having no chest pain, palpitations, nausea, sweating or other symptoms.

   The patient and his wife request he be transported to a hospital with extensive heart services where he has received care in the past. His physician practices at that hospital, and has advised him that his symptoms are due to a worsening of his chronic congestive heart failure—he will need to be seen by the cardiologist who has done his prior heart catheterizations.

   The paramedic starts an intravenous lock. The patient gets oxygen and nitroglycerin, and is placed in a sitting position on the stretcher. He is not in respiratory distress, so continuous positive airway pressure is not needed. New medical protocols have also decreased the importance of giving a diuretic in the prehospital environment, so none is given. The patient says good-bye to his wife as the house is locked up, then he's loaded into the ambulance, and the wife gets into their car to drive to the hospital.

   The paramedic calls his report ahead to the hospital, and as he completes his patient assessment and gives a short ETA, he hears those evil words: "Sorry, sir, the emergency department has just gone on diversion. You will have to take that patient somewhere else."

   Oh, no! At least the patient is stable. But giving him the diversion news means he is now upset that he cannot go to his preferred hospital and be cared for by his doctor. What's more, his wife is already en route there in the car, with no cell phone. The paramedic has to quickly prioritize calling the medical report to other hospitals, finding out if anyone else is on diversion, calling dispatch to try to find the wife, and notifying the ambulance driver about where to drive. He simply asks for the ambulance to pull over.

   He is very concerned about the patient's wife, so the first call is to dispatch. He asks if police can try to find the lady based on the description of her car. He will quickly try to locate an available hospital so they can advise the wife where to find her husband. The dispatcher is aware that another hospital, located in the opposite direction in the city, is open. Quickly, the paramedic contacts that hospital, and they are willing to accept the patient. The ambulance can now begin transport in the opposite direction to that hospital.

   The dispatcher has placed a request for the police to find the wife and advise her that her husband is fine, but is going to another hospital. They will have to instruct her how to get there. The dispatcher must also contact the original hospital ED and notify them that the family is likely to show up at their department. He is worried that the wife and other family members will arrive at the first hospital and be upset they cannot find the patient. The already-busy staff will have to explain that the hospital is on diversion and contact other EDs in the area to find him.

   The patient is unchanged on the trip to the hospital and arrives in the open emergency department stable. The crew shares the patient history with the emergency staff, and makes them aware that the patient and his family are going to be unhappy about being at this hospital. They advise that all patient records are at the other hospital. They then call the dispatcher, who advises them the wife hasn't been located yet. They call the original ED to ensure their message has been relayed to the greeting staff, so they know to look for the wife. They offer to return to the patient's residence and try to find the wife in case she returned to the house. As she has not arrived by the time they are ready to return to service, they ultimately do this.

   ED staff evaluate the patient and finally obtain his records. He needs to be admitted, and is assigned a new doctor and a new cardiologist. His wife arrives at the ED about three hours later. She had arrived at the original hospital and sat in the waiting room quietly for an hour before asking the staff about her husband. She was advised to go to the second hospital, but got lost as she tried to find it. She arrives in tears, and asks the ED staff how she can register a complaint against the EMS agency.

Case Discussion

   This case demonstrates the great difficulties that can result from hospital diversions, especially in communities that do not have organized and central systems for communicating diversions to EMS crews.

   Diversion has a broad range of definitions. In different areas, it may be called rerouting, bypassing or red-lighting. The definition typically has some local history. The term diversion is used to reflect that the hospital has reached some form of limitation in available services. It should always reflect that hospital staff has a concern about their ability to deliver high levels of medical services, and not be done for the convenience or financial benefit of the hospital or its staff.

   Diversion has been a significant national issue since about 1999. It is temporally related to the reduction in payments to hospitals from federal sources and from managed care. This resulted in fiscal tightening, loss of patient beds, hospital downsizing and a concomitant shortage of nursing personnel. In the last 6–7 years, many ambulance systems have also experienced financial restructurings. These result in tighter scheduling and availability of ambulances.

   Hospital diversion results in offloading responsibility for patient destinations to EMS providers. This can be done on a patient-by-patient basis or systemwide. Hospital priorities typically involve the internal needs of the patients they are serving. EMS providers generally are not aware what's going on within hospital walls.

   The emergency department and its leadership are central to the issue of diversion. The ED, on an everyday basis, is the buffer for many of the busiest units of the hospital. The ED staff holds and manages patients waiting for open operating rooms, critical care beds, dialysis units, cardiac cath labs, invasive radiology intervention rooms or CT scanners. The problems referred to as "boarding" result from the holding of patients who should be going to one of those units or to inpatient beds, but instead are occupying beds and staff in the ED.

   All hospitals have the potential for diversion. A hospital can catch fire, lose utilities, be contaminated or suddenly and unexpectedly be unsafe for patient care. In these circumstances, it is necessary to divert care to another site if possible. When diversion results from the much more common capacity issues, it is a function of hospital efficiency, staffing and ability to handle volume fluxes across weeks and seasons.

   Response to capacity issues at the hospital level is twofold. First, leaders can overhaul the everyday business of the hospital, which allows improved patient flow, turns over beds (particularly in the units with the tightest capacity) more quickly, and reduces the influx of elective procedures when resources are tight. The second response is a process to allow effective decision-making when resources become tight. This is crisis management resource allocation—when hospital leaders must staff closed units, move patients expediently out of critical care beds to step-down or general units, cancel elective cases, and communicate with medical staff members.

   An EMS system must prioritize the emergency needs of its community as a whole. In urban areas, where there are hospitals closer together, it is typically felt that diversion carries less of a penalty for community patient care. In areas where single hospitals stand geographically isolated, there will be significant transportation issues for patients and their loved ones if care is diverted.

   The prehospital emergency medical system is well structured and capable of delivering excellent care services and transporting patients to a wide choice of facilities to serve them well. This flexibility works well when all facilities are open and available to provide care. But systems can become dysfunctional when facilities begin to reroute, and chaos grows as more EDs come to diversion status.

   EMS leaders can help develop solutions to diversion. System best practices to address crowding of EDs and hospitals include:

  • Having a regional rerouting policy embraced by all public and private transportation providers and hospitals.
  • Having centralized communication centers for EMS that can tie together the work of regional EDs and EMS providers. These are most efficient if there is a community-based bed status information system.
  • Police responsibility for alcohol-related incidents and individuals.
  • Cooperative relationships between hospitals, home care and extended-care facilities to minimize overuse of emergency departments.
  • Having an effective community-based mental health patient management system.

   James J. Augustine, MD, FACEP, is a medical advisor for Washington Township Fire Department in the Dayton, Ohio area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

Initial Assessment

   An 80-year-old male with shortness of breath and chest discomfort.

   Airway: Intact and uncompromised.

   Breathing: No respiratory distress; can speak in full sentences.

   Circulation: Normal capillary refill, pink skin.

   Disability: No neurologic deficits.

   Exposure of Other Major Problems: Patient has swelling to his ankles, and reports his weight is increased by 5 lbs. over baseline.

Vital Signs
Time HR BP RR Pulse Ox.
1950 120, irreg. 170/100 24 92%
1957 116, irreg. 180/96 28 98% on O2 by cannula
2010 112, irreg. 184/80 20 98% on O2 by cannula

AMPLE Assessment

   Allergies: None.

   Medications: Patient is on eight medications, including Coumadin, Lasix, potassium and lisinopril.

   Past Medical History: History of atrial fibrillation, congestive heart failure and hypertension.

   Last Intake: Breakfast, then a small amount for dinner at 1730.

   Event: Exacerbation of chronic congestive heart failure.

   Customer Service Opportunity: Diversion affects both patients and their loved ones. It is not unusual for patients to have preferred hospitals, perhaps where their physicians practice or where they've had diagnostics and treatments done in the past. Taking such patients to other hospitals may significantly compromise their care, or result in the use of more resources than would be used at their preferred hospitals. EMS personnel are challenged to explain to patients why they can't be taken to their preferred facilities. Patients may further vex EMS by deciding to self-transport, so they can't be diverted. Then crews are faced with making nontransport decisions. Elderly patients are often affected more dramatically by being required to switch hospitals, doctors and medical records. As in this case, asking families to adapt to the change can also be easier said than done.

   Learning Point: Diversion affects patient transport in a significant way, ultimately impacting patients, families and EMS system function. Regional EMS leaders should develop solutions for diversion to allow expedient transport and optimal medical care.

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