ED diversions banned by Seattle-area hospitals
Critically ill to go by ambulance to nearest facility
A new policy in King County, WA, means that hospitals in the area, which includes Seattle, will no longer go on diversion. The policy, adopted by the Central Region Emergency Medical Services & Trauma Care Council, requires critically ill patients to be taken by ambulance to the hospital of their choice or the nearest hospital — even if it doesn't have room for them.
"It hasn't even been a month, but I can already tell you that the pre-hospital care providers have noticed a huge difference," says Chris Martin, RN, BSN, administrative director of the ED at Harborview Medical Center in Seattle, and chair of the council. "Hospital administrators have all agreed that diversion is really a throughput problem and not an ED problem, and they've agreed to work long and hard to get beds open."
They were hearing anecdotally that pre-hospital care providers were having a hard time finding hospitals to take patients, she recalls. "The hospitals to which the patients were taken would be 30-40 miles from where they were," Martin says. "In addition to being too far to travel for definitive care, this took some medic units out of their service areas."
This difficulty was confirmed by the Hospital Capacity Web Site — a countywide site administered by Harborview that registers each time an area hospital goes on divert. "If you look on the screen, you'll see the emergency status: green is all open; red means divert," explains Martin, noting that updates are made twice a day or if the status changes. "I asked our technical person to run some reports, and they were right: We had hospitals on divert 30% of the time," she reports.
Martin brought the issue to the council, where pre-hospital providers who are council members made their case. "Every hospital agreed that diversion was the ethically wrong thing to do," says Martin. The group decided to reconvene in four weeks after conferring with their administrators. When they returned, they voted unanimously to no longer use the word "divert" and to always remain open for life-threatening cases.
If a hospital is very overloaded, they can go on "ED saturation" two hours at time, and then will go back to green, Martin says. "They can only do this for a total of six hours in every 24, so, theoretically, a hospital could still go red, but it doesn't ever count as red for a critical patient," she says.
How do the EDs handle incoming critically ill patients when they're crowded, don't have sufficient staff, and/or don't have beds? "I can't say we ever don't have sufficient staff," says Vicki Seaman, RN, director of the ED at Auburn (WA) Regional Medical Center. They simply rearrange staff for low and high acuity, Seaman says. "If we have to manage the patient in the ED for awhile, we can do it because most of our nurses have critical care backgrounds, so it's not something they're not used to managing," she says.
Adjusting the system
To accommodate the new policy, says Martin, adjustments had to be made to the web site. "We had to reconfigure it because we now have three colors: green for go, red for ED saturation — which has to be timed out after two hours — and yellow for treat and transfer, when you can't find an open bed," she says.
Martin says having a large group address the problem made it easier to solve it. "All us who live and breathe this problem in the ED recognize this as a hospital problem, not an ED problem — that EDs are overcrowded and backed up most of the time because their patients could not get to beds," she says. "But sometimes, until as an administrator you are forced to face the issue, you may not have been looking too hard at it."
There were beds open and not occupied, but administrators did not believe they had the staff to take care of them, Seaman explains. "Each hospital had to look internally at what they were doing to see the problem," she says.
Seaman already has seen significant improvement. "There have been occasions when someone had to go on ED saturation, but much less frequently than before," she notes. Every facility is taking patients, so no one place is hit with a huge influx of ambulances and medics, Seaman says. "I do believe the flow is better, and medics believe that, too," she says. "They don't have to search for EDs like they had to before."
Sources
For more information on ED diversions contact:
- Chris Martin, RN, BSN, ED Administrative Director, Harbor-view Medical Center, Seattle. Phone: (206) 731-4097. E-mail: [email protected].
- Vicki Seaman, RN, ED Director, Auburn Regional Medical Center, Seattle. Phone: (253) 333-2561.
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