Diversion's not a problem for this ED
On divert for just 1 hour in 2 years
The ED at Tahlequah (OK) City Hospital has been on diversion for just one hour in the past two years, says Brian Hail, RN, director of the department. According to Hail, his department has combined the good fortune of close proximity to another hospital with an array of targeted strategies to achieve such an impressive statistic.
Tahlequah City Hospital is located mere yards away from Hastings Indian Medical Center. The two hospitals have never been on divert at the same time, according to Kyle Kuhns, Tahlequah's emergency medical services director. On the rare occasion when there is a divert, the ambulance simply has to go up or down a hill.
"They have a higher volume because they have a fast-track unit," says Hail of the neighboring facility. "If they do approach divert status, then we will feel the pressure as well, since patients will be hoping for a shorter wait." His department has been to maximum capacity (the department has 11 beds) more than that single time in the past two years, Hail says, "but we have a few ancillary beds, and we will also treat some patients in the waiting room."
A dedicated telephone hotline between the two EDs helps keep things from getting out of hand, says Kuhns. "It's there for physicians or nurses to discuss patient load or specific patients," he says. "If they want to transfer someone here for nuclear medicine or imaging studies, if they need our hospitalist, or if we have patients that present here who want to be admitted there, then we will call and transfer them up." If either ED is approaching saturation, that information generally will be communicated to the other facility. Hail's ED has a policy called "maximum capacity," which employs color-coded levels to indicate how crowded the department is.
A graduated response
Depending on the level in the ED or in the waiting room (red is the most serious), there is a graduated response. "On the first level above normal, we contact the house supervisor and say we face first-phase maximum capacity, and they will try to help us with throughput by giving us priority for beds and usually bringing in an extra RN," says Hail. "On the next level, we will get a physician extender or another physician." [Editor's note: A copy of the form used at Tahlequah can be found here. A copy of the entire policy is available with the on-line version of ED Management.
The key to this protocol, he says, is that it strives to be proactive early on, rather than waiting until the divert stage to take action. "We also utilize EMA [emergency medical evacuation] and air ambulances for transfers if patients are going to have to wait too long," Hail adds.
Tahlequah City Hospital has made a commitment to avoiding diversion, he says. "If we have transfers pending, EMS will put on extra trucks to move the patients out," Hail says.
Technology offers backup
If these procedures ever prove inadequate, says Kuhns, there is a statewide database accessible online that has current information on the bed and ED status of every ED in the state. "It lets us know what facilities have — what specialties are on call that day and are available," says Kuhns, noting they use this information to transfer patients, as needed. In addition, he can tell at a glance which hospitals are on divert.
The database has helped streamline the processes tremendously in the past six months, Kuhns adds. This statewide call panel even extends into Oklahoma and Texas hospitals, and they've been told Arkansas will be on-line in the near future, he says.
Of the interstate transfers, Hail says, "We've never really had to do that, but I regularly enter our information. It's a function I perform daily."
'A longstanding relationship'
The benefits of Tahlequah City Hospital's close proximity to Hastings Indian Medical Center extend beyond the virtual elimination of diversions, reports Kuhn. "Since they are literally next door, we've had a longstanding relationship where we share supplies," he says. "There was even one patient who stole a wheelchair in the ED at Hastings and wheeled themselves down the hill to us."
Kuhn says it's easy for the department heads to walk back and forth between their facilities and talk to their counterparts. That is the real key to keeping those diversions at a minimum, he says. "It's just a case of constant communication. We know what they're working on, and they know what we're working on."
Hail says this cooperation is facilitated by the fact that many staff members work at both facilities, and both he and his counterpart at Hastings have worked in the other's ED in the past, so the level of familiarity with both operations is quite high.
Sources
For more information on keeping diversions to a minimum, contact:
- Brian Hail, RN, Director, Emergency Department; Kyle Kuhns, Emergency Medical Services Director, Tahlequah City Hospital, 1400 E. Downing, P.O. Box 1008, Tahlequah, OK 74465. Phone: (918) 456-0641.
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