Avoid diversion by looking outside of your ED
Do investigative work first
If your ethics committee is serious about avoiding emergency department (ED) diversion, look outside the four walls of your ED. "You need to know how busy the paramedics are and what the status is at other EDs," says Edwin Homansky, MD, FACEP, chief of staff for the ED at Valley Hospital in Las Vegas. "ED managers must know what’s going on at the other facilities to know how busy you’re going to get."
Much better use of available information and demand planning systems is needed, says James J. Augustine, MD, FACEP, CEO of Premier Health Care Services, a Dayton, OH-based physician management group that provides ED staffing and consulting. He recommends using a system for bed status management, used by the hospitals, the major payers, and the general medical community.
"This would allow the regional health system to operate at a more efficient level while still enabling the community to access excellent care at peak demand times," Augustine says. A bed status management system was successfully introduced in several metropolitan areas, reports Augustine. "The status of key community resources is communicated to providers," he explains.
Here are ways to avoid diversion by increasing awareness of community resources:
• Address underlying problems with emergency medical services (EMS) and ED capacity. When developing a strategy to reduce diversion, answer the following questions about ED and EMS capacity, recommends Augustine:
- Are these two resources able to manage demand for services 95% of the time?
- Would greater capacity in one or both be able to buffer demands so that diversions are not necessary?
- Can the hospital better manage existing capacity or resources (for example, the CT scanner) so that those resources will be available when peak demands occur?
- Can more of the tightest resources, such as cleaning staff to prepare rooms between patients, be strengthened?
- Can the hospital use information systems to predict peak times and then staff for them?
- Are there regional pools of resources that can be used more effectively?
• Defer patients or get them to alternative environments. Some patients who are going to be admitted might be able to be managed with home care or direct admission to a nursing facility, suggests Alan C. Woodward, MD, FACEP, chief of emergency services at Emerson Hospital in Concord, MA. "We use our transitional care unit to place patients in nursing homes," he says. The thresholds change as it gets more desperate."
Shortages of hospital beds might need to be addressed by using a broader base of beds in the community, says Augustine. "This pool of beds would have to be staffed by a competent and flexible set of hospital employees, who would be providing services in a nontraditional environment." The hotel and extended care facilities in a community may be the best source of excess capacity for the acute health care system, suggests Augustine.
At the peak of the viral season three years ago, the Dayton area had many of its hospitals at or near diversion status, with EMS units held in the field waiting to find which hospital was open to take a patient, recalls Augustine. "The EDs were thrust into a leadership position," he says. "My first calls were to the local Marriott hotel for their availability of beds in their hotel or into their local extended care facility." Under this type of crisis scenario, ED managers must take on leadership responsibilities, stresses Augustine.
• Use EMSystem. In the Kansas City metropolitan area, EDs have worked in the pre-hospital community to implement EMSystem, a computerized tracking of the system’s availability, which is accessible 24 hours a day.
Dennis Allin, MD, medical director of the Kansas City EMS system and director of emergency medicine at the University of Kansas Medical Center, says, "This system delineates the type of diversions recognized in our community. It also gives the pre-hospital personnel, hospitals, and dispatch centers up-to-the-minute knowledge of available resources."
It is critical that all hospitals in an EMS system have a relationship with each other, he stresses. "The pre-hospital component allows for a discussion of what resources are available and a consensus on what types of diversion will be allowed and how these will be communicated," Allin says.
Community protocols were developed in the Kansas City metropolitan area to establish policies for the use of EMSystem, notes Allin. EMSystem is a web-based, real-time hospital ED diversion and mass casualty incident-reporting system manufactured by Infinity HealthCare in Mequon, WI. "Through this system, a hospital is held more accountable for how often they divert and for what reasons, since this is tracked throughout the community," he adds.
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