New ambulance policy slashes diversion hours
Average number of patients drops 70%
In the fall of 2001, ED diversion hours in San Diego County, CA, were averaging 4,006 a month, with a monthly average of 1,320 diverted ambulance patients. Area hospitals were on diversion status an average of one out of every four hours. Two years later, average monthly diversions had dropped to 1,508 a month (a 63% decrease), and the average number of diverted ambulance patients had dropped 70%, to only 399.
The source of this dramatic improvement was a new, voluntary system agreed to by all EDs in the county. The system was based on three core parameters:
- Ambulance diversion status only could last one hour before a hospital would have to again accept ambulance patients.
- After coming off of ambulance diversion, a hospital’s ED staff would have to accept at least one patient before they could declare themselves back on diversion.
- Regardless of diversion status, hospitals were required to accept patients originally discharged from their facility.
"We had started to track bypass hours [ambulance diversion hours] through our various county medical associations and noted they had been steadily increasing over time, to the point that almost 25% of the total hours EDs were open were spent on bypass," recalls Gary Vilke, MD, FACEP, FAAEEM, medical director for San Diego County Emergency Medical Service (EMS), associate professor of clinical medicine at the University of California San Diego (UCSD), and an attending physician in the UCSD Medical Center ED. "The other thing we noted, from a practitioner’s standpoint, was while one ED was on bypass, a neighboring hospital would receive a patient requesting the other hospital," he says.
In other words, a patient who was discharged from Hospital A after a complicated admission might later call 911 because the patient was having problems and seek to return to Hospital A. "Let’s say [that person} gets diverted because that hospital is on bypass," Vilke posits. "[The person] ends up in a neighboring hospital with no records. A lot of manpower and hours are spent reinventing the wheel — getting new labs, getting old records — only to find out many times the patient’s physician already knew the patient was coming in and had made arrangements to meet him at the original hospital."
That situation ties up a bed in Hospital B while staff wait for the patient to be transferred to Hospital A, he notes. With situations like these multiplied across the system, logjams easily formed, and before long, 14 or 15 of the area’s 21 EDs could be on diversion.
The final impetus for change, says Vilke, was that certain local jurisdictions, such as Sacramento County, had started working on "no bypass" legislation.
Bypass clearly was being overused, he concedes. "The system ran best when no one was on bypass, or when everyone was on bypass," Vilke says. The idea was that hospitals needed to be on bypass less often, he says. "But we didn’t need regulations to control that," Vilke says. "We needed to step up to the plate and get the numbers down."
To address the problem, the San Diego County Medical Society created an EMS Medical Oversight Committee, co-chaired by Vilke and Roneet Lev, MD, an ED physician at Scripps-Mercy Hospital in San Diego. Each receiving hospital ED had members on the committee, including nurse managers and ED directors; other participants included paramedic agencies, paramedic base hospitals, the county division of EMS, and the local health care association.
The guidelines were determined by the overall goals of the practitioners. "For example, we needed a break of an hour or so — time to clear out a bed — so we needed to get the patient to the right facility the first time," Vilke says. They didn’t want to see a 90-year-old post-transplant patient, for example, sitting in the ED and unable to give staff a history, he says. "That’s where rule of You will take your own’ comes into play," Vilke explains.
The system was voluntary, he says. Reports were sent on a weekly then on a monthly basis, he says. "We blinded’ them so as not to truly embarrass hospitals, but ED directors could take them back to their facility and say, Look, we were the worst ED; we need help from administration,’" Vilke explains. "We used the reports as motivation, rather than as a stick."
It certainly seems to have worked. "It’s been terrific for us," says Ray Poliakoff, MD, chief of emergency medicine at Kaiser Permanente in San Diego. It allows EDs to have continuity of care, he notes. "We receive patients who we know and who we have records for," Poliakoff explains.
However, the changes weren’t always easy. "We had to change some of our protocols," he says. "The ambulances have to unload these guys right now [they have 20 minutes] and get into the field, but once it became policy, the more we did it, the more we liked it."
Since the new policy was implemented, "we went up 10% to 20% in ambulance drop-offs, but even then we were able to reduce our diversions almost to zero," Poliakoff adds.
Sources/Resource
For more information, contact:
- Ray Poliakoff, MD, Chief of Emergency Medicine, Kaiser Permanente San Diego, San Diego Mission Road, San Diego, CA 92101. Phone: (619) 528-5133.
- Gary Vilke, MD, FACEP, FAAEEM, Attending Physician, University of California San Diego Medical Center, 200 W. Arbor Drive, San Diego, CA 92103 Phone: (619) 543-6463. E-mail: [email protected].
A detailed description of the San Diego ambulance diversion program is provided in the following article:
- Vilke GM, Castillo EM, Metz MA, et al. Community trial to decrease ambulance diversion hours: The San Diego County patient destination trial. Ann Emerg Med 2004; 44:295-303.
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