Diversionary Tactics

     Between 2003 and 2006, California's population grew by 3.4%. During that same period, EMS transports in the state increased by 8.4%. And during that same period, total ambulance diversion hours among the state's emergency departments dropped by more than 34%.

     Not everyplace saw decreases. But enough did for an overall reduction that was statistically quite impressive. Such progress demands a double take from other areas suffering the woes of diversion and its ugly cousin, patient turnover delays. So what happened in the Golden State? A lot of people caught on to something.

     "Successful communities are the ones that work on the total problem," says Mike Williams, director of the California ED Diversion Project, a two-year effort to assess the issue and help implement solutions in several California communities. "There are lots of best practices published out there already. There may be more to discover. But it's not really about adopting best practices. It's about having executive resolve at the highest level—be it the EMS level, the hospital level or the regional government level. An executive resolve that says, 'You know what? We need to fix this.'"

     With that resolve—and an eye toward the systems aspect of the problem—improvements are often attainable. There are, in fact, things hospitals can do to keep their EDs open. There are plenty of things EMS can do to keep its units in service. And there are important things the twain can accomplish jointly.

     Here's how it's happening, in California and elsewhere.

THE 'US' FACTOR
     The truth about diversion is that it's not just a hospital problem and not just an EMS problem—it's a healthcare system problem.

     "We all have to own it," says Williams, president of The Abaris Group, an emergency care consultant based in Walnut Creek, CA. "Sometimes I see EMS pointing fingers at the hospitals, and the hospitals pointing fingers at EMS—they talk about their patient versus my patient, when in fact we should be talking about our patient."

     EMS and hospitals are partners in this process, and must work in concert to deliver optimal care. Step No. 1, then, is this: When you're not on the same page, get on it. Don't let differences in policy and approach manifest at crunch time, when the patient on the stretcher is helpless in the crossfire.

     "Our first advice," says attorney Doug Wolfberg, of the prominent EMS law firm Page, Wolfberg and Wirth, "is that before EMTs and paramedics are having arguments with staff in the emergency department, EMS administrators sit down with hospital administrators and work for some reasonable understanding and accommodation of the needs of both sides. Both sides have legitimate considerations that should be discussed in a noncritical setting."

     It may be desirable to pursue a standardized diversion policy across your community, so that hospitals use the same criteria for going on and off divert. That was a key element of the so-called Sacramento Solution, which Williams and Abaris devised a few years back for California's capital (the experience was published and has since become a well-known case study). But even that isn't always necessary, as long as the hospitals themselves have defined criteria they articulate and adhere to.

     "We expect each hospital to have a policy of how to go on diversion, and to show us that policy, signed off by their hospital," says Kathleen Schrank, MD, medical director for Miami Fire-Rescue. "However they develop their own policy is fine with EMS, as long as they have one. Then we set the ground rules for how we work with it."

     This leads to the area of ED status monitoring. Advancing technology has been a great boon in keeping EMS apprised of EDs' status. Products like EMSystem, ReddiNet and a growing number of others provide easy access to that information, including notice of closures, in near-real time. Such systems can represent huge savings in time and effort for both sides.

     "Our main concern in going to it was the disaster polling of hospitals: Who can handle how many reds, yellows and greens?" recalls Brad Mason, special operations chief for Johnson County (KS) Med-Act in suburban Kansas City, an early adopter of EMSystem. "We had to do that one at a time on a single-channel VHF radio system—calling this hospital, calling that hospital. It could take up to half an hour to get the answers back. So our primary draw to EMSystem was that, through the Internet, we could quickly send the alert out, and they could quickly answer back. What previously took 30 minutes now took five."

     For Med-Act, in fact, the diversion benefit was almost a bonus. But for area hospitals, it was the main driver. Previously, for an ED to go on divert, staff had to fill out forms and fax individual closure notices to around two dozen regional EMS agencies.

     "That was a waste of time as well," says Mason. "For them to be able to just go online, click 'We're closed,' 'We're open,' 'We're on trauma diversion,' or what have you, in a matter of seconds, that was the sizzle with the steak in terms of selling this project in our region."

     Med-Act's adoption of the EMSystem product was followed by statewide implementation across first Missouri, then Kansas. And in fact, at this point, monitoring of this nature is fairly widespread nationally. Many systems track hospital diversion statuses and ambulance wait times. The degree of real-time information available to EMS has never been higher.

     Look at www.medcontrol.com. Among other information, this site, a function of the Pinellas County (FL) EMS medical director's office, shows active fire/EMS calls, hospital statuses and ambulance statuses at any given time. Clicking the site's "Hospital Status" link shows closures and available services reported by area hospitals. The "Ambulance Status" tab shows who's en route and who's waiting where, along with how long. When this information changes, managers and on-duty crews are automatically alerted, so they can adjust operations accordingly.

     "We watch the data, we watch the bed delays, and we watch ambulances being held," says director Chuck Kearns. "That way, when we start to see it creep up, we can do preventive maintenance."

     As it turns out, there's a lot of prevention EMS can do—with or without the cooperation of its hospitals.

THE 'ME' FACTOR
     It starts with knowing that diversion is, at its core, a favor. As long as an ED can conduct basic assessment and stabilization, EMS can choose to ignore requests to go elsewhere. Under EMTALA, if you show up with a patient, that patient is theirs to help.

     With the law on its side, EMS in some jurisdictions has simply stopped honoring diversions. Sometimes this works, but it may or may not be in the patients' best interests. If an ED truly does lack the resources to help them, they'd obviously have been better off taken elsewhere. And declining diversion requests has, in some cases, been linked to handoff delays, which can also be violations of law.

     "CMS has published memos that suggest the practice of patient parking is a violation of EMTALA," says Wolfberg, who has presented on diversion/delay issues at EMS conferences. "A lot of providers think that when a hospital tells them they have to sit with the patient for two hours on their stretcher in a hallway, they're required to do that. Under the law, it's very clear that the patient is the hospital's responsibility when they arrive on hospital property."

     Faced with lengthening drop times, some systems take measures like sending supervisors to watch over multiple waiting patients, letting crews get back in service. Others just announce that they'll only wait so long. DC Fire and EMS, for one, recently proclaimed a 25-minute limit to its patience.

     "That's the time I'm saying is reasonable for a stable patient to either be taken off our stretcher onto the resources of the hospital or to go wait in the waiting room," says Medical Director Michael Williams, MD (not the same as Abaris' Williams). "By that point you're either dying, in which case you're not stable and shouldn't be on an EMS stretcher, or you're stable by definition and can sit anywhere."

     Having a supervisor, or some kind of EMS presence, in the ED periodically is a good strategy. ED staff, upon using diversion to clear their backlog, have been known to forget to tell EMS they're clear to receive transports again.

     "It's important for EMS to police it," says Schrank, whose department realized a 64% decrease in diversion hours among its main hospitals from 2006 to 2007. "When we didn't drop by the hospitals that claimed they were overloaded, they didn't really police themselves. There were a lot of unnecessary diversion hours called. We'd go and look, and there'd be no one in the ED."

     EMS should also utilize live data to manipulate its resources more effectively. DC FEMS put an EMS supervisor at the district's public-safety communications center to take over destination decisions when things get busy.

     "Historically, our units determined where they wanted to go," says Dr. Williams. "Now they'll tell us what they have, and we'll tell them what's available and least busy, based on the acuity of their patient."

     This mechanism helped enable a reduction in diversion hours its first year, even as calls for service and transports in the district rose.

     The technology that allows monitoring of ED statuses and wait times can have another benefit as well: It enables the easy calculation of cumulative hours hospitals spend on diversion, and how often they delay crews during dropoffs. That information is generally EMS' to publicize—and a powerful motivator for hospital brass.

     Pinellas officials disseminate monthly reports showing percentages of dropoffs of more than 20 minutes at each hospital. These go to all the CEOs, who can all see how they did compared to everyone else. It's an accountability tool: No one wants to be the worst—not good for business.

     "We knew the results before we started to publish them, so we knew some people were going to be OK with it, and others were going to have heartburn, which they did," says Kearns. "But I've found that few individuals are as competitive as hospital CEOs. Even hospitals with the same ownership will compete against each other. I'd think this would work in any community with more than one hospital."

     The same tactic worked in Miami—almost too well.

     "Diversion hours plummeted because some CEOs told their EDs 'You will never close,'" says Schrank. "Then we had some staying open far beyond safety limits. We had to run one cardiac arrest in the parking lot, because there was literally no way to get a stretcher in the door. We went back to that CEO and said 'Yes, we want to keep diversion hours down, but please, when it's unsafe, you have to let your ED go on diversion!'"

Additional Ways to Reduce Diversions
     Alternative destinations—Can EMS screen and transport (or even call a cab for) appropriate patients to doctors' offices, clinics or alternative destinations? "Only about 30% of ED arrivals by EMS are ultimately admitted to the hospital," notes Abaris' Williams. "A large percentage of these patients don't need an ambulance."

     Advice nurses—Can 9-1-1 callers be questioned and directed to nonemergency treatment by a call-center nurse? Montreal is among the locations doing this; some major U.S. cities are on board too.

     Zones—Many cities use zone-type systems to group their hospitals. Typically, multiple hospitals in a zone can be diverting simultaneously, but once they're all on, they all automatically go off.

     Home hospitals—San Diego relies on this concept, in which patients are taken to their "home" hospitals even when those facilities are diverting. Their records are there, they're known to caregivers, and it prevents a transfer later.

     Proactive management—Can public-health outreach to key groups (e.g., low-income, the elderly) prevent 9-1-1 calls from happening? Think areas like disease/injury prevention, chronic disease management and social services for frequent flyers.

     No-wait EDs—A new breed of hospitals is being built with larger capacities and improved patient-flow processes—and no waiting rooms. Patients are taken directly to beds, and all information-gathering and preliminary testing is done there.

     Use your leverage—If your system is looking to designate regional specialty resources, you have leverage. If a hospital can't handle normal patient loads, you can't exactly consider it for your STEMI or stroke center (and its correlating revenue and prestige), can you? "That may make the administrators unhappy, but I think it's a fair thing to say," says DC Fire and EMS medical director Michael Williams, MD. "If you can't handle the average person coming in, you definitely can't handle the high-acuity, resource-intensive patient we'll be bringing you with an MI or stroke."

     Play hardball—Long offload times forced Miami-Dade Fire-Rescue to report several of its hospitals for potential EMTALA violations. Obviously, this should be a last-ditch tactic, but the law is clearly on EMS' side, and this mechanism is always available if other strategies fail.

THE 'YOU' FACTOR
     Beyond everything EMS can do, the truth is that diversion is mostly a problem of hospital throughput, which hospitals themselves must address. They must improve their internal patient-flow processes.

     This can involve measures like doing discharges in the mornings, to free up inpatient beds for those coming through the ED; postponing elective surgeries during times of surge; streamlining housekeeping to turn rooms around more quickly; implementing predivert plans to relieve congestion before it gets critical; and requiring EDs to get permission from top brass to close.

     "The entire hospital experience has to be valued as part of the diversion mitigation challenge," says Abaris' Williams. "When we go to emergency departments that are compromised, probably 80% of them have done pretty much everything that's within their capacity to do. But most hospitals haven't taken on the inpatient thing. And around 50% of all admissions come through the emergency department."

     The system view forms the basis of an effective approach to patient flow being used at United Hospital in St. Paul, MN. United monitors its entire facility at a 24/7 patient placement center that works much like a dispatch hub, tracking patient movement and identifying potential bottlenecks.

     "We're always looking at where things are starting to build," explains Steve Tredal, MD, United's medical director in charge of patient-flow issues, "and working to get additional resources in place when we see volume coming."

     In the ED, that's yielded a prediversion protocol to bring in extra staff when things start to build. Additionally, hospital leaders are working with university researchers to develop computer forecasting and staffing models to help better anticipate and plan for demand. That should be implemented for testing soon. And ultimately, the hospital's experience will be written up for publication.

     "For a long time, we thought the problem was the emergency room, and we just had to fix that," says Tredal. "But clearly a great part of the emergency room's problems are a reflection of the system problems."

Project Aims at Spreading Proven Strategies
     While parts of California saw diversion hours drop from 2003 to 2006, others were, and are, still suffering. The California ED Diversion Project is aimed at finding ways to help them. Participants are working in four counties—Los Angeles, Ventura, San Bernardino and Santa Clara—to reduce the hours EDs spend closed to ambulances.

     The effort began with a comprehensive review of the problem across the state; that report is now available at www.caeddiversionproject.com. Identification and implementation of best practices followed. In comparing diversion practices in high- and low-diversion regions, investigators found some common threads: Systems with low hours typically required hospitals to have diversion-resolution plans; had system monitoring by EMS; and notified other hospitals when one went on divert. In three of four regions with the highest diversion hours, EMS and dispatch personnel were not notified of ED diverts.

     "Once the project is completed, we'll have 60 or 70 best practices published on the website," says project director Mike Williams, of EMS consultant The Abaris Group. "Eventually we'll open it all up as a public resource."

     Contra Costa County is a success story, maintaining low diversion rates even with high patient volumes. It has utilized strategies like EMS drop-ins at closed EDs and forcing EDs wishing to close on weekends to get permission from the county health officer. The county eventually turned to a no-divert policy when one of its hospital EDs closed, and that worked too: Things actually got better.

     "What they found was, diversion begets more diversion," says Williams. "But for that first hospital diverting, the next hospital wouldn't have had to. So [banning diversion] can smoothe the volume, like on-ramp lights on the freeway."

ALL TOGETHER NOW
     Within hospitals and across entire 9-1-1 systems, nothing happens in a vacuum. Emergency departments are often a point of failure, but less often the cause. Ergo, to fix the problems of ED closures, ambulance diversions and patient turnover delays, hospitals and EMS must fix their system issues together. The good news is, there are proven ways to do it.

     "Don Berwick, president of the Institute for Healthcare Improvement, says that every healthcare system is designed to do exactly what it does," says Abaris' Williams. "I've found that to be true. If our emergency departments are screwed up, it's because we designed them screwed up. If we have diversion, it's because we've designed it. The message for both hospitals and EMS delivery systems is to look for collaborations, and to look at the whole problem, not just the emergency department."