EMS on the Outside Looking In

The running joke in Las Vegas over the last few years, as a pair of new hospitals were being built, was wondering how long it would take the ambulance diversions to begin once they opened. The punch line, when it came, didn't make anyone laugh.

     "It wasn't days or weeks," says Rory Chetelat, EMS Manager for the Southern Nevada Health District, the public-health body governing the Sin City region. "It was hours."

     Perhaps you can feel Chetelat's pain. ED overcrowding and ambulance diversions are phenomena that have afflicted hospitals and EMS systems across the U.S. In 2003 alone, more than half a million ambulances were diverted nationally--roughly one every minute. Around 45% of EDs have utilized the tactic.

     The problem is worst in large departments that absorb more than 50,000 visits a year. Representing 12% of all EDs, these account for 18% of those that went on diversion, 47% of all hours spent on diversion and 70% of the total ambulances diverted. The patient-flow crunch is felt most acutely in big cities. That's certainly true of Las Vegas, a city in the midst of a rapid-fire population explosion. But almost every major metropolitan area has its own horror stories to tell.

     Increasingly, though, there are other kinds of stories being written--success stories. Using a combination of techniques, a number of metro areas have confronted their diversion problems and reduced, if not eliminated, them. Some have acted with EMS in mind; some have incorporated EMS into their solutions.

     This article looks at the steps taken by five such cities.

Las Vegas: Just Say No
     The most facile answer to stopping ambulance diversions is to simply ban them. Don't give hospitals the option, the thinking goes, and they'll make whatever changes they have to make to keep taking patients.

     A number of U.S. cities have done this, and in some it's worked well. It was a strategy that Las Vegas leaders turned to when previous steps like diversion limits and hospital zones proved insufficient.

     "What we'd had was a one-hour diversion limit per hospital per zone," explains Chetelat. "We had city hospitals divided up into three zones, and no more than one hospital could go down for more than an hour at a time per zone. That basically just became a rotation. Hospital A would go on diversion for their hour, then B would go on for their hour, then C, then we'd be back to A. This had gone on for years, and it was really just passing the buck around."

     With patients losing patience and offload delays at open EDs soaring, Vegas officials proposed a ban on diversion. The hospitals weathered the change, and while the offload times didn't improve, life at least got a bit less aggravating for EMS crews.

     "Did it make things better on the EMS side? Not really," says Chetelat. "The offloads didn't improve substantially. But we had an easier system, because we simply went to the nearest facility or the patient's hospital of choice. People were getting where they needed to be. It was easier on EMS and created a more satisfied customer."

     The diversion/offload balance can be a tricky one. If hospitals don't fix their internal flow problems, banning diversion may simply shift the ED overflow burden to EMS.

     "In some communities that try to ban diversion altogether, it explodes on them," says Mike Williams, president of The Abaris Group, a California-based consulting firm specializing in emergency and outpatient services. "Without mitigating the flow and process side of it, chances are you're just moving the problem to EMS. That's what we're seeing now, in very significant degrees, where offload times have significantly increased."

     That leads to an important truth about the diversion/delay conundrum: There's only so much EMS can do about the phenomenon of ED saturation. Issues like patient throughput and the "boarding" of admitted patients in EDs are up to the hospitals to fix. Other contributors, like a paucity of nurses and some specialists and what ED observers say is the increasing acuity of patients' conditions, must be addressed by the healthcare community at large. Still others, like the large number of Americans without health insurance, are complex social issues demanding multifaceted solutions at high levels of government.

     So to a certain extent, all EMS can do is roll with the punches. In Vegas, that has entailed creative solutions like leaving a single crew or supervisor at the hospital to watch over multiple patients until ED staff can assume care, which at least frees up other crews to get back in service.

     Even this, however, wasn't enough to keep things working at last year's holiday crunch. Things got so bad then that EMS was driven to a somewhat desperate gambit.

     "Just before New Year's, we actually didn't have any units available to respond," says Chetelat. "So we decided that if things got desperate enough, at 30 minutes, our crews could just offload patients without the hospital necessarily accepting them. We just felt 30 minutes was long enough. It caused a bit of an uproar, obviously. We did set some criteria that they had to be on hospital equipment, a hospital bed, that kind of thing. But if a crew absolutely had to go, they could go. We started doing that, and amazingly, the hospitals started finding ways to deal with the patients."

Sacramento: In Synch
     In California's capital, things were deteriorating at an alarming pace. In 1999, area hospitals were on diversion for a cumulative total of 4,131 hours. By 2001, that jumped to 23,785--an increase of 476%.

     "It was really warping the system," says Williams, whose company was asked to tackle the problem.

     The first thing Williams discovered was that different hospitals had different criteria for going on and coming off diversion. This was remedied by a standardized policy imposed on all of them. By mid 2002, everyone was playing by the same rules.

     In addition, the region's hospitals were divided into geographic zones, much as Las Vegas had done, with a policy that the minute every hospital in a zone was on diversion, all would come off. Two hospitals in a three-hospital zone could be on diversion simultaneously, but not all three. A widely used Internet-based monitoring/tracking system, EMSystem, was installed at every hospital and the EMS dispatch center to keep EMS crews updated about ED statuses. Finally, a committee was created to hold the hospitals accountable to the changes. If they were out of compliance too much, they had to explain why and provide a plan for improvement.

     Internally, hospitals were asked to analyze the causes of their diversions and draft plans to address them. They developed pre-diversion avoidance processes by which they could ramp up resources and capabilities or take other steps to avoid diversion when it appeared imminent. And diversions were limited to three hours in length. After that, an ED had to reopen for at least an hour.

     "Probably the most important step was to get all the diversion policies to synch up," says Williams. "Now everybody goes on and off for the same reasons. And you can't go on diversion unless you get the highest administrative authority in the hospital to approve it. The idea is that they're supposed to be asking for more help and resources before they go on diversion. And that's worked wonderfully."

     By 2003, total diversion hours dropped to 7,143--a 70% reduction over two years before.

     Area hospitals employed other tactics as well. If an ED bogs down, for instance, a physician might leave the back and come to the front to do preliminary screening of incoming patients, weeding out those who can be seen or treated elsewhere.

     "With a simple three- or four-minute check," Williams says, "some hospitals have experienced a 30% discharge rate right from the front door. We build all these barriers to getting the patient to the back. If an emergency physician's not busy because all the ED beds are paralyzed--they're all filled with patients waiting for tests or patient beds--why not move that physician up front until they clear the queue?"

     As well, basic tests can be started in backed-up EDs upon a patient's arrival. Then, by the time he gets to a bed, the results are on hand, saving valuable time.

     "These are all things the ambulance industry learned many years ago," Williams says. "Now we're trying to translate them to the hospital industry."

San Diego: Right The First Time
     There were three main components to the diversion-reduction efforts San Diego initiated in 2002: Diversions could last only an hour; when a diversion ended, a hospital had to accept at least one patient before going back on diversion; and regardless of diversion status, hospitals had to accept their own patients.

     That last item is the notable one for our discussion. The main focus of San Diego's efforts was on getting patients to their "home" hospitals--where their primary-care physicians are, where their records are, and where they may ultimately end up anyway (after a second EMS transport).

     "The thing that was frustrating to emergency physicians," says Gary Vilke, MD, medical director for San Diego County EMS at the time, "was that you'd get patients who'd been discharged from different hospitals, with complicated histories, who couldn't give you much of their own stuff. They'd come back later, but couldn't go to the hospitals where they'd had all their records and care, because that was on diversion. So we'd spend an inordinate amount of time trying to get their information or transfer them back to that original hospital. There were a lot of wasted resources."

     Area hospitals didn't need much persuading to give this idea a try. Managed-care organizations certainly had an incentive to accept and treat their own patients, and docs liked seeing patients whose histories they knew or could quickly reference.

     "I'd rather take care of a patient who has old chest x-rays and EKGs in my system that I can look up than somebody who doesn't, who requires a workup," says Vilke. "We used that as sort of our launch point to get people to embrace the concept. Getting patients to the right place the first time was something everybody could agree on."

     With their freedom to resort to prolonged diversions restricted, San Diego's hospitals, like Sacramento's, had to make some internal fixes as well.

     "What some of them did was make it a hospital-wide issue, not just an emergency-department issue," says Vilke. "They set up programs where they had a sort of red/yellow/green-light system. If an ED was getting close to going on bypass because of admitted patients being held there, they'd call a code yellow, and the hospital would make an effort to discharge or transfer patients to open up beds upstairs. Red status would mean things had gotten extreme and you had to take action. Some opened up more beds by getting waivers to utilize gurney beds. One actually hired extra nursing to guarantee every ambulance would be received."

Syracuse: Climate Change
     You may have noticed a theme in the cases discussed so far: Attacking the diversion problem requires a two-pronged approach. Individual hospitals have to streamline their processes, yes, but the issue must also be attacked at the community level. Hospitals that improve their own operations may still suffer under other facilities' overflows. Engaging everyone in the battle prevents the problem from simply being shunted back and forth.

     That truth was embraced in Syracuse following a spike in diversion hours between 1996-2000. Total hours spent on diversion by the city's four hospitals rose from 4,156 in 1996 to 11,398 in 2000. By that point, the city's hospitals were on diversion nearly a third of the time.

     At the community level, the solution emphasized data. Using EMSystem to tally such metrics as hours spent on diversion and ambulances received while on and off diversion, the governing Hospital Executive Council began distributing daily reports showing top staff at each hospital how they were doing compared to the others. This not only stimulated discussion and analysis, it led to a cultural climate that valued staying off diversion.

     "Everybody gets a look every day at what's going on," says Ron Lagoe, PhD, the council's executive director. "We put a big priority on getting these data to people and making that an incentive. And it's interesting, in a four-hospital system, there's always one that wants to improve the situation. You'd like to have it with all four, but there's usually somebody cracking down on the diversion hours. And it's visible every day. Right now we have one that's really stepped up. This used to be the hospital where we'd [accept] the third-largest number of ambulances in the community, and all of a sudden it's number one. You don't think that gets people's attention?"

     The hospitals did their part as well. The senior administrative staffers who must approve diversions got tough. In one case that meant demanding a plan for reopening before granting approval. In another it meant requiring notification when certain thresholds were exceeded that made diversion likely, thus allowing countermeasures to be taken before the fact. In a third, it meant approving diversions for an hour, but mandating reauthorization each hour thereafter.

     Other tactics included staffing up during periods when overcrowding was expected; imposing standing orders for some testing so that results could get to physicians sooner; adding resources like cardiac monitors and telemetry beds; fast-tracking certain patients for speedier transfer and discharge; and faster turnaround of patients upstairs to free up beds.

Denver: Fewer Choices
     Painting diversion as a serious step--one to be avoided if possible and never to be undertaken lightly--was also a strategy used in Denver.

     "We used to have eight or nine [categories of] diverts," says James Cusick, MD, longtime EMS director for the Rocky Mountain region of Kaiser Permanente and now national medical director for AMR, as well as a member of the American College of Emergency Physicians' EMS Committee. "We had psych diverts, OR diverts, pediatric diverts, ICU diverts--a whole host of diverts. People could select what divert they wanted to be on, so everybody was always on some kind of divert."

     The strategy here was to go to a single whole-hospital divert centered in the ED.

     "We got rid of all the other categories. You were either open or closed, and that started solving the problem right there," Cusick says. "It put you on whole-hospital divert, and that meant you couldn't take anything. So it forced the EDs to stay open longer and try to fix their issues."

     The system did retain certain advisory categories--critical care, psych, O/B, trauma/OR and CT--that EMS was asked to observe if it could. But if the EMS situation were dire enough, those could be ignored.

     "On a good day in EMS," Cusick explains, "we'd say, 'Try to work with the hospitals and pay attention to the advisories.' On a bad day in EMS, if the system was overloaded, they'd mean nothing. We'd go back to just open or closed."

     Denver also employed zones and utilized EMSystem to share information. And independently, a pair of its hospitals went even further: They began screening patients coming into the EDs and referring some to clinics elsewhere.

     Denver isn't the only city where this has been tried, and it is controversial. But studies suggest that a third of the care provided in U.S. EDs could be more appropriately obtained elsewhere. According to a Washington Post account from April 2004, ambulances had, in the preceding six months, delivered three patients to one of these EDs for hangnails. "That kind of behavior wrecks the system," a doc there told the paper.

     ED visits at that hospital dropped by 20% once the "rational rationing" began.

     The long-term issues, Cusick says, are more staffed beds and better throughput.

     "All these things, in a way, are a just a Band-Aid," he says. "We're lucky they're succeeding, but we're not sure for how long. We need more staffed beds, and we need flowthrough efficiency throughout the whole hospital. Getting patients upstairs quicker, getting patients discharged quicker--it's all part of the puzzle."

What EMS Can Do
     There are, of course, other efforts in other places to address the diversion problem. Again, there's only so much EMS can do, especially where its actions are constrained by law. But some additional ideas may include:

• Transporting patients to urgent-care centers, freestanding ED-type clinics or other destinations besides actual EDs.
      

  "Pretty much every study,"Williams says, "documents that for anywhere from 40%-60% of all emergency department visits, that's not necessarily the best place of care for them. It feels accessible to the patient, but there are other accessible sources."

• Basic medical screening of 9-1-1 callers.
       

  "Our studies show that only about 40% of ambulance patients ultimately get admitted to the hospital," says Williams. "Is there any way we can better stratify those patients who call for an ambulance? Houston Fire, for example, is pilot-testing a nurse advice line concept. If you call in and meet certain criteria, you don't get an ambulance; you get transferred to a nurse advice line, and they'll help determine what services you need--including helping you schedule a same-day appointment with your physician. That's a radically new way of thinking about this business."

• Sharing EMS tactics like peak-hour staffing with our hospital brethren.
       

  Williams: "Most hospitals don't change their staffing by hour of the day or day of the week. In EMS, that's fundamental. We wouldn't even think about having static staffing during the busiest hours of the day. Many hospitals are still of this mind-set that you never know who's going to walk through that door. Well, it turns out we do know, and to a high level of precision. We can carry those experiences over to the hospital industry."

     In that sense, there's actually a good bit EMS can do to help solve the diversion problem. We just have to avail our colleagues of our wisdom and experiences--and maybe even our clinical skills.

     "I'm a real proponent of having EMS personnel working in hospitals," says Cusick. "Especially at a time when we're short of nurses, we need to utilize the personnel we have. Why not have an EMS person in the discharge unit who can facilitate transport out, whether it's by family, cab, ambulance, whatever? Have somebody who deals in transport there with the nurse to assist. And medics are great at running arrests and giving respiratory medications and the things they're certified to do on the outside. We should make it easier for them to do it on the inside."