Hospitals on "divert" status...

[mrsmall]

I live in Marion County FL. We have a population of about 300k, and the city of ocala has a population of about 50k. We have 4 EDs in our county. We're surrounded by many main cities in FL such as Gainseville, Orlando, Tampa, Daytona, etc. 1/4 of the largest retirement community in the nation is in our county. The rest of the county is also populated with senior citizens.

This is just a little bit about our county. Around January, many senior citizens fly down to their winter homes. We here call them snow birds, as they live in FL only during the cold seasons. So many come down during this time that many business only make money during this time. At the same time our hospitals are flooded with people. Also, when flu season comes in, it puts even more stress on the hospitals.

Our hospitals have some kind of formula where if they fill up a certain % of beds and cannot move pt's for a certain period of time, they go on what they call "divert". I dunno if other people have this. It basicly means, go to another hospital if possible. All of our EDs are close enough that it usually isn't a problem when a hospital goes on divert...

However, with the current flu season all of our hospitals have been on divert. When this happens, divert means nothing. However, it does mean that you will be waiting on the wall with a pt for a long time. I have had to wait up to 4 hours with a pt on the cot, waiting for bed. That seems kind of extreme, I mean.. 4 hours?

Trauma alerts, stroke alerts, etc. They will ALWAYS make room for these of corse.

Does anyone else experience this.

[KE5EHI]

We have the same thing here. They changed the local divert protocols for our service to where the hospitals can request divert and they get one hour. After that, they have to call for any additional hours, at which point a supervisor goes to the hospital and evaluates the situation to see if they will get another hour or not. The other option is they have to wait an hour before they call again to go on divert for another hour. We have a total of six local EDs we use. Two are major trauma centers, two are good all around EDs, two are just about glorified clinics (this one is my opinion of course).

The reason the EDs are only allowed an hour (as opposed to up to six hours in the past) is because it was discovered that the divert status was being abused by some of the hospitals. They were using divert just to not have to deal with ambulance traffic. It was also found that the hospitals weren't moving patients as fast as they should be, which during flu season and summer time when it's busy is a must. They were taking their time on things like labs and moving patients upstairs. So this was a large factor.

The new protocols solved a lot of the issues that were causing all of the EDs to go on divert, since when one went on divert, the next closest hospital would get overran with ambulance traffic, and within an hour, all hospitals were forced open. Now with the city and suburbs growing and more people abusing EMS and EDs, they hospitals are all about at capacity we we've had to wait in the ER for 30-40 minutes for a bed.

[usapride2004]

This is a very interesting topic. I live in Rhode Island, the smallest, yet second most densely populated state in the country at 1,003.2 people/mi[sup:d65e5f5c7f]2[/sup:d65e5f5c7f].

In out tiny little state (1,545 mi[sup:d65e5f5c7f]2[/sup:d65e5f5c7f]... and 32% of that is water) we have a total of 13 hospitals with emergency departments (not including the 7 other hospitals we have without ERs). Of those 13 ERs, we have one Level 1 Adult Trauma Center, Level 1 Pediatric Trauma Center, one Level 2 Trauma Center (trying to move toward Level 1 status), one Primary Stroke Center (certified by JCAHO), three fully functional Cardiac Catheterization labs (and a bunch more "diagnostic" catheterization labs), two hyperbaric facilities (one 24 hour--not including the U.S. Naval Hospital)...

We have a pretty substantial hospital system. Yet, we seem to always have facilities diverting. The way we are set up, no more than 2 facilities in the north or south can be diverting at a time (our Level 1 is considered to be in both the north and south). Once the third facility diverts, it forces everyone open. The most I have waited because of this is about a half an hour... If I were waiting for 4 hours, I would be having a shit fit (on my way to another hospital).

Lately, there have been a sharp increase in the number of diversions. I had never been diverted before 2008... it had just never happened. Now, it happens once a week to me... and God help you if you take a patient in when they are diverting... you'd think you just shot their dog, lol. It had better be a code... It goes to show that we need more/bigger ERs to handle to demand... and more staff to move patients faster.

When I was doing my clinical time, my very first IV went into a 40's hispanic gentleman who came into the ER with chest pain. Pt was s/p AMI 3 months prior, and states that the pain is similar to what he felt then. Priority patient, right? Wrong. He got some ASA and NTG a couple HOURS later. I had thought that he had gotten it from the RN when I wasn't around... nope. He did get a stat 12-lead... whoopee! Sometimes I wonder if our patients would be better off if we just kept them in our ambulances, instead of bringing them to the damn ER, lol. That ER was diverting. That says to me, clear as a bell, that they are understaffed. Not to mention, only our Level 1 has any triaging procedure. I swear, no one else knows what the word means...

So, back to the topic. yes, we have a diversion plan in place, and yes, it sucks being diverted all over the damn place, and waiting in bust ERs, and then watching your patient be ignored by nurses and doctors who are busy with other things.

[stcommodore]

County is divided into "North", "Central" and "South" clusters. " Each has three hospitals, execpt "South" who has four including two trauma centers. No more then 50% of hospitals in each cluster can be on divert, one trauma center is in "south" and "central". Divert is for I believe 2 hours with 2 hours off before you can divert again, if more then the 50% try and divert then everybody is "forced open." We also have 'trauma only' which is what the busier trauma center(s) end up doing around the end of day shift when we hit them with 2-3 traumas to add to there day long back up.

[tinman694]

Gawd---my county is bigger than RI...YEA!!!

We only have 3 facilities (1 aid station calling itself an ED, one ED (sorta like a Quiki Med with a Doc in the box), and a Level 1 trauma Center) Usually, when the level 1 goes to diversion, the other 2 follow (just because)

Its more fun to get a patient and just come on in to the one you think will best treat the pt. Screw the administration and their 'policy'. 4 hours of you waiting to get in? I would be raising hell with the charge nurse immediately. WTF??????

Guess you gotta do what you gotta do...but geez...why do we get crapped on when it comes down to bringing in the business for the ED?

hmmmm.......

[stcommodore]

It's called EMTALA, they can't close the front door so they try and block the back. Until society and abuse of Emergency services changes or EMTALA changes then this is our reality.

[JPINFV]

The new protocols solved a lot of the issues that were causing all of the EDs to go on divert, since when one went on divert, the next closest hospital would get overran with ambulance traffic, and within an hour, all hospitals were forced open. Now with the city and suburbs growing and more people abusing EMS and EDs, they hospitals are all about at capacity we we've had to wait in the ER for 30-40 minutes for a bed.

But that's also a problem with forcing hospitals open. There's a hospital in LA County (Bell Flower Medical Center) that only has 3 beds in their ER. Now, under county protocol, after so much time on divert (3 hours, I think. LA County wasn't a main service area of my old company), the hospitals are required to be open for 15 minutes. Well, if 100% of your beds are full and there is literally no other place to put patients, then being forced open for 15 minutes is really just a cruel joke on the ambulance crews.

On the other hand, one of the hospitals in Orange County (Hoag Memorial), has a rather awesome system set up. They're one of the busiest (60k patients/year circa 2005 [hospital website]. Received 6k paramedic escorted EMS patients, accounting for 11% of all paramedic calls, most including the trauma centers in 2006) with one of the lowest divert times [11 hours in 2006. Only one with less divert time is no longer a receiving center and only received 100 paramedic patients that year. [2006 Annual System Activity Report, OCEMS]. On a pure personal note, I have never had to wait for a bed, regardless of the acuity of the patient, for longer than 5 minutes. 99% of the time, there was no wait time at all.

Having volunteered at Hoag, I think a lot of the low divert time/high patient volume stems from them finding every nook and cranny to put a gurney and a monitor (they're new monitor/alarm system allows for portable cardiac monitors essentially making every bed a potential monitored bed) as well as the "Triage Plus" system. Essentially, if you're complaining of something that isn't serious, but will require lab results, they will call you back for an assessment (by a physician) and to draw labs and then send you back to the lobby to wait for the results. Furthermore, they've taken over a few other patient care areas after the respective department closes (Radiology holding room, for example). This expands the ER's capacity by 4 beds in the afternoons and weekends.

If there's a will, there's a way.

[HellsBells]

I have had to wait up to 4 hours with a pt on the cot, waiting for bed. That seems kind of extreme, I mean.. 4 hours?

Its not out of the ordinary to wait that long here ( Calgary, AB.) when its busy. Our city has a pop around 900,000. We have four hospitals, out of which one is a trauma centre, and one is the childrens.

We even have a new program set up with the health region called transfer of care paramedics. It involves one Paramedic, one EMT who sit in the hall their entire shift, they have five beds and look after low priority patients who would otherwise be waiting for hours with ems crews. They act as kind of a pre-emergency room bed.

[mobey]

We even have a new program set up with the health region called transfer of care paramedics. It involves one Paramedic, one EMT who sit in the hall their entire shift,

How are these people viewed by the rest of Calgary EMS?

Are they below average people who coulden't cut it? Or just the opposite?

[Richard B the EMT]

Sitting in a hallway, and getting paid for it? I'll be presumptive that it involves taking vital signs at set intervals, and possibly getting patient medical histories.

With my bad back and knees, and the cardiac stent, if this position doesn't involve lifting, sounds like a great "light duty" posting, not offered here at any New York City hospital.