Ambulance Diversions

[kristinaemtb]

our medical command is strict,they go to the closest facility period.then if they determine a need for transport elsewhere they call u back in to take them-waste of my pt time if the need it.

[Beagle189]

We have 2 hospitals in my county. The one in the city that we serve takes approx 70% of all county pts. They go on divert regularly. The 2nd hospital is approx 6 miles away. If we have a pt that is critical and the primary is on divert we can take them to the primary until they are stabilized(then transfer the pt out). Sometimes the primary staff doesn't see it that way but when the pt is reported on the radio that they are critical/unstable airway/ unstable heart they can't really refuse.

But if pt is not critical we go to the next city. Now when that hospital goes on divert( usually w/in one hour of our primary going to divert) then each hospital only takes pts from their primary area/city.

Gotta tellya sometimes they dn't inform us until after our radio reports and its a booger. Affect Pt care - I try and not let it.

[PRPGfirerescuetech]

This applies for everyone in the US.

Everyone forget about EMTALA?!!

If you have a patient that wants to go to a hospital on divert, THE HOSPITAL CANNOT REFUSE THE PATIENT!!! It's Federal Law. I've pissed off my fair share of staff because of it, but I don't care. I take my patients where they want to go.

Amen. An ER is an available ER 24 hours a day. If ED staff would spend the time they spend avoiding patients on clearing them out, they wouldnt have to go diverting anyway.

Their, at one point, was hospitals in the Southwest part of the US who were stopping EMS diversions alltogether. Denying the ED the ability to do it simply ground them into clearing out the house quicker. Im still looking for the article...

[MedicRN]

The only time there is a diversion here, it's ICU diversion - meaning no ICU beds are available and they don't foresee an openings in the next several hours. We have two Level I Trauma Centers within 3 miles of each other so it's not a very big deal. The third receiving facility in town is not a trauma center, but will occasionally go on ICU diversion. If the an ER is packed with a 6-8+ hour walk-in wait, the facility might REQUEST ambulance patients go somewhere else, but they very, very, very rarely go on ER diversion.

[csr]

Anytime a hospital gos on divert here they notify the EMS service and it is anounced over the radio for all units to hear.

[Doczilla]

Actually, it has very little to do with the state of things in the ER. It has more to do with how things are looking upstairs. A hospital will typically go on diversion when there are no beds available for admission (particularly ICU beds) and they have already maximized the discharges as best they can. This is not a small thing for the hospital. The number of times they go on divert is tracked, and they may have their accreditation endangered if it is too frequent. Even when the ER is horribly crowded, they will continue to accept patients, even in excess of admission capacity, if it is felt that they can open up more beds upstairs or discharges can be expedited by bed control.

The hospital cannot turn away patients at the door when they arrive via POV, as they have not met the "screening exam" requirement of EMTALA. They also cannot refuse a patient who insists on going there, though you can explain that the chances of them getting off the stretcher into a real bed for a few days is small, and that they will most likely board down in the noisy, hectic, bright, and unrelaxing environment of the ER. Nor can the hospital turn away a critical patient from EMS. If your patient is crashing and the hospital is on divert, your legal responsibility is to transport to the nearest facility regardless of diversion status.

'zilla

[bullmedic]

We have 6 hospitals in our parish(county). We generally go to hospital of choice unless they are on "divert". This happens pretty often here and the patients has to chose another facility. Basicaly the only exceptions are patients that have to be transported to the hospital that handles a specialty. We only have one hospital that can handle burns, one that handles true head injuries, and 2 that handle true pediatric emergencies. If you fall into one of those categories you go to that facility despite the divert status.

If four hospitals are on divert you go to the "closest most appropriate facility". We had to come up with some way to get stretchers cleared and trucks back in service. When we ignored divert statuses our units would be held up in ED's for hours, literally. If we get 4 of our 8 units tied up in ED's we are sunk. So it is in our best interest to observe the divert status. It also works out to be in the patients best interest because they get seen quicker.

I think the bigger issue here is that too many people use the ED as their PCP and that causes huge delays in the ED's. Something has to give and I know we are having huge problems trying to figure out a solution.

[bullmedic]

We have 6 hospitals in our parish(county). We generally go to hospital of choice unless they are on "divert". This happens pretty often here and the patients has to chose another facility. Basicaly the only exceptions are patients that have to be transported to the hospital that handles a specialty. We only have one hospital that can handle burns, one that handles true head injuries, and 2 that handle true pediatric emergencies. If you fall into one of those categories you go to that facility despite the divert status.

If four hospitals are on divert you go to the "closest most appropriate facility". We had to come up with some way to get stretchers cleared and trucks back in service. When we ignored divert statuses our units would be held up in ED's for hours, literally. If we get 4 of our 8 units tied up in ED's we are sunk. So it is in our best interest to observe the divert status. It also works out to be in the patients best interest because they get seen quicker.

I think the bigger issue here is that too many people use the ED as their PCP and that causes huge delays in the ED's. Something has to give and I know we are having huge problems trying to figure out a solution.

[strippel]

I was actually able to talk with the charge nurse today in our ER. She used to be an EMT with our service, and still has understanding of EMS. Even though the staff gets rapidly overwhelmed, and pissy, she did realize that at least at our service, we try offer up hospital choices to the patient. Others do not.

As of 0700, there were 21 holds, waiting for beds upstairs. There was only one regular female bed available in the hospital (400+ beds). They were not on divert.

She told me that a certain ALS service was actually transporting cardiac patients to her hospital (on divert), bypassing two closer hospitals, including the one affiliated with that service. At least two of these patients wanted to go to the closer hospital, and were convinced not to. (Both those hospitals have full service ERs and ICUs, and limited cath labs. They do not offer OHS).

Then there was another service who transported a patient to the only hospital that was on divert. She wanted to go to the other hospital, and requested that hospital. That was where her physician and all of her records were. She was fully alert and oriented, and very angry. EMS took her to the hospital they wanted to go to. The hospitals are only 6 blocks apart.

[txemsdoc]

This applies for everyone in the US.

Everyone forget about EMTALA?!!

If you have a patient that wants to go to a hospital on divert, THE HOSPITAL CANNOT REFUSE THE PATIENT!!! It's Federal Law. I've pissed off my fair share of staff because of it, but I don't care. I take my patients where they want to go.

Actually, you appear to be quite WRONG about this, unless the ambulance has already made it onto the property of the hospital... here's the relevant parts of the statute that I have found....

Cut and paste...

[a hospital is bound under EMTALA if the individual...]

(3) Is in a ground or air ambulance owned and operated by the hospital for purposes of examination and treatment for a medical condition at a hospital’s dedicated emergency department, even if the ambulance is not on hospital grounds. However, an individual in an ambulance owned and operated by the hospital is not considered to have "come to the hospital’s emergency department" if—

(i) The ambulance is operated under communitywide emergency medical service (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance; for example, to the closest appropriate facility. In this case, the individual is considered to have come to the emergency department of the hospital to which the individual is transported, at the time the individual is brought onto hospital property;

(ii) The ambulance is operated at the direction of a physician who is not employed or otherwise affiliated with the hospital that owns the ambulance; or

(4) Is in a ground or air nonhospitalowned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital’s dedicated emergency department. However, an individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital’s emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. The hospital may direct the ambulance to another facility if it is in "diversionary status," that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital’s diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department.

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So, it appears to only involve hospital owned ambulances where EMTALA can be invoked, and even in that case, there may be exceptions...

Chris