Hospital Diversions are at the least an annoyance for EMS crews. If you are in a city that only has one or two Emergency Departments¹, it can be a major annoyance. If you are in a city that has a lot of Emergency Departments, it’s less so, but it’s still an annoyance. At best it means you’re taking a patient to a hospital that they might not particularly like. At worst, you are traveling well outside your response area and leaving reduced or even no EMS coverage in your community.

For those of you who aren’t familiar with the concept, EDs are supposed to go on divert if their ED patient load is so large that they can not care for additional patients. Nice theory, but in practice what happens is that in patient units that are filled up refuse or delay acceptance of ED patients. This means that patients will be “boarded” in the ED until a bed is ready. It’s not particularly unusual for patients to be in the ED for up to 24 hours. Some hospitals will even bring a regular hospital bed into an ED room so that the patient is more comfortable while waiting for a floor or unit bed to open up.

The problem with boarding is that it ties up rooms, resources, and nurses that are supposed to be used for emergency patients. A patient that has been diagnosed, stabilized, and admitted is no longer an emergency patient and should be moved somewhere else. The problem being that “somewhere else” might have to be another hospital, which the original hospital would like to avoid.

This all sounds too much like a bowel obstruction for my liking, but I guess the comparison is apt. But I digress.

Once the ED backs up, there is really only one alternative open. “Close” the ED to ambulances. It’s not really closing, although that is one of the common terms used. Truth is that if a patient absolutely, positively, wants to go to a particular ED they generally (at least in my area) can. A hospital that flat out refuses to accept a patient that presents via ambulance is at some risk of litigation or complaint to regulatory agency. Nor can trauma centers generally close to trauma even if their ED is on divert.

All of which puts the EMT or medic in the position of being the filling in a crap sandwich. I’ve lost count of the number of times I’ve patiently explained to a patient (no pun intended) that “their” hospitals ED is packed like a can of sardines only to be told that “It’s my hospital and my doctor is going to meet me there”². Which puts me in a bad position, really. Now I have to call the ED on the radio, explain the situation and that I’ve explained the ED status to the patient and that they insist on going anyway. Which invariably leads to some variation of “Will bring there here if you must, but they’re going to sit for hours and hours until someone can see them”. Usually, at least in my imagination, followed by a sigh. Or maybe that’s just suggestive static on the radio.

Sometimes we do convince the patient to go elsewhere, but you know how that goes. Anything from a misdiagnose to a lack of Jell-O in the patients preferred flavor is because the ambulance drivers wouldn’t take the patient where they wanted to go.

Either by design (unlikely) or apathy (more likely) hospital administrators and others who make the decisions that lead to increased diversions make the lives of EMS folk harder.

Well, at least in Massachusetts that’s going to change come January 1, 2009.

The Department of Public Health has announced policy that will bar hospitals from going on divert.

Effective January 1, 2009, ambulance services may honor diversion requests only when a hospital’s Emergency Department (ED) status is “code black”, which means that it is closed to all patients due to an internal emergency.

Technically, DPH is not telling hospitals they can’t go on divert. They ARE telling EMS services that they can not honor a diversion request absent a catastrophe such as a fire, flood, loss of power, or the chinese joint down the street won’t deliver.

There is still a little wiggle room in the policy and I think the hospitals will try to insert more between now and the beginning of 2009, but it’s a pretty good step overall. This is more so when you consider that Mr. Auerbach has never been considered in these parts to be a particular friend of EMS. In fact, until fairly recently, OEMS has been fairly hostile to EMS providers. That, however, is a story for another day.

You should read the entire letter to get the details. It’s obvious that a lot of thought was put into this policy change and the interests of EMS systems and providers were high on the priority list.

OEMS has also released a new statewide Point of Entry plan, which should help EMTs make destination decisions with far less angst than they currently have. Once I get a copy of that, I’ll blather dispense some more wisdom.

1 I use the term Emergency Department instead of the more common Emergency Room because ACEP believes that since Emergency Medicine is a separate specialty the facility in which that specialty is practiced deserves to be referred to as a “department” as opposed to a “room”. I think they are correct in this and strive to use their preferred term. Then again when I started it was still called the “Accident Floor”.

2 This goes along with “The check is in the mail” and “I won’t-“, well you get the idea.