NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 2310
POLICIES AND PROCEDURES
Subject:
Medical Control
Humboldt County Hospital Emergency Department Diversion Policy
Associated Policies: 2100s, 2301
I. Authority and Reference (Incorporated herein by references):
A. Division 2.5 of the Health and Safety Code.
B. California Code of Regulations, Title 22.
C. North Coast Emergency Medical Services Policies and Procedures.
D. Joint Commission on Accreditation of Healthcare Organizations.
II. Purpose:
To provide guidelines and a mechanism for hospitals to request appropriate temporary discontinuance (i.e. diversion) of ambulances arriving at their facility.
III. Principles
A. Good management of ambulance diversion actions by hospitals is designed to enable patients to be received at the hospital best suited to care for them. When hospitals experience brief periods of excess demand upon fixed resources, ambulance diversion may be a reasonable option if neighboring hospitals are adequately prepared and in close geographic proximity.
B. When the EMS system’s network of hospitals experiences demand which exceeds the capability of multiple hospitals and all hospitals are impacted, ambulance diversion no longer serves the patient.
C. If the rerouting of ambulances greatly increases transport time, ambulance diversion no longer serves the patient.
D. Diversion of ambulance patients from a hospital facility does not negate the hospital’s obligation to continue receiving walk-in patients (per COBRA regulations). Once a patient in an ambulance is on hospital property, that patient cannot be diverted, must become an ED patient and must undergo a medical exam per the institution’s policy.
E. Hospital, County Health Departments and EMS system personnel should strive to promote prevention efforts in order to reduce disease and injury that has the potential to overwhelm local resources during events such as flu outbreak or disasters.
F. Public information regarding proper use of ambulance and emergency department services should be ongoing, and should be reinforced during peak demand periods (i.e. flu season).
G. Hospital emergency preparedness/disaster plans must establish action to be taken when demand is excessive and diversion is no longer an option.
IV. Policy
A. A receiving hospital may divert patients away from its emergency department when it has determined that the hospital is not staffed, equipped and/or prepared to care for additional patients in accordance with State laws and regulations governing hospital accreditation, and this EMS policy.
B. Hospitals’ diversion responsibilities:
1. Develop an internal diversion policy and facility-specific diversion procedures in accordance with this North Coast EMS policy. Submit the diversion policy (and any future updates) to North Coast EMS.
2. Designate administrative or other staff who are authorized to recommend, approve and rescind diversion on behalf of the emergency department.
3. At all times be accountable for all facility functions, such as inpatient bed capability/capacity, discharges, transfers, staffing, equipment, physical plant operations, vital services, etc.
4. Notify appropriate personnel (as defined in this policy) as to diversion status.
5. Determine a procedure to rescind diversion status, including decision authority and communication thereof.
C. Hospital shall develop aggressive internal program, in tandem with their diversion policy, which assists in avoiding the use of diversion by avoiding or relieving saturation (i.e. high census, low staffing). This program shall also include steps to be taken so that the hospital may most rapidly rescind diversion status.
D. Hospitals should annually review and revise their emergency response plans to follow the Hospital Emergency Incident Command System (HEICS).
E. North Coast EMS, through the EMCCs and the Humboldt-Del Norte Medical Society Disaster Subcommittee, will assist with planning for situations when multiple hospitals experience saturation simultaneously (i.e. disaster planning).
V. Procedure
A. Diversion Request Categories:
A hospital may request ALS traffic to be diverted for the following reasons using the following terminology:
1.
“Divert-Saturation:”
Hospital’s ED
beds are fully committed and are not expected to become available during the
next two hours for incoming ALS transported patients.
Divert-ED status automatically expires at the end of a two hour period,
unless renewed.
2.
“Divert-C/T”
Hospital is unable
to provide access to the use of a CT scanner at this time.
Prehospital personnel (with base hospital control) will make
destination decision for patients having a need for immediate CT scan (i.e.
new CVA, first time seizure, new ALOC, isolated head injuries, multiple trauma
patient).
3.
“Divert-Internal
Disaster”
Hospital cannot receive any patients due to internal disaster within the facility, such as bomb, earthquake damage, flooding, etc. which materially and significantly affects the provision of patient care. This does not apply to minor ED inconveniences (such as paging system down), and may not be permissible in a regional declared disaster situation when other hospitals are affected.
B. A hospital may request ambulance traffic to be diverted for the following reasons; however, it is expected that the following occasions would be very infrequent. Hospitals are strongly encouraged to make every effort to have adequate plans avoid:
1. Staffing shortages
2. Lack of inpatient beds
3. Lack of ICU beds
4. Lack of OR staff
5. Cath lab full
C. Hospital Procedure
1. Once a diversion has been determined to be necessary and appropriate by the hospital administrator or his/her designated staff, the ED will notify the following personnel as to the type of diversion being initiated (using the terminology above) and an estimated duration of diversion. A diversion status update shall be given every two hours, as well as notification when diversion is rescinded, to:
a. appropriate internal staff
b. ambulance providers at the time of the pre-alert contact
c. base hospital (if the facility is a receiving facility)
2. If a facility fails to provide notification after two hours on diversion, the facility will be considered open.
3. Final authority for patient destination rests with the base hospital physician, unless the patient has requested another facility.
4. Patients exhibiting uncontrollable problems in the field will be transported to the most accessible medical facility regardless of its open/closed status. Examples of patient conditions include:
· unmanageable airway
· uncontrolled hemorrhage
· cardiac arrest
· obstetrical emergencies
· any BLS ambulance with a Code 3 patient
· any patient which the base hospital physician determines to be in need of transport to the nearest facility regardless of diversion status.
5. If two or more hospitals in the same geographical area are closed (exception made only for internal disaster), the diversion request cannot be honored for either facility and the patient will be transported to the most accessible facility regardless of open/closed status.
6. Closure due to ED saturation shall not preclude a Base Hospital from providing on-line medical control.
7. Hospital shall document all diversion activity, and North Coast EMS will review as part of the Continuous Quality Improvement Program (see Monitoring).
D.
ALS Procedure
1.
EMS teams shall communicate directly with the facility to determine their
ability to accept a patient.
2.
Dispatch shall not be used to provide notification between ALS and
prehospital providers as to diversion status.
3.
No EMS team shall transport a patient, other than prearranged
interfacility transports and in extremis patients, to a facility that is on
diversion.
4.
If a facility has a diversion status unknown, the transporting team
should contact the facility directly for a status update.
E. Monitoring
1. North Coast EMS will provide a monitoring mechanism for hospital diversion activity:
a. Each hospital emergency department will submit to North Coast EMS, on the first day of each month, the previous month’s diversion log form. The log shall include:
1. Name of the person who authorized diversion.
2. Name of person who provided notification of diversion to ED staff.
3. Date and time of diversion began and ended.
4.
Reason for diversion.
5. In-house strategy used to handle the crisis prior to calling diversion, if situation differed from internal facility plan.
6. Time that base hospital was notified of diversion, if applicable.
7. Time that base hospital was notified of discontinuance of diversion, if applicable.
b. Quarterly data will be compiled as to the total time on and reason(s) for diversion, and trends established, in order to evaluate the impact of diversions.
2. North Coast EMS will review cases involving hospital diversion in the following instances:
a. Submission of case review form by another party in the EMS System.
b. Diversions which fall outside the scope of this policy as to reason for diversion.
c. Failure to follow established communication protocols relating to diversion.
d. Indication from the diversion log and the aggregate diversion data that diversion is used excessively or inappropriately, as determined by the North Coast EMS Medical Director.
3.
Hospital will keep a record of diversions initiated by their ED for a
period of two years. NCEMS reserves the right to perform unannounced site visits
to hospitals on diversion status to ensure compliance with this policy.