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Discussion

ED Diversion

Just curious to know how other ED's go on diversion. What is the protocol in your ED? Who makes the decision to go on diversion and what is your criteria? My hospital has a no diversion policy, apparently under any circumstances. I got in trouble for closing when we had 4 critical patients, 2 crashing, and one with no pulse or respirations, all the beds were full, people in the hallway and 4 ambulances had called in and the triage rack was full. We were short a nurse, so I was both charge and triage. Our ED runs with 20 beds, 1 doctor, 2 PA's and 6-7 nurses. I was yelled at because I closed without going through proper protocol. We are to notify the nursing supervisor, who will then come to the department and see what is going on. The supervisor then calls the director on call (it was a Sunday, so the director is at home). The supervisor lets the director on call know the situation and the then the director on call says if we can close. My defense was that with acuity in the department and all our resources directed to patients in immeninent danger, I did not feel it was prudent to wait 20 to 30 minutes for someone to tell me I could close. This has been an on going issue in our department, and those of us who do charge are curious how other departments handle it. Any info would be helpful. Thanks!

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    Diversions are really hard. I work in a city where there is a level 4 center that is open until 11 pm. It will see almost anything that can be seen, and sent....but people are afraid of waiting!!!! Even though the wait they are looking at is hours and hours! We have to OFFER diversion to any Triage patient who is level 4 and 5...even some level 3's. And we also have After Hours Clinic Bussiness cards in our triage room. Unfortunately though, all ambulances come to us in the city and surrounding areas!

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    We have to go through the house supervisor who first tries to facilitate the resolution of any underlying issues like bed holds or lack of OR space or lack of ventilators, etc.

    In the last few months, we have gone on diversion due to a malfunction in the OR gas delivery system that caused a delay in surgeries (so trauma diversion only), a lack of ICU space and on one occasion, for an absurd number of patients in the waiting room (89). When did have one day where we considered it for large numbers of critically ill patients, including 4 we recieved at one time but the house supervisor resolved the issue by sending us an icu nurse and personally facilitating one of the patient's admission to the unit.

    I am not a big fan of diversions. When one hospital in our city goes on diversion, everyone fills up quickly and then more people go on diversion and all the patients end up at one place and never get seen. The grid is the grid for a reason. EMS divides the city up as best it can...

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    This is regulated by law - some states do not allow for ambulance diversions at all. If you are in a state that does allow diversion there are still very specific criteria that must be met and so it is appropriate to get your house supervisor involved as you are building toward the boiling point. Your attending MDs can go up their chain of command for guidance too.

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    • Expert

    My experience is very similar to VICEDRN's.

    The Charge can't make the call to go on divert, there is a protocol that has to be followed that satisfies the state/Fed regs.

    EMS was really good at communicating with us and each other, so while the decision tree to divert was in motion they could make the call, based on their location, whether to come to us or go to another hospital.

    Because of all things being equal among the hospitals in the area, in 5 years we only ever had to go on a geographical divert (location determined the hospital).

    We had the added complication of having a separate Peds ED, nurses were usually cross trained and could be pulled to either side, but the patients themselves couldn't physically spill over.

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    • Expert

    Diversion.......that life saving measure to save a drowning department and staff.

    Diversion.......that seven letter word despised by administrators everywhere used by the staff "just because they are a little busy"

    Diversion is a complex multifaceted problem nationwide. Every state has come up with their own version on how to deal with over crowding and significant waiting delays that delay treatment. You need to check with your state and determine what those guidelines are and how they are to be instituted.

    Most (all) states allow for diversion and are very specific about requirements. The onset of diversion regulations was due to dangerous overcrowding and ambulances having to pull over to find accepting hospitals.....causing litigation for death and disability that could be directly caused by these delays.

    Back in 2000 my state instituted a multilevel diversion state wide policy with guidelines about multiple hospitals in one district/area when they go on diversion all are posted back to green. Yet still this caused litigation and delays of treatment as well as some catastrophic consequences when EMS has left their normal coverage area while being covered by neighboring towns and delay of response time causing serious disability and even death. There has been re-evaluation of EMTALA/COBRA and the requirements mandated by law. Massachusetts has now adopted a NO DIVERSION policy as of January 2009. (and it is a struggle) The only diversion at present is BLACK/internal disaster/quarantine.

    I have worked at facilities that allowed the ED staff to make these decision and i have worked at facilities that do not. The facilities that do allow the front line to make theses decisions are not happy with revenue loss and don't feel that the staff is making prudent decisions. Some are just control freaks.

    The facilities where I have worked at in the past decided diversion based on acuity and beds available/movable/staffed (which is still reported daily to MEMA, MA emergency management agency) Individual facility policy was activated after set criteria was met but proper notification of administration/supervision was required.

    Here are some interesting references for New York if you are still there. Call around to the other ED's in your area to see what their protocol they use. Is this something that you will actually be able to change? I would engage your EDMD's to help you. But if this is what senior management wants....you may be stuck. I would also check with the ENA on their position statement bout diversion and Holding.

    I always trained and trusted my charge nurses to make these decisions, they just had to let me know sometime before the end of their shift so I could be prepared in the morning with the numbers and actual documentation in the AM to administration. (I had access to the ED tracking, patients and status at all times from home) I would make a call to the local EMS control to find out actual diversion numbers. If I disagreed.....I would let them know how to handle it next time.

    I don't know if this helped but at least you can see it's not an easy answer.

    http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Holding_Patients_in_the_Emergency_Department_-_ENA_PS.pdf

    http://www.health.ny.gov/nysdoh/ems/pdf/06-01.pdf

    http://www.law.nyu.edu/ecm_dlv4/groups/public/@nyu_law_website__journals__journal_of_legislation_and_public_policy/documents/documents/ecm_pro_065432.pdf

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    • Author

    Thank you for all the feedback. I am not one to quickly go on diversion, and only have actually had to do it one time, when all our resources were stretched to the point that safety was being compromised. There are 5 hospitals in our county and we are the last to go on diversion. Our ED docs are also always involved in the decision, and there are times that they are the ones making the request to close. I guess my big problem is having the decision made by someone who is sitting at home and not actually assessing the situation at home. Also if the decision is made to stay open, send some help and provide support instead of letting us just deal with it. I understand that diversion should only be used as a last resort, but if the policy is going to be no diversion, provide the resources that will keep everyone safe.

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    We close to traumas and transports when we're overwhelmed. It's a decision made by the charge nurse and attending together- nursing supervisor is notified but since they're not on the floor in the department and intimately aware of what's going on, it seems odd to delegate the decision to them.

    Obviously you still deal with walk ins, but it helps to get things under control if we're on divert. And if an ambulance shows up anyways we can't turn them away, so it's really more of a courtesy.

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    Our protocol is nursing supervisor to ER manager to go on divert. Maybe done twice a year, maybe. Not once in '11. We just suck it up and rearrange pts to accomodate. As in svt conversion in hallway, hooked up to lifepack for monitoring.

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