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Not all diversions are alike, according to James J. Augustine, MD, FACEP, CEO of Premier Health Care Services, a Dayton, OH-based physician management group that provides ED staffing and consulting. "Each cause of diversion should have a unique communication associated with it," he states.
Bringing a cardiac arrest or unstable trauma patient to an urban ED that has lost electrical power clearly could endanger the patient, Augustine explains. "Therefore, the reason for diversion should be communicated with the diversion message," he stresses. "If an ED is on diversion due to internal safety issues, that ED should not be utilized except in the most dire circumstances."
You must communicate your "diversion message" to the prehospital system effectively, says Augustine. (See "Communication of a diversion message," in this issue.)
The EMS system can become dysfunctional when facilities begin to reroute, and chaos grows as more EDs come to diversion status, warns Augustine. "The EMS system has a difficult job in understanding and conveying the diversion message," he says. Here are ways to do this effectively:
In some areas, it’s mandated that an unstable patient still must be taken to the closest facility, even if that hospital is on diversion, says Augustine. "That can be a real problem, if the hospital is on diversion because of safety problems within the ED," he adds. When diversion is needed for safety reasons, explain those reasons to EMS, Augustine advises. He reports that the Dayton, OH, area has diverted patients from hospital EDs during the following incidents:
In all of these circumstances, patient care could not be provided, and all ambulance and ambulatory patients were diverted. In several cases, a medic unit was placed at the ED doors to transport away any patient brought by other means to the hospital, Augustine says. The ED staff, working outside at these incidents, provided initial evaluation and stabilization, documented the interaction on paper, and referred the patient to another specific hospital, he explains. "In the hazardous materials incident, no vehicle traffic was permitted into the area of the hospital, so no incoming patients were possible at all," he adds.
When patient safety is at risk, such as loss of utilities at the hospital, you must announce that risk very clearly so that EMS will not deliver patients to you, stresses Augustine. Another goal is for walk-in patients to make the decision to drive to another hospital, he says. Patient care is compromised if the patient has an unstable medical condition that cannot be managed by the EMS crew, says Augustine. "An airway that cannot be captured, IV access that cannot be obtained, antibiotics that are not available, or other lifesaving procedures may be time-delayed if the EMS crew is diverted around the closest ED," he says.
In these circumstances, the rerouting message, which explains that a hospital has been incapacitated and cannot safely receive patients through the ED, should go out through the electronic media to the general public, Augustine advises. "That ED might only be able to manage patients in the back of an ambulance, performing life saving stabilization procedures," he adds. Other diversion messages should go to EMS providers, with instructions to divert certain types of patients to other facilities, he says.
Diversion also can be caused by shortages of available staff, equipment, or beds. Augustine suggests using the term "Potential Care Compromise Situations." Here are examples of this:
"Many dispatchers are police or civilian personnel and must be given an explicitly worded message to deliver," he adds.