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EDs closed for hours at a time. Ambulances transporting patients to hospitals that take an extra 20 minutes to reach. Overloaded EDs forced to accept patients because all EDs in the area are on diversion status. Do these disturbing scenarios sound all too familiar? While high diversion rates used to occur only in flu season, overcrowded EDs in many areas now are confronting the problem year-round, due to factors such as hospital cost-cutting, an aging population, and the nursing shortage, according to experts interviewed by ED Nursing.
When many EDs in the same area go on diversion status, all must open their doors — even if they’re dangerously overcrowded. "When everyone is on divert, no one is," according to George D. Velianoff, RN, DNS, CHE, executive vice president of nursing for the Emergency Nurses Association in Des Plaines, IL. "Patients will come to the closest facility regardless," he says.
If EDs are experiencing unsafe levels of overcrowding, this situation can put critically ill patients at risk, he stresses. One recent case underscores this danger: When an elderly patient with joint pain arrived at an overcrowded ED in Boston, he was left unattended and died after going into cardiac arrest.
Diversion should be used only as an absolute last resort, says Velianoff. "Usually, when you are on diversion, so is everyone else," he says. "That puts the EMS folk and the patients at risk of driving around town to find a hospital." (See "Communication of a diversion message" and "Desert Springs Hospital diversion plan 2000-2001," in this issue. For a copy of Premier Health Care Services’ diversion decision flowchart, click here.)
Here are effective ways EDs have reduced their diversion rates:
• Create new nursing roles. Two new nursing roles created at Massachusetts General Hospital in Boston have been key in preventing ED ambulance diversion, reports Mary Fran Hughes, RN, MSN, the ED’s nurse manager. An ED "access nurse" receives referrals from physicians who are sending their patients into the ED for evaluation or admission, Hughes explains. "The access nurse is able to assist the referring physician in identifying if it is appropriate for the particular patient to be a direct admit to the inpatient area, bypassing the ED, and can facilitate this process if needed," she says.
A triage nursing supervisor receives all requests for ICU beds, from areas of the hospital such as the ED and externally from other hospitals. "This individual prioritizes the acceptance of patients by the ICUs and coordinates the transfers of patients to the appropriate ICUs," says Hughes.
• Analyze reasons for diversion. At Massachusetts General’s ED, length of stay was examined by diagnoses and treatment modality, says Hughes. "For example, we identified that patients were queuing up waiting for CT scans in our department," she explains. "By working with our radiology colleagues and senior management of the hospital, we were able to install a second CT in the ED."
It also was determined that waits for certain lab test results were prolonging the disposition decision for some patients. "We worked with our laboratory staff and senior management to create an on-site laboratory in the ED for quick turnaround of selected lab tests," says Hughes.
• Create a physician-nurse team. At Massachusetts General, a physician/nurse team was created to begin evaluation of patients who are waiting in the waiting area for an ED stretcher to open up, Hughes reports. "This team initiates lab and X-ray studies, completes screening exams, and starts IV hydration and medications," she says.
• Switch to "internal disaster" mode. Implement "internal disaster" mode to bring resources to the ED and move patients to other areas of the hospital when needed, says Velianoff. "This mode requires a different staffing plan to be put into action, like you do when there is a disaster call," he explains. The "internal disaster" mode also might include canceling of elective admissions and establishing transfer agreements with other facilities in advance, Velianoff advises.
• Don’t allow diversion to be treated as an "ED problem." The ED needs to push the process of reducing diversion rates, but not allow it to be deemed an "ED problem," warns Mary M. MacLeod, RN, BSN, MBA, director of emergency services and pre-hospital care for Hamilton Health Sciences Corp., a four-facility hospital system based in Ontario, Canada. "Find individuals who are willing to bring it to the senior management table for discussion and an action plan," she advises.
Obtain support from a chairperson in the inpatient area and the chief of staff of the physician group, MacLeod recommends. "Do not do this with emotional plea. You need to develop a skilled strategy with some hard data to back it up," she says. MacLeod suggests asking other departments, such as quality assurance, to help with the data indicators and how to present them to get the full effect. The goal is to "tell the story" with data, ask for help from the whole hospital, and give a few recommendations as to how change could start, says MacLeod. (See "Here’s what you need to measure," in this issue.)
• "Stay a bed ahead." Diversion often occurs because of problems securing inpatient beds for ED patients ready to be admitted, Hughes notes. "The senior management of our hospital is working with ED managers to decrease length of stay for admitted patients and increase availability of inpatient beds to the ED," she reports. Availability of testing, earlier discharge times, and staffing and support for the inpatient areas are being addressed, says Hughes. Two areas for additional inpatient beds will be opening over the next several months, she adds.
Constantly ask yourself: "If we have to accommodate one more patient right now, how would that happen?" MacLeod advises. "Most delays come from poor planning or no planning for the what if’ scenario." Plan for seasonal fluctuation in your patient population if there are any, recommends MacLeod. "Patient volumes are greater in the winter in colder climates, so plan for extra beds at this time," she says.
For more information on diversion, contact:
• Mary Fran Hughes, RN, MSN, Emergency Department, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Telephone: (617) 724-4127. Fax: (617) 726-9202. E-mail: firstname.lastname@example.org.
• Mary M. MacLeod, RN, BSN, MBA, Emergency Services and Pre-Hospital Care, Hamilton Health Sciences Corp., Hamilton, Ontario, Canada L8L 2X2. E-mail: email@example.com.
• George D. Velianoff, RN, DNS, CHE, Emergency Nurses Association, 915 Lee St., Des Plaines, IL 60016. Telephone: (800) 900-9659 or (847) 460-4000. Fax: (847) 460-4004. E-mail: GVelianoff@ena.org.
A publication titled Diversion Policy Resource Guide is available from the Emergency Nurses Association. The 12-page softcover guide contains information about developing an appropriate diversion policy to comply with the Emergency Medical Treatment and Active Labor Act. The cost is $7 for members plus a $5 shipping charge and $15 for nonmembers, plus $5 shipping and handling. To order a copy, contact:
Guidelines for ambulance diversion are available from the American College for Emergency Physicians (ACEP). The guidelines were published in October 1999 as a policy resource and education paper (PREP) to supplement ACEP’s January 1999 policy statement on ambulance diversion. Single copies are available free of charge. To order a copy of the policy statement or the PREP guidelines, contact:
• American College of Emergency Physicians, 1125 Executive Circle Drive, Irving, TX 75038-2522. Telephone: (800) 798-1822, ext. 6 or (972) 550-0911. Fax: (972) 580-2816. E-mail: info@ acep.org. Web: www.acep.org. For the January 1999 policy statement, go to "Policies/Resources" and click on "ACEP Policy Statements." Click on "List all policy statements" and scroll down to "Ambulance Diversion." For the October 1999 guidelines, click on "PREPs" on the home page.