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Is your emergency department (ED) going on diversion throughout the entire year instead of just the flu season? Are your diversion rates at an all-time high? When your ED is not able to go on diversion, do you feel that the overcrowded conditions are potentially unsafe and unethical for patients?
If your answers to these questions are "yes," circumstances in your ED reflect a growing trend that can endanger patients, says Alan C. Woodward, MD, FACEP, chief of emergency services at Emerson Hospital in Concord, MA. "The system is under significant duress and on the verge of crisis," Woodward warns. "This is going to continue to get worse and worse." Despite taking steps to address the problem, ED managers report record increases in diversion rates and may turn to ethics committees for help.
The problem is receiving attention from medical groups, too, such as the Chicago-based American Hospital Association (AHA). AHA president Dick Davidson, MD, announced recently that ED diversions are part of AHA’s 2001 Advocacy Agenda and the association’s commitment to seeking regulatory relief to improve patient care.
According to Davidson, ED diversions are the result of a larger health care problem including more patients, fewer beds due to mergers, and fewer nurses and support staff. "Hospitals are overregulated. We need to be taking care of people and not taking care of paper," says Davidson. He pointed out that a number of legislative and funding issues have hurt patients’ access to quality care — namely Medicare reimbursements and lack of medical insurance.
"Last summer, our diversion rate was almost as high as the previous winter," says Woodward. "In the last eight months, there were only three days when not a single hospital in eastern Massachusetts was on diversion."
The ED at Massachusetts General Hospital in Boston is on ambulance divert up to 45 hours per week, says Alasdair Conn, MD, FACEP, chief of emergency medicine. "However, ambulance divert merely slows but does not stop the flow of ambulances into the ED," he notes. "Physicians continue to ask patients to come to the ED for evaluation and management."
When more than three hospitals are on ambulance divert, the 911 center opens all of them, says Conn. "This really puts a strain on the ED and is putting patients in danger," he adds. Often, even though the situation in the ED is recognized as unsafe due to overcrowding, hospitals are being denied diversion or are told they must go off diversion, because there is no place to divert patients to, Conn says.
The nursing shortage has compounded the problem, adds Woodward. "The shortage is particularly acute here. Even though we have closed half of the hospital beds in the state, most hospitals can’t even fully staff the remaining beds they have," he says.
Here are effective practices implemented at EDs to address the problem of diversion:
• Decrease patients’ overall length of stay.
Do everything possible to process patients faster, which makes room for the next patient, urges Conn. "We have analyzed patient delays to find out where the road blocks are," he reports. At Massachusetts General’s ED, a satellite lab was opened to improve lab turnaround times, with the goal of staffing it around the clock, he says. "Also, radiology was identified as a bottleneck, so a second helical CT scanner was installed," Conn adds.
However, the ED can’t solve the problem alone — length of stay must be decreased hospitalwide, advises Conn. "Every one-tenth of a day decrease in overall length of stay opens up 12 new beds," he says. Conn recommends transferring patients to subacute facilities when appropriate and hiring additional nurses for the intensive care unit.
• Use hard data as leverage to add additional staff.
At Massachusetts General, nursing and physician workloads were analyzed with a national benchmarking database from the San Rafael, CA-based QuadraMed Corp., reports Conn. "This is a tool that is used elsewhere in the hospital and by many other hospitals in the U.S., so we are able to use the data for benchmarking," he notes. It was determined the ED nurses were putting in workloads equivalent to 150% of the nursing workload at similar institutions, says Conn. "We were working at a high-risk’ percentage," he says. "It’s no wonder we had a high turnover rate."
To bring the percentage down, the ED added 20 more full-time equivalents, including two ED physicians, says Conn. "We argued that one cannot add nurses without adding more administrative positions — we asked for 22, but were given eight — and more physicians," he adds.
Conn also has used work-related value units (WRVUs) to compare the physician workload with benchmarks from the Lansing, MI-based Society for Academic Emergency Medicine. "Although provisional, the annual benchmarks for emergency medicine are about 4,000 WRVU per year," he notes. "Our physicians are working at over 6,000."
• Redirect physician responsibility.
The ED at Massachusetts General has a trauma acute area with 10 beds, a general area with 16 beds, five pediatric beds, and a fast-track area. Recently, a rapid diagnostic unit with six monitored beds opened. "We asked that the attending physicians for our other areas now cover these additional monitored beds," says Conn.
Patients are now triaged as needing a monitored bed in the waiting room, says Conn. "Although emergencies, these are not usually life threatening — abdominal pain with stable vitals," for example," he adds. "We may have 10 or even 20 patients at a time in this category. So there is a risk that they may have to wait hours and become unstable."
The additional ED physician resources are used to relieve the other attending staff, treat the patients in the rapid diagnostic unit, and manage these patients at triage, says Conn. "This new position can also initiate labs or X-rays and provide screening exams," he explains.
• Use an algorithm.
Using a "diversion decision diagram" enables you to focus on necessary activities when you are already very busy, says James J. Augustine, MD, FACEP, CEO of Premier Health Care Services, a Dayton, OH-based physician management group that provides ED staffing and consulting. "You must have a policy, and you must have an expeditious process to carry it out," he stresses. (To see the diversion decision diagram, click here.)
Augustine recommends including the following key points in your policy:
• Address diversion as a hospital problem.
In the Boston area, the number of acute care beds decreased by 35% over the last 10 years, so hospitals are running at very high occupancies, reports Conn.
Because of high diversion rates, a Massachusetts state task force on diversion developed a series of best practices that area hospitals have adopted. Here are some examples that affect the ED, but involve other departments:
To reduce diversion rates, the ED requires buy-in from administration and other departments, Conn insists. "Our hospital CEO realizes that this is a hospital problem, not an ED problem," he says.
For more information about revising or adapting your diversion policy, contact:
• James J. Augustine, MD, FACEP, CEO, Premier Health Care Services, 8111 Timberlodge Trail, Dayton, OH 45458. Telephone: (937) 435-1072, ext. 102. Fax: (937) 435-8626. E-mail: firstname.lastname@example.org.
• Alasdair K. Conn, MD, FACS, Massachusetts General Hospital, Emergency Services, 55 Fruit St., Boston, MA 02114. Telephone: (617) 724-4123. Fax: (617) 726-9202. E-mail: email@example.com.
• Alan C. Woodward, MD, FACEP, Emergency Services, Emerson Hospital, 133 Ornac, Concord, MA 01742. Telephone: (978) 287-3690. Fax: (987) 287-3674. E-mail: firstname.lastname@example.org.
Guidelines for Ambulance Diversion are available from the Dallas-based American College for Emergency Physicians (ACEP). The guidelines were published in October 1999 as a policy resource and education paper (PREP) to supple-ment ACEP’s January 1999 policy statement on ambulance diversion. Single copies are free. 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: email@example.com. Web: www.acep.org. For the January 1999 policy statement, click on "Policies/Resources" and then "ACEP Policy Statements." Click on "List all policy statements" and scroll down to "Ambulance Diversion." For the October 1999 guidelines, click on "PREP available."