EMS: Diversion Or Not: That Is The Question?

Paramedic Company 14 to Mercy Hospital, we are inbound with a 68-year-old male, substernal chest pain—”

“Stand by, Paramedic Company 14, this is Mercy Hospital, we have no beds available, you need to divert to another hospital.”

“OK! We’ll try another hospital. This is Paramedic Company 14, we acknowledge your transmission. Paramedic Company 14 to Community Hospital, we are inbound with a—”

“Negative Paramedic Company 14, this is Community Hospital, we are also diverting patients, we have no beds.”

Sound familiar? It seems that hospital diversions are becoming more of an issue for fire services around the country. Fire service EMS managers around the country agree this problem has gotten steadily worse.

What is adding to this problem? Most agree it is a compilation of several things. First, the baby boom population is becoming older and more susceptible to diseases and illness. Also adding to the equation is the fact that managed care has made hospitals more financially accountable for their operations. To save money, hospitals are not staffing as many beds as they once did. Finally, a nursing shortage does not help the matter.

This past winter, the flu season in many parts of the country dramatically impacted this delicate balance of accepting or diverting patients from hospitals.

During the height of the flu season this past January, a St. Louis Fire Department ambulance was diverted from seven different hospitals with a chest-pain patient. One afternoon, the Houston Fire Department found 12 area hospitals on “diversion” status, causing the department to use its Critical Resources Dispatch protocols for the fleet of 62 ambulances. Tucson officials had to meet and change the current diversion policy because ambulances were crisscrossing town, trying to find hospitals to accept patients. As one official said, “It’s gotten to a point where something has to be done, because it’s had a very negative effect on our ability to serve.”

The problem got so severe with the number and variety of closings in the Twin Cities, Minneapolis and St. Paul, that a deal that had been struck last June had to be implemented. That arrangement says only two hospitals can close at any one time in either the west or east metropolitan areas. If a third one says it also needs to close, then all hospitals have to remain open to all patients.

Central Florida, Chicago, Greenville, NC – name your area this past flu season. By mid-January, the federal Centers for Disease Control (CDC) in Atlanta said 21 states were reporting major outbreaks of flu – obviously putting a severe strain on hospitals and fire departments that provide EMS transport.

What many services do not realize is that diversions should be an “advisory” status only. Most hospitals cannot refuse patients unless the facilities are physically closed. Federal laws are in place and apply to participating hospitals. A participating hospital is any hospital which accepts funding from the Medicare program administered by the Department of Health and Human Services, Health Care Financing Administration (HCFA). This applies to virtually all hospitals in the United States, with the exception of specialized hospitals, such as Shriner’s Hospital for Crippled Children.

The federal laws do not apply to just Medicare patients. The chief federal law that prevents hospitals from refusing treatment to patients is the Emergency Medical Treatment and Active Labor Act (EMTALA). The purpose of EMTALA is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to “charity hospitals” or “county hospitals” because they are unable to pay or are covered under the Medicare or Medicaid programs. In essence, hospitals are required by law to screen all patients seeking emergency care and to provide medical treatment to stabilize those patients with emergency conditions or women in labor.

A 1997 report showed that hundreds of hospitals violate the EMTALA laws. The report, Hospital Violations of Emergency Medical Treatment and Labor Act, revealed that between April 1, 1995, and Sept. 30, 1996, over 250 hospitals across the country – listed in the report – were named for violating the federal law.

The report showed that a new type of “patient dumping” was occurring, other than that involving patients who had no insurance. The new trend finds that patients are being “dumped” because their managed care insurance plans refuse to pay for emergency care.

So what are fire agencies, hospitals, and communities doing to address the issue of hospital diversions?

First, patient care and safety should be the central consideration in all diversion decisions. A balance needs to be struck between the safety of patients in the community who may require transport to an emergency room and that of patients who may be currently receiving care in the emergency room.

A decision to divert should be based on the immediate capabilities of the emergency department to care for certain specific categories of patients. For example, an emergency room may be able to accept a fractured leg injury, but cannot accept a gunshot victim, since all the hospital’s trauma teams are tied up and unavailable. To help facilitate this method, standardized terminology needs to be used by everyone in the community as to what is a “total diversion,” “critical diversion” or any other term your community uses.

Objective criteria should be developed to help define when overcrowding in an emergency room leads to unsafe conditions:

  • Diversion policies should allow for the occasional need to minimize transport times of critically ill patients, especially those requiring immediate interventions. Many agree, these patients should be transported to the nearest appropriate facility, unless that facility is physically closed.

  • Inpatient bed availability should not directly affect decisions regarding diversion. There have been many instances of hospitals diverting patients because no beds were available on the floors with the emergency room empty. Diversion should not be indicated if the patient can be stabilized and transported to another hospital.

  • The decision to divert patients should be made by an attending emergency physician in conjunction with the nurse leader who is physically present in the emergency room and should be based upon considerations of patient treatment effectiveness and safety. There have been reported cases when typist clerks put emergency rooms on diversion only because they chose not to work certain shifts.

  • Fire agencies should develop plans with local hospitals or an agency representing the area hospitals if multiple hospitals request diversions.

  • Patient choice should override diversion status. Patients should be advised of the situation at the hospital of their choice and there may be a significant delay receiving treatment. However, if they insist, they should be transported there.

  • Some hospitals have responded to the crunch by adjusting their operational status. Some hospitals have chosen to keep their clinics open during evening hours to handle the extra load of patients of a minor nature who may need some medical care.

One thing is for sure, diversions are a courtesy which fire agencies grant to hospitals. As the population grows older, managed care penetrates health care more and no short-term fix for the nursing shortage appears, diversion problems will continue. Only those fire agencies that aggressively address this issue will provide the best care for their patients.

Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief paramedic for the St. Louis Fire Department and is the vice chairman of the EMS Executive Board for the International Association of Fire Chiefs. He has lectured nationally and internationally on fire-based EMS topics and operates The Ludwig Group, a consulting firm specializing in EMS and fire issues. He can be reached at GaryLudwig@aol.com.