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Local EMS Agency Ambulance Diversion Policies — San Francisco

EMS SECTION OF THE SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH

February 17, 1998

ACTION PLAN FOR REDUCING HOSPITAL DIVERSION

Hospital diversion of ambulances is a multi-faceted problem due to its impact on EMS system patients, providers, and EMS system readiness for the next urgent 911 call. Ambulance patients diverted from hospitals are subject to potential delays in their definitive emergency care. Also, patient continuity of care is interrupted as patients arrive at hospitals that are not a part of their usual primary care system. Ambulances, when forced to by-pass closer hospitals to deliver patients, are taken out of service longer. With more ambulances out of service, the medical 911 system is unable to quickly respond to the next 911 request for emergency medical assistance. Additionally, ambulances utilized for transferring patients to their original intended hospital destination are not available for 911 response. Finally, our EMS system’s hospitals are unable to receive their contracted patient population forcing later repatriation of patients after emergency department or hospital admission and thus delaying their definitive care.

The EMS Section is dedicated to providing a superior standard of excellence in the delivery of emergency medical services to the residents and visitors of the City and County of San Francisco. It remains crucial that EMS patients are able to get to the appropriate hospital in the most expeditious manner possible. All EMS System participants are committed to implementing the necessary system changes to minimize hospital diversion. The EMS Section is the lead-coordinating agency in bringing about those changes, in conjunction with the San Francisco Fire Department, the Private Ambulance Providers, and the Hospital Council of Northern California, the San Francisco Diversion Policy Task Force, and all Local Hospitals. The EMS Section is recommending that system providers enact the steps outlined in this Action Plan. The intent of this Action Plan is to minimize hospital diversion and its impact on both EMS system patients and providers.

ACTION PLAN FOR REDUCING HOSPITAL DIVERSION — EXECUTIVE SUMMARY of GOALS & TIMELINES:

February 17, 1998

HOSPITAL BASED ACTIONS
GoalsTimeline

SHORT TERM:

1. Develop Strategic Action Plan for Reducing Hospital Diversion.

Completed Dec ‘97

2. Standardize hospital critical care and total diversion practices.

Jan – Mar ‘98

3. Develop On-Line Communication between Hospitals and Medical Dispatch to Improve Flow & Distribution of Ambulance Patients to Emergency Departments.

Mar – Apr ‘98

4. Identify Current Number of Critical Care and Emergency Department Beds for the City and County of San Francisco.

Jan – Feb ‘98

5. Identify New Strategies for Hospital Diversion Avoidance.

Dec ‘97 – Feb ‘98

LONG TERM:

6. Increase staffed critical care beds in San Francisco to meet documented need.

Summer 1998

EMS BASED ACTIONS

SHORT TERM:

1. Identify impact of diversion on EMS patient outcomes.

Dec – Feb ‘98

2. Develop On-Line Communication between Hospitals and Medical Dispatch to Improve Flow & Distribution of Ambulance Patients to Emergency Departments.

Mar – Apr I’98

3. Improve Dispatch Management for the Flow & Distribution of Ambulance Patients to EDs.

Spring ‘98

LONG TERM:

4. Improve dispatch triage of EMS patients to the appropriate hospital and non-hospital destinations.

Summer ‘99

5. Improve field triage of EMS patients to the appropriate hospital and non-hospital destinations.

Summer ‘99

6. Improve Dispatch Technology for Managing the Flow and Distribution of Ambulance Patients to EDs.

Summer ’98 -

Early 1999

HOSPITAL BASED ACTIONS
GoalsObjectivesActivities/TasksDeliverables / Responsible PartyTimeline

SHORT TERM:

  1. Develop Strategic

    Action Plan for Reducing Hospital

    Diversion

  1. EMS Agency and Hospital Stakeholders will meet to develop a strategic action plan for reducing diversion.

1.1.1 Hospital Council to convene San Francisco Hospital Diversion Task Force meeting.

1.1.2 Actions for reducing hospital diversion to be identified during meeting.

  • Action Plan for Reducing Hospital Diversion

Cheryl Fama, St. Francis Hospital, Chair

Nathan Nayman, Hospital Council - Staff

Completed –

December 1997

2. Standardize hospital critical care and total diversion practices.

(Currently, internal criteria used for diversion vary from hospital to hospital making it difficult to do valid comparisons of diversion activities among the EMS system’s hospitals).

2.1 Develop uniform internal diversion criteria for San Francisco hospitals.

2.1.1 Complete assessment of contributing factors for diversion (staffing, bed availability, and status of ancillary services, etc).

2.1.2 Identify uniform criteria for application of Critical Care and Total Diversion (when and how to use it).

2.1.3 Standardize measures for avoiding diversion.

2.1.4 Implement criteria.

  • Uniform Internal Diversion Criteria for San Francisco Hospitals

Cheryl Fama, St. Francis Hospital

Nathan Nayman, Hospital Council - Staff

January – March 1998

BASED ACTIONS
GoalsObjectivesActivities/TasksDeliverables / Responsible PartyTimeline

3. Develop On-Line Communication between Hospitals and Medical Dispatch to Improve Flow & Distribution of Ambulance Patients to EDs.

(Currently, medical dispatch does not triage ambulance disposition of patients to hospitals. There are no active means to evenly distribute ambulance patients to avoid overloading a hospital. If a hospital is busy, but not at capacity, the only means to slow ambulance traffic is to use diversion).

3.1 Develop ambulance system status management for hospitals by initiating "pre-diversion alerts" for dispatch to identify impending hospital diversion.

3.1.1 Identify uniform criteria for application of "pre-diversion alerts" (when and how to use it).

3.1.2 Evaluate feasibility of using CHORAL system for "pre-alerts."

3.1.3 Add "pre-diversion alert" status to CHORAL computer.

3.1.4 Test "pre-diversion alert" status on CHORAL computer.

3.1.5 Coordinate with the EMS Section to develop policies and procedures for "Pre-diversion alert" status.

3.1.6 Coordinate with the EMS Section for hospital staff training on the use of "pre-diversion alerts" (hospital input of data).

3.1.7 Coordinate with the EMS Section for training medical dispatch staff on the use of "pre-diversion alerts."

3.1.8 Coordinate with the EMS Section for training field paramedics and supervisory staff on the use of "pre-diversion alerts."

3.1.9 Develop on-going forum for field and hospital communications.

  • Addition of Pre-Diversion Alert Status to EMS Section Diversion Policy & Procedures.
  • Hospital use of CHORAL system to announce "pre-diversion" alerts.

Mary Magocsy, EMS Section

Nathan Nayman, Hospital Council

March – April 1998

4. Identify Current Number of Critical Care and Emergency Department Beds for the City and County of San Francisco.

(The optimal number of critical care and beds and ED beds for San Francisco is currently unknown).

4.1. Complete evaluation of staffed Critical Care bed and Emergency Department capacity for San Francisco.

4.1.1 Survey number of emergency department beds and staffed critical care beds.

4.1.2 Compare with previous levels of staffed critical care beds and current/historical trends of patient acuity levels.

  • Documented number of Emergency Department beds and Critical Care beds.
  • Report to Health Commission on ED and staffed CC bed capacity.

Nathan Nayman, Hospital Council

January – February 1998

HOSPITAL BASED ACTION
GoalsObjectivesActivities/TasksDeliverables / Responsible PartyTimeline

5. Identify New Strategies for Hospital Diversion Avoidance.

(Operational Staff may identify new venues for addressing diversion issue. Temporarily increasing staffing levels or "staffing up" may be another method to accommodate increased patient volume).

5.1 Convene a City-wide Meeting with Hospital Staff on Duty During Holidays to Solicit Input on Avoiding Diversion.

5.2 Evaluate feasibility of rotation of "staffing up" among local hospital.

5.3 Increase the capacity of the Receiving Hospital system with the addition of the Veteran’s Administration and Chinese Hospitals

5.1.1 Hospital staff roundtable with ED, critical cares staffs on to Brainstorm Other Potential Solutions to Avoiding Diversion.

5.2.1 Define evenly rotated schedule of "no divert" hospital(s) so that staffing up costs may be evenly spread within the local hospital system.

5.2.2 Implement rotating schedule of "no divert" hospital(s) if feasible.

5.3.3 Assist the VA and Chinese Hospitals with the completion of reporting and other system requirements

  • Potential new strategies for diversion avoidance.

Cheryl Fama, St.Francis; Nathan Nayman, Hospital Council; John Brown, EMS Section

  • Rotating schedule of "no divert" hospital(s).

Nathan Nayman, Hospital Council

  • Incorporate appropriate changes in EMSS Receiving Hospital Policy

Mary Magocsy EMS Section

City-wide Emergency Department Staff Meeting held on Friday, December 5, 1997

January – February 1998

January – February 1998

LONG TERM:

6. Increase staffed critical care beds in San Francisco to meet documented needs.

(Currently, there is a shortage of critical care nurses in San Francisco).

6.1 Increase available pool of hospital critical care nurses.

6.2 Identify other potential staffing solutions.

6.1.1 Establish critical care training program for staff nursing personnel, especially new graduates.

6.1.2 Coordinate possible critical care nursing training among hospitals.

6.1.3 Cross train nursing personnel (E.D.- ICU) for critical care and non-critical care work.

  • Increased available pool of hospital critical care nurses for San Francisco.

Nathan Nayman, Hospital Council

Summer 1998

EMS BASED ACTIONS
GoalsObjectivesActivities/TasksDeliverables/ Responsible PartyTimeline

SHORT TERM:

1. Identify impact of diversion on EMS patient outcomes.

(Currently, diversion statistics provide information only on what hospitals have diverted and for what length of time. There is no information available on the numbers of patients diverted or its impact on patient outcome).

1.1 Complete short-term study on diversion.

1.1.1 One month paramedic study on diversion - survey paramedics on patient diversion (requested vs. actual destination; reason for diversion; patient outcome; estimated time).

  • Final Report to Health Commission on the impact of diversion on EMS patient outcomes.

John Brown, EMS Section

Marshal Isaacs, SFFD

Rich Shortall, SFFD

Lann Wilder, AMR

Ray Lim, King & American Amb.

December – February 1998

2. Develop On-Line Communication between Hospitals and Medical Dispatch to Improve Flow & Distribution of Ambulance Patients to EDs.

(Currently, medical dispatch does not triage ambulance disposition of patients to hospitals. There is no active means to evenly distribute ambulance patients to avoid overloading a hospital. If a hospital is busy, but not at capacity, the only means to slow ambulance traffic is to use diversion).

2.1 Develop ambulance system status management for hospitals by initiating "pre-diversion alerts" for dispatch to identify impending hospital diversion.

2.1.1 Identify uniform criteria for application of "pre-diversion alerts" (when and how to use it).

2.1.2 Evaluate feasibility of using CHORAL system for "pre-alerts."

2.1.3 Add "pre-diversion alert" status to CHORAL computer & test system.

2.1.4 Coordinate with the EMS Section to develop policies and procedures for "Pre-diversion alert" status.

2.1.5 Coordinate with the EMS Section for hospital staff training on the use of "pre-diversion alerts" (hospital input of data).

2.1.6 Coordinate with the EMS Section for training medical dispatch staff on the use of "pre-diversion alerts."

2.1.7 Coordinate with the EMS Section for training field paramedics and supervisory staff on the use of "pre-diversion alerts."

  • Addition of Pre-Diversion Alert Status to EMS Section Diversion Policy & Procedures.
  • Hospital use of CHORAL system to announce "pre-diversion" alerts.

Mary Magocsy, EMS Section

Nathan Nayman, Hospital Council

March – April

EMS BASED ACTIONS
GoalsObjectivesActivities/TasksDeliverables/ Responsible PartyTimeline

3. Improve Dispatch Management for the Flow & Distribution of Ambulance Patients to EDs.

(Currently, medical dispatch does not triage ambulance disposition of patients to hospitals. There is no active means to evenly distribute ambulance patients to avoid overloading a hospital. If a hospital is busy, but not at capacity, the only means to slow ambulance traffic is to use diversion).

3.1 Develop system "fleet manager" position at dispatch.

3.1.1 Designation of fleet manager position for SFFD dispatch.

3.2.1 Development of fleet manager training plan, CQI plan, and system provider orientation to system management.

Management of Flow and Distribution for Ambulance Patients to EDs by Fleet Manager at SFFD dispatch.

Chief Robert Demmons, SFFD EMS Division

Spring 1998

LONG TERM:

4. Improve dispatch triage of EMS patients to the appropriate hospital and non-hospital destinations.

(Currently, dispatch triage standards are being implemented. There are no formal Dispatch triage options for patients who do not require an ambulance. Revised triage criteria can include patient referral service).

4.1 To expand dispatch triage standards to include referrals.

.1.1 Expand Criteria Based Dispatch Guidelines to include referral resources.

4.1.2 Train dispatch personnel on expanded guidelines.

4.1.3 Implement expanded guidelines.

  • Referral resources in Criteria Based Dispatch Guide lines.

Mary Magocsy, EMS Section

Summer 1999

EMS BASED ACTIONS
GoalsObjectivesActivities/TasksDeliverables/ Responsible PartyTimeline

5. Improve field triage of EMS patients to the appropriate hospital and non-hospital destinations.

(Currently, there is a limited set of field triage standards for paramedics for hospital only transport. Revised triage criteria can include patient referral services or expand potential patient destinations to include hospital and non-hospital destinations (i.e., referrals, clinic transports, etc.).

5.1 To develop uniform triage standards for field operations.

5.2.1 Develop expanded list of field triage criteria to include hospital and non-hospital destinations.

5.2.2 Automate field triage criteria (Any field triage system is limited to easily remembered short lists of criteria. Automation of criteria overcomes this limitation).

5.2.3 Train hospital and paramedic personnel on field triage criteria.

5.2.4 Implement field triage criteria.

5.2.5 Develop non-emergency department receiving sites.

  • Expanded list of field triage criteria (includes hospital and non-hospital destinations).

Micki Cianciosi, EMS Section

Summer 1999

6. Improve Dispatch Technology for Managing the Flow and Distribution of Ambulance Patients to EDs.

(More accurate information on ambulance geographic positioning within the city will improve ambulance system status management by fully visualizing status of Hospitals in conjunction with ambulance flow).

6.1 To evaluate feasibility of using ambulance AVL system for hospital diversion.

6.1.1 Evaluate feasibility of using ambulance AVL system for hospital diversion.

6.1.2 Install technical components for ambulance AVL system for hospital diversion.

6.1.3 Train paramedics, dispatchers, and hospitals on use of ambulance AVL system for hospital diversion.

6.1.4 Implement ambulance AVL system for hospital diversion.

  • Feasibility study (system modifications & cost).

John Brown, EMS Section and Nathan Nayman, Hospital Council

  • Ambulance AVL system for hospital diversion.

Chief Robert Demmons, SFFD EMS Division,

Private Ambulance Providers

Summer 1998

Early 1999

GLOSSARY:
Automatic Vehicle Locator (AVL) System
An ambulance tracking system used to monitor the location and movement of ambulances within a particular geographic area (i.e. within the City and County of San Francisco). This system utilizes radio transmissions and the Global Positioning System, a satellite geographic positioning system.
Computer Aided Dispatch (CAD)
The mainframe computer used at medical dispatch for tracking ambulance requests for medical assistance and the dispatches of ambulance resources.
Computerized Hospital On-line Resource Allocation Link (CHORAL)
The CHORAL System is a software system and computer network that provides a communication link between Receiving Hospitals, CMED, and other EMS System participants. It tracks hospital resources and diversion status.
Critical Care Diversion (CC Diversion)
When a Receiving Hospital determines, through pre-established criteria, that the hospital is unable to accommodate additional critical care patients due to the availability or staffing of critical care beds AND reports this change in status to CMED and the Base Hospital.
Total Diversion
When a Receiving Hospital Emergency Department determines, through pre-established criteria, that the Emergency Department is unable to provide care to additional ambulance patients AND communicates this change in status to CMED and the Base Hospital.
System Status Management
Medical dispatch management of the allocation and deployment of all EMS response resources.

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