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Local EMS Agency Ambulance Diversion Policies — Fresno, Kings, Madera

FRESNO/KINGS/MADERA EMS AGENCY

  • Manual: Emergency Medical Services Administrative Policies and Procedures Policy Number: 547.1
  • Subject: Hospital Diversion of Ambulance Patients
  • Reference: American College of Emergency Physician's Position Paper
  • Effective: 02/15/93
DEPARTMENT OF HEALTH POLICIES AND PROCEDURES
  1. POLICY:

    Ambulance patient destination shall be determined consistent with EMS Policy #547 - "Patient Destination". However, patient destination may be modified based upon significant changes in hospital resources, such as a hospital patient overload or lack of a specific type of medical equipment (e.g., CT scanner). In such a case, diversion of ambulance patients shall not occur as a unilateral decision, rather it may occur, consistent with approved procedures, with the mutual agreement of the diverting hospital and the hospitals who would receive diverted patients. In the absence of such agreement, normal destination criteria shall be utilized.

  2. PURPOSE:

    This policy has been developed to provide an organized approach to ambulance diversion by providing the framework for communication between hospitals and EMS provider agencies. Ambulance diversion is the temporary redirecting of patients from the desired hospital to another destination due to conditions that may reduce that hospital's ability to provide appropriate patient care. Diversions are temporary and may be triggered by events such as overcrowding, fire, work action, or equipment failure. Diversions are different from triage or bypass policies, which are on-going preset protocols to route patients to facilities capable of providing a more sophisticated level of care for a particular situation, such as trauma or burns.

  3. STATUS DEFINITIONS:

    A hospital's divert status will be assigned to a hospital by on-call EMS Agency staff as a means of communicating that hospital's status to the rest of the EMS System.

    1. "Open Status" - A hospital is on "open" status when it will be receiving patients consistent with the destination criteria outlined in EMS Policy #547.

    2. "Case-by-Case Status" - A hospital is on "case-by-case" status when, consistent with approved procedures, it is diverting patients case-by-case for a specific reason.

    3. "Closed Status" - A hospital is on "closed" status when it is on a general diversion and is closed to ambulance patients or a specific type of patient condition.

  4. PROCEDURE:
    1. The diversion of ambulance patients is strongly discouraged and shall not be utilized as a means of selecting patients based upon financial status, relieving workload at a hospital, or as a mechanism for relieving a hospital of its obligation to provide emergency services under applicable federal and state laws.
    2. Hospitals should divert patients from the emergency department only when they are incapable of providing a minimally acceptable level of care; provided that medically safe alternatives are available.
    3. The diversion of ambulance patients may be appropriate when a specific hospital service is hampered by an overload of patients or by the failure of a hospital system (CT scanner). In this situation, case-by-case diversions may be appropriate if there is a nearby facility which provides a similar level of service, and agrees to accept the additional patients.

      NOTE: Diverting emergency departments should attempt to accept and treat critically ill or injured patients whose condition might be jeopardized by diversion (even if there in not bed space for subsequent admission - e.g. full ICU) unless the hospital is not capable of providing for the patient's immediate medical needs. If the hospital can care for the patient's immediate needs, the patient would be treated, stabilized (if possible), and then transferred for admission.

    4. Categorical or general diversions of ambulance patients ("closed status") should be utilized in very limited situations. This would include a massive failure in a hospital's ability to provide emergency services (electrical failure, work action, etc. . . .). Prior to considering general diversions, a hospital must exhaust internal responses to the overload (e.g., backup staff or equipment).

      In most cases, general diversions should only occur at the point that the hospital is considering closing its emergency department to both ambulance and walk-in patients.

    5. Each receiving hospital shall have an internal written policy or protocol which defines the point at which either case-by-case diversion or general diversion ("closed status") should be considered internally by the hospital. This should include some general criteria and procedures for managing peak loads (e.g. multiple intensive care patients being held in recovery areas) and procedures for recalling or reassigning staff to deal with peak overloads. The internal protocol shall additionally delineate the internal hospital procedures for gaining approval for both case-by-case diversions and general diversion.

      The internal protocol shall identify a specific staff position within the hospital (available 24 hours a day) which would be the contact point for internal personnel to initiate a diversion status for the hospital, as well as a contact point for other hospitals and the EMS Agency to contact regarding diversions. The title and 24-hour phone number for this position shall be provided to the EMS Agency. This individual should be knowledgeable on both the internal hospital procedure and this EMS procedure for diversion and should understand the system-wide implications of diverting ambulance patients.

      Examples of positions which would be utilized for this purpose could include on-duty emergency department supervisor, house supervisor, or emergency department physician. Each hospital should select the position which most effectively functions within the hospital's internal management structure regarding implementation of hospital diversions.

    6. In order to implement either case-by-case or general diversions ("closed status"), the following procedure shall be followed:
      1. The diverting hospital's designated contact person shall make all appropriate internal notifications and receive all necessary internal approvals for seeking a diversion, consistent with the hospital's internal protocol regarding diversion of patients.

        NOTE: If the cause of the diversion allows for some advance notice (such as a scheduled power outage due to construction or a possible work action), contact EMS Agency staff as soon as possible to advise them of the situation.

      2. The designated contact person at the diverting hospital shall contact the EMS Dispatch Supervisor at the Fresno County EMS Communications Center at 456-7800 and advise of intent to divert patients. For general diversions, the EMS Staff person on-call shall make contact with the designated contact at the requesting facility to discuss the initiation of the diversion plan.

        1. For Fresno and Madera County hospital diversions, the designated contact person shall request the initiation of a HEAR radio all-call for diversion notification. The EMS Dispatch Supervisor will initiate the following actions:
          1. Initiate a HEAR radio all-call. Conduct a roll-call of all hospitals. Once each hospital identified, make an announcement of the following information:
          2. Hospital _____ is requesting the initiation of a diversion of ambulance patients due to ______________________.
          3. There will be a HEAR radio broadcast by Hospital _____ at _____ hours (10-15 minutes from now) to discuss this proposed action.
          4. Each hospital is requested to have their diversion contact person available to communicate with Hospital ____ via the HEAR radio at the time of this broadcast.
          5. Repeat roll-call for acknowledgement.
          6. Notify the on-call EMS Agency staff person and advise them of the time of the HEAR radio broadcast. For general diverts, the EMS staff person on-call will generally participate in the HEAR radio broadcast and will clarify the proposed diversion plan so that it can rapidly be communicated to prehospital and Base Hospital personnel. If EMS staff is not on-line during the HEAR radio broadcast, the designated contact person shall contact EMS staff through the EMS Communications Center to request the initiation of the diversion plan.
          7. At the time of the HEAR radio broadcast, the designated contact person at the hospital requesting the diversion will confirm that the representatives of the other hospitals are on-line and ready for the broadcast. The designated contact person will briefly review the cause of the diversion, the type of diversion proposed, the types of patients being affected, and the proposed duration of the diversion. The designated contact person will determine the ability and willingness of these other receiving hospitals to accept the diverted patients.
        2. For Kings County hospital diversions, the designated contact person shall contact the hospitals that may be affected by the diversion for diversion notification. The designated contact person will briefly review the cause of the diversion, the type of diversion proposed, the types of patients being affected, and the proposed duration of the diversion. The designated contact person will determine the ability and willingness of these other receiving hospitals to accept the diverted patients. The EMS Agency shall be contacted to request the initiation of the diversion plan.

      3. After an agreement for diverting patients has been reached with all involved hospitals, the EMS Communications Center, at the direction of EMS Agency staff, will implement appropriate plans to facilitate diversion by notifying appropriate prehospital providers and, if appropriate, Base Hospitals of the diversion plan (case-by-case or closed) and appropriate additional information. This information will be documented on the EMS Dispatch Hospital Diversion Report Form (Attachment A) by the EMS Dispatch Supervisor. Once the form is completed, it should be forwarded to the EMS Agency.

      4. The three types of diversion are:

        1. "CT Diversion" - Implemented by notifing the ambulance dispatch center who will then notify prehospital personnel and Base hospitals. Prehospital personnel shall initiate early Base Hospital contact (using the same Base Hospital as they would in normal circumstances) for patients who may require the use of a CT in order to determine the patient's destination (see figure A).
        2. "Case-By-Case Diversions" - Case-by-case diversions will be implemented by notifying prehospital personnel and Base Hospitals that the hospital is on "case-by-case status" and the type of patients affected by the diversion. Prehospital personnel shall initiate early Base Hospital contact (using the same Base Hospital as they would in normal circumstances) for the type of patients affected by the diversion in order to determine the patient's destination. The Base Hospital will determine the patient's destination based upon the specific needs of each individual patient, as presented through a call-in from prehospital personnel, and, if appropriate, in consultation with the diverting hospital. The hospital which will be receiving the patient will be consulted and agree to receive the patient (see figure B).

          The diverting hospital's emergency department should attempt to accept and treat critically ill or injured patients whose condition might be jeopardized by diversion (even if there is not available bed space for admission - e.g. full ICU) unless the hospital is not capable of providing for the patient's immediate medical needs. If the hospital can care for the patient's immediate needs, the patient would be treated, stabilized (if possible), and then transferred for admission.

        3. "General Diversions" - General diversions will be implemented by notifying prehospital personnel and Base Hospitals of the hospital on "closed status", the type of patients affected by the diversion, and the modified destination criteria. Prehospital personnel will determine the patient's destination based upon the modified destination criteria (see figure B).
      5. The implementation of diversion status will be documented by the diverting hospital's designated contact person on the Hospital Diversion Report Form (Fresno/Madera Counties - Attachment B1, Kings County - Attachment B2). A copy of this completed form will be forwarded to the EMS Agency.

      6. For Fresno and Madera County hospital diversions, the diverting hospital will initiate a repeat HEAR radio broadcast every 4-6 hours throughout the diversion in order to update information and, if appropriate, request continuation of the diversion status.

        For Kings County Hospital Diversions, the diverting hospitals designated contact shall re-contact the appropriate hospitals and the ambulance dispatch center every 4-6 hours throughout the diversion in order to update information and, if appropriate, request continuation of the diversion status.

      7. When a diversion process is being discontinued, the diverting hospital shall promptly notify EMS Agency staff (through the EMS Dispatch Supervisor at the Fresno County EMS Communications Center at 456-7800). In Fresno and Madera Counties, a HEAR radio broadcast will be utilized to notify all affected hospitals of the return to normal operating procedures. In Kings County, the designated contact person shall notify the appropriate hospitals and the ambulance dispatch center (TCCAD) of the return to normal operating procedures. EMS provider agencies will be notified of the return to normal operating procedures by the ambulance dispatch center (TCCAD).
    7. Local hospitals may mutually agree, in advance, on criteria for implementing diversion for selected situations (such as a failure in services (e.g. lab, X-ray)). In this case, such criteria will be added as an addendum to this policy and may allow for immediate implementation of diversion followed by notification of the affected hospitals. This type of procedure may be utilized as long as there is prior mutual agreement between the involved hospitals.
    8. The situation may occur where non-diverting hospitals are unable to accept diverted patients because of their own internal problems in providing care. This may be identified when one of the local hospitals is attempting to initiate a diversion or may occur after a prolonged period of diversion has created a severe increase in workload for one or more of the non-diverting hospitals who have been receiving diverted patients. In this case, the rule - "If all are closed - all are open" -will be utilized. That is, if there is not mutual agreement to divert and receive patients, patients will not be diverted and will be transported to the closest appropriate emergency department according to the normal destination policy. The only exception would be in the case where a hospital has completely "closed" to all walk-in, ambulance, and direct admit patients.
    9. In all "closed status" situations (general diversions by one or more hospitals) and in selected "case-by-case status" situations (as initiated upon the request of the EMS Agency or affected hospitals), a hospital bed inventory will be conducted each day at 1000 hours and 2100 hours. This process can be initiated by notifying the on-call EMS Agency staff.

      In Fresno and/or Madera Counties, the bed inventory will be conducted via the HEAR radio. The initiation of the bed inventory procedure will be announced by a HEAR radio alert by the Fresno County EMS Communications Center. Each bed inventory will be initiated and coordinated by Valley Medical Center. In Kings County, the initiation of the bed inventory shall be conducted by the Base Hospital by landline.

      NOTE: The joint radio coordination between Fresno and Madera Counties is prompted by existing joint disaster communications procedures and does not imply an obligation for either counties' hospitals to accept diverted patients.

      Bed inventory information shall be gathered in the format noted on Bed Status Inventory Report (Attachment C). Each hospital shall utilize the information for transfer coordination. Base Hospitals shall additionally utilize the information for assisting in prehospital destination determination.

ATTACHMENT A
EMS Dispatch Hospital Diversion Report Form
DIVERSION ACTIVATION DIVERSION TERMINATION
DateDateTime TimeEMS Dispatcher Supervisor Hospital Representative Terminating DiversionEMS Agency Representative Hospital Requesting Diversion EMS Dispatcher SupervisorReason For Diversion EMS Agency RepresentativeType Of DiversionGeneral
Case-By-Case (Type):
NOTIFICATION LIST NOTIFICATION LIST
AGENCY/HOSPITALPERSON CONTACTEDTIMEAGENCY/HOSPITALPERSON CONTACTEDTIME
Coalinga City Fire Dept.

935-1134

Coalinga City Fire Dept.

935-1134

Fresno Comm. Hosp. Emer. Dept.

442-3990

Fresno Comm. Hosp. Emer. Dept.

442-3990

Madera Comm. Hosp. Emer. Dept.

673-7946

Madera Comm. Hosp. Emer. Dept.

673-7946

Madera County Ambulance Providers

Madera/Mariposa CDF 966-3621

Madera County Ambulance Providers

Madera/Mariposa CDF 966-3621

Sanger City Fire Dept.

875-6565

Sanger City Fire Dept.

875-6565

Selma City Fire Dept.

896-2525

Selma City Fire Dept.

896-2525

St. Agnes Med. Ctr. Emer. Dept.

431-6285

St. Agnes Med. Ctr. Emer. Dept.

431-6285

TCCAD-Kings County Ambualnce Dispatch 730-3010 TCCAD-Kings County Ambualnce Dispatch 730-3010
University Medical Ctr. Emer. Dept.

251-5466

University Medical Ctr. Emer. Dept.

251-5466

Hanford Community - Kings County 582-4300 Hanford Community - Kings County 582-4300
"All-Call" to all Fresno EMS Providers via Paging System "All-Call" to all Fresno EMS Providers via Paging System

Fresno and Madera County

ATTACHMENT B1

Emergency Medical Services Hospital Diversion Report Form

Date: Time: Hospital:
Reason For Diversion:
Type Of Diversion: General Case-By-Case (Type):

INTERNAL NOTIFICATIONS NOTIFICATION OF HOSPITALS TO RECEIVE DIVERTED PATIENTS
NameTimeApprovedHospitalContact NameTimeApproved
Yes No Clovis Community Hospital

House Manager 323-4000

Yes No
Yes No Fresno Community Hospital

Diversion Coord. 442-6000

Yes No
Yes No Kaiser Permanente Hospital

House Supervisor 448-5555

Yes No
Yes No Madera Community Hospital

E.D. Shift Charge Nurse 673-7871

Yes No
Yes No St. Agnes Medical Center

E.D. Shift Coord. 449-3205

Yes No
Yes No Valley Children's Hospital

House Supervisor 225-3000

Yes No
Yes No University Medical Center

House Service Coord. 453-4000

Yes No

EMS Agency Notification

Contact The Fresno County EMS Communications Supervisor And Ask To Speak With The EMS Agency Representative For Fresno County. 456-7800 EMS Agency Representative Contacted: Time Contacted: Time Of Divert:

Re-Notification Of Continuation Of Diversion

If Diversion Status Continues For A Time Period Greater Than Four (4) Hours, Affected Hospitals And The EMS Agency Representative Shall Be Recontracted Every Four (4) To Six (6) Hours To Confirm Continuation Of Diversion. See Reverse For Flow Chart.
Time For Re-Notification: Time Re-Notification Completed: Time For Re-Notification: Time Re-Notification Completed:

Termination Of Diversion

To Terminate Diversion Status, Contact The Fresno County EMS Communications Supervisor And Ask To Speak With The EMS Agency Representative For Fresno County. 456-7800
Hospital Representative

Terminating Diversion Status:

Date: Time: EMS Agency

Representative Contacted:

Time:

INTERNAL RE-NOTIFICATIONS RE-NOTIFICATION OF HOSPITALS TO RECEIVE DIVERTED PATIENTS
NameTimeApprovedHospitalContact NameTimeApproved
Yes No Clovis Community Hospital

House Manager 323-4000

Yes No
Yes No Fresno Community Hospital

Diversion Coord. 442-6000

Yes No
Yes No Kaiser Permanente Hospital

House Supervisor 448-5555

Yes No
Yes No Madera Community Hospital

E.D. Shift Charge Nurse 673-7871

Yes No
Yes No St. Agnes Medical Center

E.D. Shift Coord. 449-3205

Yes No
Yes No Valley Children's Hospital

House Supervisor 225-3000

Yes No
Yes No University Medical Center

House Service Coord. 453-4000

Yes No

EMS Agency Re-Notification

Contact The Fresno County EMS Communications Supervisor And Ask To Speak With The EMS Agency Representative For Fresno County. 456-7800 EMS Agency Representative Contacted: Time Of Divert:
Forward Photocopy Of Completed Form To The EMS Quality Improvement Coordinator At The Fresno/Kings/Madera EMS Agency.

Kings County

Attachment B2

Emergency Medical Services Hospital Diversion Report Form

Date: Time: Hospital:
Reason For Diversion:
Type Of Diversion: General Case-By-Case (Type):

INTERNAL NOTIFICATIONS NOTIFICATION OF HOSPITALS TO RECEIVE DIVERTED PATIENTS
NameTimeApprovedHospitalContact NameTimeApproved
Yes No Central Valley General Hospital

ED Physician 583-2250

Yes No
Yes No Corcoran District Hospital

ED Physician 992-5051

Yes No
Yes No Hanford Community Medical Center

ED Charge Nurse 582-4300

Yes No
Yes No Yes No

TCCAD - Ambulance Dispatch

After the notification of hospitals, notify TCCAD of diversion at 730-3010 Person Contacted: Time contacted:

EMS Agency Notification

Contact The Fresno County EMS Communications Supervisor And Ask To Speak With The On-Call EMS Agency Representative at 456-7800 EMS Agency Representative Contacted: Time Contacted: Time Of Divert:

Re-Notification Of Continuation Of Diversion

If Diversion Status Continues For A Time Period Greater Than Four (4) Hours, Affected Hospitals and the EMS Agency Representative Shall Be Recontracted Every Four (4) To Six (6) Hours To Confirm Continuation Of Diversion. See Reverse For Flow Chart.
Time For Re-Notification: Time Re-Notification Completed: Time For Re-Notification: Time Re-Notification Completed:

Termination Of Diversion

To Terminate Diversion Status, Contact the Fresno County EMS Communications Supervisor and ask to speak with the EMS Agency Representative at 456-7800
Hospital Representative

Terminating Diversion Status:

Date: Time: EMS Agency

Representative Contacted:

Time:

INTERNAL RE-NOTIFICATIONSRE-NOTIFICATION OF HOSPITALS TO RECEIVE DIVERTED PATIENTS
NameTimeApprovedHospitalContact NameTimeApproved
Yes No Central Valley General Hospital

ED Physician 583-2250

Yes No
Yes No Corcoran District Hospital

ED Physician 992-5051

Yes No
Yes No Hanford Community Medical Center

ED Charge Nurse 582-4300

Yes No
Yes No Yes No
Yes No Yes No

TCCAD - Ambulance Dispatch

After the notification of hospitals, notify TCCAD of continued diversion at 730-3010 Person contacted: Time contacted:

EMS Agency Re-Notification

Contact the Fresno County EMS Communications Supervisor and ask to speak with the EMS Agency representative for Fresno County. 456-7800 EMS Agency Representative Contacted: Time Of Divert:
Forward Photocopy Of Completed Form To The EMS Quality Improvement Coordinator At The Fresno/Kings/Madera EMS Agency.
Attachment C

Emergency Medical Services Hospitals Bed Status Inventory Report
Fresno County and Madera County

Date:

Time:

HOSPITALCRITICAL
CARE
BEDS
TELE
BEDS
MED/
SURG
BEDS
PED
BEDS
OTHER
(PED OR NEONATAL ICU)
TOTAL
BEDS
TOTAL
PATIENTS

 

Chowchilla Memorial Dist.
Clovis Community
Coalinga Regional Med. Ctr.
Fresno Community
Kaiser Permanente
Madera Community
Sanger General
Selma District
Sierra Community
Sierra Kings (Reedley)
St. Agnes Med. Ctr.
Valley Children's
University Medical Center
Veteran"s Administration
Central Valley General Hosp.
Corcoran District Hospital
Hanford Community Hosp.

Instructions:

  1. Complete report for your hospital with the most current information available. If patients are being held for admission, report bed availability as a negative number for the individual category (Example: All Critical Care beds are filled and three (3) patients are waiting critical care admission; report negative three (-3) for critical care beds).
  2. In Fresno and Madera Counties, report status via HEAR radio system at scheduled intervals.

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