Organization Title


Local EMS Agency Ambulance Diversion Policies — Riverside


  • General Policy (BLS/ALS) Policy: 5310

Date: 4/1/97

  1. The purpose of this policy is to define when it is appropriate for Riverside County receiving hospitals to go on ambulance diversion.
  2. Hospitals shall make every attempt to prevent diversion of ambulances. However, in certain circumstances patients may be diverted. PATIENTS WITH AIRWAY COMPROMISE SHALL NOT BE DIVERTED.
  3. ED Overload Definition
    1. The acceptance of another patient with a life-threatening illness or injury would severely compromise patient care and safety (volume and acuity of patients at the time are the determining factors) or
    2. An internal disaster, HAZMAT, or similar unusual internal situation has occurred.
    3. ED overload shall not preclude a Base Hospital from providing on-line medical control.
    4. Neither in-patient staffing nor census may enter into the decision to divert.
  4. The decision to divert is made as permitted by hospital policy. The following steps are then taken:
    1. The Charge Nurse updates the EMS Agency and all local ambulance dispatch centers when going on and off diversion.
    2. Internal notification steps are taken in accordance with the needs of each hospital.
  5. When the two closest hospitals to a patient are both on diversion, the ambulance will take the patient to the closest, most appropriate facility regardless of its diversion status.
  6. Trauma Center Diversion
    1. Trauma cases may be diverted if one or more of the following conditions exist:
    2. If the CT scanner is inoperable, isolated head injuries may be diverted.
    3. Surgery is at maximum capacity and another crew cannot be mobilized. The O.R. will keep the emergency department notified of status.
    4. Trauma diversion will occur utilizing the same hospital specific internal authorization channels as specified above.
    5. If the closest trauma center is on diversion, the patient should be transported to an alternate trauma center within 45 minutes from the initial scene.
    6. In cases where an alternate trauma center is greater than 45 minutes from the initial scene, the patient shall be transported to the closest most appropriate facility.
  7. Diversion Evaluation
    1. The EMS Agency will provide regular reports to each Emergency Department Manager of the diversion data for that hospital that will include: dates, times on and off diversion, reasons listed for the diversion, initials and any comments or special circumstances.
    2. A report will be sent to the PCAC and EDDAC, for the purpose of evaluating opportunities for continuous quality improvement.
    3. Diversion records shall become part of the Continuous Quality Improvement process within each hospital and the EMS Agency.

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