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Local EMS Agency Ambulance Diversion Policies — San Francisco County

San Francisco County

HOSPITAL DIVERSION POLICY

POLICY REFERENCE NO.: 1010
EFFECTIVE DATE: 01/01/90
SUPERCEDES: 08/10/87

Ambulance Diversion Policy
  1. PURPOSE
    1. To establish guidelines under which Receiving Hospital Emergency Departments divert ambulance patients when it has been determined, through pre-established criteria, that the hospital is unable to accommodate additional patients.
    2. To define procedures for communicating changes in diversion status. To establish guidelines for ambulance provider operations when a Receiving Hospital is on diversion.
    3. To define exceptions to the Ambulance Destination Policy when hospital(s) follow procedures as outlined herein.
  2. DEFINITIONS
    1. 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.
    2. 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.
    3. Computerized Hospital On-line Resource Allocation Link (CHORAL): The CHORAL System is a network of computers, software, radio, and telephone equipment that provides a communication link between Receiving Hospitals, CMED, and other EMS System participants.
  3. POLICY
    1. This policy shall not override or interfere with the Psychiatric and Trauma Center Diversions policies.
    2. Receiving Hospitals shall report diversion status and subsequent changes on the CHORAL System in accordance with established procedures, as described in this policy.
    3. CMED shall use the CHORAL System to obtain the diversion status of Receiving Hospitals and communicate this status to on-duty ambulance personnel.
    4. CMED and Receiving Hospitals shall have personnel trained to operate the CHORAL System on-duty 24 hours a day, seven days a week.
    5. Patients meeting Specialty Care Triage criteria (i.e., Burn, Trauma, Replantation, Obstetrics, and Emergency Department Approved for Pediatrics) shall not be subject to Critical Care or Total Diversion. Receiving Hospitals designated as Special Care Facilities shall continue to receive these patients at all times unless granted exemptions after successfully petitioning the Emergency Medical Services (EMS) Agency. Such petitions shall include:
      1. treat and transfer policies
      2. written transfer agreements
      3. quality assurance standards and reporting mechanisms, and
      4. internal policy and notification process.
    6. The Base Hospital shall retain the ultimate authority in determining ambulance destination. The Base Hospital may override a hospital’s CC Diversion status if, in their judgment, they feel the patient could deteriorate as a result of bypassing a Receiving Hospital on CC Diversion.
    7. In determining ambulance destination, the Base Hospital shall utilize the Ambulance Destination Policy which considers the patient's condition, the patient's location, the patient's requested hospital in the case of medical/surgical transports, the capabilities of the nearest Receiving Hospital, and the diversion status of the Receiving Hospitals.
  4. DIVERSION CATEGORIES

    The ability of the various Receiving Hospitals to receive patients according to their approved capabilities under the Receiving Hospital Agreements shall be determined in accordance with the categories listed below. Ambulance providers shall transport patients to hospitals in accordance with the principles outlined below.

    1. Open

      Receiving Hospitals shall be designated "OPEN" when fully capable of receiving all patients who request that facility and/or would be transported to that facility according to the Ambulance Destination Policy. A Receiving Hospital is Open when the CHORAL System displays their three letter facility indicator in the color "green".

    2. Critical Care Diversion (see Section II Definitions)
      1. A Receiving Hospital shall be on CC Diversion when the CHORAL System displays their three letter facility indicator in the color "yellow" AND the message line displays the words "Critical Care".
      2. Patients Subject to CC Diversion
        1. The following guidelines lists critical clinical conditions which may warrant the diversion of a patient when the closest or desired Receiving Hospital is on critical care diversion:
          1. airway obstruction or respiratory insufficiency with inadequate ventilation
          2. potentially life threatening dysrhythmias
          3. hypotension with shock
          4. imminent respiratory or cardiac arrest
          5. chest pain in the setting of possible myocardial ischemia
          6. hypothermia
          7. altered mental status unresponsive to Naloxone or Dextrose 50% Water
          8. status epilepticus
        2. The Base Hospital has the ultimate authority in determining whether or not a patient is subject to critical care diversion.
        3. Cardiac, respiratory, or traumatic arrest or post arrest patients are NOT subject to CRITICAL CARE DIVERSION.
        4. The paramedic unit shall notify the Base Hospital when destination criteria mandate transport of a critical patient to a hospital on CC Diversion.
    3. Total Diversion (see definition above)
      1. A hospital shall go on Total Diversion only when the Emergency Department has an overload of patients who require immediate attention and, therefore, would not be able to free staff or space should it receive an additional patient requiring immediate intervention. A hospital shall report Total Diversion due to Emergency Department overload only, not due to lack of staffed inpatient medical/surgical or critical care beds.
      2. A Receiving Hospital shall be on Total Diversion when the CHORAL System displays their three letter facility indicator in the color "red" AND the message line displays the words "Total Divert".
      3. When a Receiving Hospital is on Total Diversion, no patient shall be transported to that hospital by ambulance.
      4. Immediately upon remedying the ED overload, the Receiving Hospital shall change their diversion status to Open or CC Diversion on CHORAL as appropriate.
      5. When a Receiving Hospital is on Total Diversion, the on-call EMS Agency staff at their discretion, may:
      6. inquire about the status of the Emergency Department and its ability to treat critically ill patients
      7. inquire if the hospital has initiated its internal Total Diversion policy as well as what actions are being taken to return to Open status.
      8. request the names of the hospital’s medical, nursing, or administrative staff who were contacted to assess and to attempt to rectify the Total Diversion situation.
  5. DIVERSION PROCEDURE

    Hospitals and CMED shall follow the procedures outlined below whenever Receiving Hospital diversion status changes are deemed necessary.

    1. Changing Diversion Status on the CHORAL System
      1. When a hospital determines the need to change their diversion status, hospital personnel shall enter the hospital’s appropriate diversion status on the CHORAL System.
      2. Receiving Hospitals shall confirm on the CHORAL dialing screen that the status change was received by CMED, the Base Hospital at San Francisco General Hospital, and the EMS Agency (designated on the screen as CMD, SFG and EMS, respectively). If the dial-up does not work, hospital personnel shall immediately report the problem to CHORAL (1-800-228-0790) and follow the Back-Up Telephone Procedure, described in Section V.B.1-4.
      3. CMED shall announce to all ambulance personnel by radio any time there is a change in diversion status entered into the CHORAL System.
      4. CMED shall make routine diversion status announcements by radio to all ambulance personnel at intervals no less frequently than every two hours.
    2. Back-Up Telephone Procedure (if CHORAL is inoperable)
      1. The Receiving Hospital shall notify CMED of any diversion status changes via telephone.
      2. CMED shall notify the Base Hospital of any diversion status changes via telephone.
      3. CMED shall announce any diversion status changes to ambulance personnel as stated above.
      4. CMED shall announce any diversion status changes to hospital personnel via HEAR Net, both when there is a change in status and every two hours.
  6. SUSPENSION OF CRITICAL CARE DIVERSION
    1. Definition

      When five or more Receiving Hospitals are placed on a combination of CC or Total Diversion, the EMS Agency may suspend CC Diversion. Patients shall then be transported to the closest hospital not on Total Diversion. Once CC Diversion suspension is lifted, all transports shall be conducted according to the Ambulance Destination Policy.

    2. Procedure For Suspension Of CC Diversion
      1. CMED shall notify EMS Agency staff when the CHORAL System shows five or more hospitals on any combination of CC or Total Diversion.
      2. The EMS Agency shall notify the administrator or their designee at each Receiving Hospital on CC Diversion of the impending suspension of CC Diversion within 60 minutes, if five or more hospitals remain on diversion.
      3. If five or more Receiving Hospitals remain on diversion after the 60 minute notification period, the EMS Agency shall suspend CC Diversion.
      4. The EMS Agency shall notify CMED and the Base Hospital of the suspension of CC Diversion.
      5. CMED shall enter a suspension notification on CHORAL as well as notify the ambulance personnel via field radios of suspension of CC Diversion.
      6. Receiving Hospitals should continue to enter their appropriate diversion status on the CHORAL System when CC Diversion is suspended.
    3. Procedure for Lifting Suspension of Critical Care Diversion
      1. When the Base Hospital notes that there are three or fewer hospitals on CC or Total Diversion, or after six hours of the suspension, the Base Hospital shall call each Receiving Hospital via telephone to verify their diversion status (Open, CC, or Total Diversion).
      2. When it is verified that three or fewer hospitals are on CC or Total Diversion, the Base Hospital shall notify CMED that the suspension is lifted.
      3. The Base Hospital shall call hospitals that remain on CC Diversion to inform them that the suspension has been lifted.
  7. SUSPENSION OF TOTAL DIVERSION

    CMED shall notify EMS Agency on-call personnel when five or more hospitals are on Total Diversion. The EMS Agency may determine that further continuation of the situation might result in a danger to the public health and safety. On consultation with the Director of Public Health, the EMS Agency may suspend the Total Diversion and require all Receiving Hospitals to accept both critical and non-critical patients. This step would be taken after consultation with the hospital administrator or designee and only if it was felt to represent an imminent danger to the public health and safety. If authorized by the Director of Public Health, the procedure for suspending Total Diversion shall follow the same procedure for suspension of CC Diversion as described above.

  8. QUALITY ASSURANCE AND RECORD KEEPING
    1. Problems related to the implementation of this policy shall be reported to the EMS Agency through the Unusual Occurrence Report System.
    2. All Receiving Hospitals shall maintain on file at the EMS Agency a copy of their internal procedures for determining diversion status.
    3. All Receiving Hospitals shall periodically critique their internal diversion procedures for appropriateness of utilization. Receiving Hospitals may wish to keep a record of the hospital’s diversion activity for this use.
    4. When a hospital uses the CHORAL System to change their diversion status, the System automatically records the event in a diversion log. The EMS Agency will monitor and report monthly the diversion activity for all San Francisco Receiving Hospitals. The report shall be edited to exclude hours when diversion is suspended.
    5. EMS Agency staff shall conduct its own review of hospital diversion activity and will report to the EMS Agency Quality Improvement Council (QIC) on the following diversion activity quality indicators:
      1. Unusual events reported by the Prehospital Unusual Occurrence Report System.
      2. A Receiving Hospital is on diversion for an average of more than 15% during any consecutive three month period of review.
      3. A Receiving Hospital is on diversion for 30% during any one month period.
      4. A request for diversion not covered by current policies.

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