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Local EMS Agency Ambulance Diversion Policies — San Luis Obispo County EMS Agency

PREHOSPITAL POLICY

Policy Reference No: 202

Effective Date: 3/1/98

Supersedes: N/A

HOSPITAL DIVERSION
  1. PURPOSE:
    1. To provide a system-wide mechanism for receiving hospital emergency departments to divert ambulances to other facilities when their ability to provide appropriate care for additional patients has been significantly compromised.
    2. To establish standards for initiation and termination of ambulance diversion.
  2. GUIDELINES:
    1. Appropriate reasons to initiate ambulance diversion include:
      1. Critical/unstable patients occupy all suitable emergency department (ED) beds and cannot be immediately transferred to in-patient beds.
      2. Loss of a key resource required for care of specialty cases, e.g., loss of CT scanner for head injuries, operating room disabled for major trauma.
      3. An ED in-house disaster, e.g., fire, flooding, loss of electrical power which compromises patient care/safety.
    2. Based upon the factors, a receiving ED may initiate ambulance diversion for specialty cases or complete diversion of all patients.
    3. The Base Station directing care has the ultimate responsibility to determine whether critical care diversion is appropriate.
    4. Extremely unstable patients, e.g., cardiac, respiratory, or traumatic arrest or post arrest patients are not to be diverted unless an ED in-house disaster has occurred.
    5. Ambulance diversion is not to be initiated because of:
      1. Lack of in-patient staffing or beds.
      2. Key resources being reserved for anticipated elective patient care, e.g., elective surgical cases or radiologic studies.
    6. EDs on diversion status will use all available resources to rectify situations causing diversion in order to return to full receiving status as soon as possible.
  3. PROCEDURE:
    1. Receiving EDs will have a procedure for determining when diversion is necessary based upon the consensus of the ED physician and hospital administration.
    2. The receiving ED initiating diversion will provide to all other receiving EDs and Med-Com the following information by landline or EMS radio:
      1. Type of diversion being initiated: specialty care or complete diversion of all ambulance patients.
      2. Estimated duration of the diversion.
      3. An update on the ED’s diversion status every two hours.
    3. When dispatching transporting ambulances, Med-Com will inform the ambulance personnel of any hospital diversion in effect.
    4. When a receiving ED determines that its diversion status should be changed or suspended, it will immediately inform all other receiving EDs and Med-Com of the change by landline or EMS radio.
    5. No two receiving EDs can simultaneously initiate ambulance diversion without the approval of the EMS Agency Executive Director or Medical Director, or their designee. The initial contact with the EMS Agency Directors will be performed by Med-Com. The only exception to this policy is two EDs initiating specialty diversion for different types of cases, e.g., head injury vs. multiple trauma, which does not require EMS Agency Director approval.
    6. Every receiving hospital will keep a record of all diversions initiated by their ED for a period of two years for possible review by the EMS Agency.

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