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Local EMS Agency Ambulance Diversion Policies — San Mateo COUNTY

PATIENT TRANSPORT AND DIVERSION

APPROVED:

_____________________
EMS Medical Director

______________________
EMS Administrator

  1. DEFINITION
    1. Appropriate Receiving Hospital means that the hospital has no restrictions to receiving this particular type of patient (see Receiving Hospital Policy).
  2. TRANSPORT PRIORITY

    Selection of a transport priority should take into account patient condition, rescuer safety, safety of other motorists and/or pedestrians, as well as other weather and traffic considerations which could affect the safety of transport. These guidelines are meant to supplement, not replace provider discretion.

    1. Priority 1

      The following patients should be transported as soon as possible. Unless extrication is prolonged, interventions prior to transport should only include airway management, ventilatory assistance, chest compression, spinal immobilization, and control of external hemorrhage. Transport should not be delayed for starting IV lines.

      1. Obstetrical
        • Abnormal fetal presentation (leg, arm, buttocks)
        • Third trimester vaginal hemorrhage
        • Prolapsed umbilical cord
        • Severely distressed neonate (e.g. heart rate <120, APGAR <7)
        • Issue Date: August 1, 1998
        • Effective Date: June 29, 1998
        • Review Date: March 2000
        1. Adult patients
          • Systolic blood pressure less than 90
          • Respiratory rate <10/minute or >30/minute sustained
          • Penetrating trauma to head, neck, trunk, or groin
          • Unable to follow simple commands
        2. Pediatric physiologic criteria

          Age < or = 3 years old

          Age > 3 years old

          Respiratory distress Respiratory distress
          Respiratory rate <20 or >50 per minute sustained Respiratory rate <16 or >40 per minute sustained
          Loss of peripheral pulse Loss of peripheral pulse
          HR < 80 or > 180 bpm, sustained HR < 60 or > 160 bpm, sustained
          Systolic BP < 70
          Behavior not appropriate for age Behavior not appropriate for age
          Paralysis Paralysis

          Note: These vital signs are used as a guideline, and are at the high end of a spectrum. A patient with "better" vitals than these may actually be sicker than they appear.

        3. Additional Priority 1 Patients
          1. Inadequate ventilation and/or severe respiratory distress
          2. Cardiac arrest
          3. Shock of any cause
          4. Severe allergic reaction (with respiratory distress or cardiovascular compromise)
          5. Status epilepticus
          6. Patients who do not meet Priority 1 transport criteria may be transported Priority 1 based upon the professional judgment of the EMT-P and/or receiving hospital physician.
  3. DESTINATION
    1. Socioeconomic Considerations

      The selection of a receiving hospital will not, in any way, be based upon the patient's perceived inability to pay, socioeconomic factors, race or ethnicity, or medical conditions except as specified in this policy. If the closest hospital needs to be chosen due to medical conditions, insurance will not play a factor in the determination of the receiving hospital.

    2. The following patients will be transported to the closest appropriate receiving hospital.*
      1. Priority 1
      2. 5150 holds (Welfare and Institutions Code)

      * Note that dual diagnosis patients (5150s with concurrent medical complaints) will be transported to the closest facility able to deal with the most acute problem appropriately.

    3. San Mateo County Jail Inmates
      1. Jail inmates shall be transported to the closest appropriate facility if they meet any criteria in Section 2. above.
      2. All other jail inmates needing ambulance transport shall be taken to San Mateo County General Hospital.
    4. Transport To The Facility Of The Patient's Preference
      1. Patient's facility of preference is defined as the hospital that a patient, or his/her family, or patient's private physician, requests to be the destination.
      2. All patients, except those requiring transport to the closest appropriate receiving hospital, will be transported to the hospital of their preference as long as that hospital is not located more than 20 minutes further than the closest appropriate receiving hospital (exception - on the coast this time parameter is increased to 30 minutes).
      3. A patient who does not specify a facility of preference will be transported to the closest appropriate receiving hospital.
    5. Multiple Patients In One Ambulance

      If more than one patient is being transported in an ambulance, all patients will be transported to the same receiving hospital.

  4. RECEIVING HOSPITAL NOTIFICATION OF TRANSPORT

    The transporting ambulance will contact the receiving hospital at the earliest opportunity.

  5. AMBULANCE DIVERSION
    1. Policy: Hospitals make every attempt to prevent diversion of ambulances. However, in certain circumstances patients may be diverted. Patients with a compromised airway or who are in cardiac arrest will not be diverted.
    2. ED Overload
      1. Definition
        1. All monitors are legitimately in use or;
        2. 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;
        3. An internal disaster or HAZMAT (or similar unusual internal situation).
    3. Neither in-patient staffing nor census may enter into the decision to divert.
    4. The decision to divert is made by the Emergency Charge Nurse and the Emergency Physician. The following steps are then taken:
      1. The Charge Nurse updates the CHORAL computer.
      2. Internal notification steps are taken in accordance with the needs of each hospital.
    5. When the two hospitals closest to a patient are both on diversion, the ambulance will take the patient to the closest appropriate facility, regardless of diversion status, based on patient condition and patient request.
    6. Diversion Evaluation
      1. The EMS Agency will provide a monthly CHORAL report to each Emergency Department Manager of the diversion data for that hospital that will include: date, times on and off diversion, reasons listed for the diversion, initials and any comments or special circumstances notes.
      2. Diversion records will become part of the Continuous Quality Improvement process within each hospital.

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