# What does diversion mean to you?



## WuLabsWuTecH (Jul 24, 2009)

I heard something interesting just now which got me thinking.

When your hospitals divert, what does that mean to you?  No pts at all?  Only unstable/critical pts?  Just to advise your pt that they'll have possibly a long wait and if they still insist they'll take them?

I just heard a nurse and a medic get a bit nasty on the radio.  Medic called, and nurse advised him they were on divert.  He advised her that the pt was a cancer patient at their facility and wanted to be seen there and to see if they would take her.  The nurse responded, "We are on divert.  It would be UNSAFE for us to take any more patients."  The medic started to get snappy back saying "A yes or no will suffice, and I will advise my patient to try and make another choice but she'll probably just have to transfer here anyway."

I know of other hospitals that will tell them they're on divert but if the patient insists after being informed they might be sitting in triage for a bit.

Working at the area's only childrens hospital, we never divert.  When I was at the adult hospital, we were the area's only Level I trauma center so we also never diverted.  Just wondering what you guys do in cases of diversion.


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## eynonqrs (Jul 24, 2009)

Well where I come from, the hospitals have different types of diversion:

When they are on "critical care", it means that the ICU and Tele floors are full, and more than likely the ER is holding pt's over and don't have any vents or EKG equipment to handle any more CC pt's.

All beds full - means there is no inpt beds left in the hospital, and the ER is holding pt's.

ER diversion - the ER is overloaded and no one else can be accepted. If the pt demands to go there, then they normally accept them [but sometimes with an attitude].

CT Scan warning, if the hospitals CT scan goes down, they warn us not to take any pt's that may need them [i.e. CVA or head injury]

Peds diversion - no peds beds available in the hospital.

We have 3 rather large hospitals in the city of Scranton. 1 is a trauma center, 1 is a Cardiac Center, and 1 is for labour and delivery, peds, and general medical. We also have a small hospital between Scranton and Carbondale which is general medical, it has only 5 ER beds and 1 inpt floor. In Carbondale City it is also only a general medical hospital. 

The area is in Lackawanna County PA [Northeast part of the state.]

There are some days/nights that all 3 hospitals in the city are on ER bypass.

This can be for another topic, but if people that could wait to see their family doctor instead of going to an ER, this diversion problem would not be as bad.


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## Aidey (Jul 24, 2009)

For my agency it depends on the hospital. With 2 of the hospitals it's non-negotiable, diversion means they do not take anyone by ambulance period. If the patient wants to refuse ambulance transport and drive POV to the hospital they can, but we discourage that. 

For the other two, it depends on the situation. One of them will always take acute strokes, and trauma no matter their divert status. They will also take Peds and Labor/Deliver pts if they are on divert because those both go do a different part of the hopsital than the main ED. They are both acute cardiac hospitals, and when they are on divert they will only take cardiac pts if the other hospital is also on divert.


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## JPINFV (Jul 24, 2009)

Massachusetts: As of the beginning of this year the only divert status possible was due to internal disaster. They may be a few other specialty diverts (see below), but none that I know of. 

Orange County, CA: Several divert statuses are possible. Trauma hospitals (2 level 2s, 1 level 1, with another level 1 or 2 right outside of the county) can go on trauma divert to divert trauma patients. All ERs can go on internal disaster or ER saturation divert. In addition, stroke patients can be diverted if the CT is down (CT diversion). This said, diversion only applied to 911 patients and not interfacility patients, but we'd normally try to avoid transporting to hospitals on divert because no one wants to be holding the wall for hours.


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## CAOX3 (Jul 24, 2009)

In my area it means no beds available in the hospital, you can still bring treat and street patients there, just no possible admissions.


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## Epi-do (Jul 24, 2009)

Around here a diversion means the ER is not accepting ambulance patients and you will be diverted, regardless of the situation.  They can have different types of diversion, and they are all pretty self-explainable - total, ID/psych, critical care, ob, etc.


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## wyoskibum (Jul 24, 2009)

As you can see from the other responses, it really depends on the facility as to what it means.  In my old service the hospital would go on "critical divert" if the ICU was full or even sometimes if they didn't have enough staff.

Where I'm at now, our main hospital will divert us to the hospital in the next town if the patient meets a certain trauma criteria.


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## amberdt03 (Jul 24, 2009)

in my area, everytime i've been advised a hospital is on divert, they have said we can still bring the patient there, but we will have to stay with the patient until the er can take over care......so in other words....divert to another hospital


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## TransportJockey (Jul 24, 2009)

If it's something other than University, divert means no patients. If it's University, they'll still take Lvl 1 traumas, since they are the only trauma center in the state


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## paccookie (Jul 25, 2009)

We have two types of diversion - in-county and out-of-county.  In-county means they try to divert everything possible.  Out-of-county means they only try to divert anything coming in from another county.  BUT if a patient requests to come to that facility, they can't turn them away.  They can't turn away anyone who walks in the front doors or who comes in the back doors.  Non-critical patients are often sent to triage if at all possible or EMS may have to wait "on the wall," meaning literally waiting on the wall still on the stretcher while they try to figure out where to put the patient.  Sometimes it can take hours.  Sometimes it only takes ten minutes.  It's frustrating, but that's the way it is when ERs are overcrowded and overworked.  I can see why the nurses get pissed at us, but what can we do when the pt is adamant about going to a particular hospital???

That said, we are a smaller medical center that is trying very hard to grow.  They try not to send patients elsewhere, but sometimes it's unavoidable.  The trauma center 20 minutes north has several types of divert - critical care, neuro, OB, trauma, med/surg, etc.  Just depends on which type of beds are full, but that's mainly for interfacility transfers only.


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## MSDeltaFlt (Jul 25, 2009)

Some hospitals will go on critical care diversion.  Some level I's will go on level II/III transfer diversion.  They won't accept these transfers, but they will accept level I's.  However, they can't go on 911 diversion.  I've even had a metropolitan paramedic tell me his level I center has gone on level II/III 911 diversion.  All level II/III traumas go to the level II center in town.

...if memory serves...


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## marineman (Jul 26, 2009)

Our main hospitals are actually really good about keeping us informed, they will call our dispatch and let us know when they go on diversion and what type of diversion it is. We have a written policy with all the hospitals in the area that if they don't notify us of diversion status prior to the time we call in our radio report we can still bring a patient. 

Only time I've seen it was an ER diversion at a smaller hospital, simply ran out of beds in the ER.


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## WuLabsWuTecH (Jul 26, 2009)

All of the hospitals in our area report to a central location when they go on diversion.  There is only one type of diversion, either you are accepting patients by ambulance, or you are not.  All of them are required to accept unstable patients except in extreme circumstances (power outage AND no backup generator, etc) that would amount to them not being able to stabilize a patient anyway.  Also, trauma centers are never allowed to reject a trauma unless here are the same extreme circumstances present.

At dispatch time we are given a list of hospitals on divert over the radio, and once again when we mark on scene.  (Ex.  "Medic 1 on scene."  "Medic 1, this is dispatch, All hospitals open, 1445" )  When we are running with an MDT, theres a list that pops up telling us who is diverting.

If 3 or more hospitals (we only have 10 hospitals with ERs-9 regular ERs and 1 Pediatric ER) go on divert, one of the dispatchers goes on a triage frequency where we have to request permission to transort a patient before we can do so (except for critical or trauma patients).  The point of doing this is to prevent a 4th hospital from going on divert and therefore possibly causing all the hospitals in a certain part of the city to be effectively closed.


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## Medic744 (Jul 27, 2009)

For the most part where I am divert is a courtesy on our part if we take the patient somewhere else.  If they are able to be stabilized in the ER then we still take them to the nearest appropriate facility.  The only way for a hospital to totally deny an ambulance patient or any patient is to lock the doors and turn out the lights (not joking).  As a courtesy if there is a hospital not on divert for a particular area near the one that is we will take them there, but not always.  We use Houston's medical center as a main destination and there are times the 2 most appropriate are on divert and the patient has to go somewhere, so we go where we need to or the patient wants to.


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## emtbill (Jul 28, 2009)

Just remember that if your patient needs the closest hospital and the nurse on the radio at that hospital is arguing with you to take them somewhere else, take them to that hospital. The hospital will be breaking all sorts of EMTALA and COBRA regulations if they don't treat the patient.


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## WuLabsWuTecH (Jul 28, 2009)

emtbill said:


> Just remember that if your patient needs the closest hospital and the nurse on the radio at that hospital is arguing with you to take them somewhere else, take them to that hospital. The hospital will be breaking all sorts of EMTALA and COBRA regulations if they don't treat the patient.


But if they are overburdened wouldn't that reduce quality of care?  If your trauma is sitting there waiting for 20 minutes since the trauma docs are all in surgery and the trauma bay is still dirty from the last 5 that were in there?

Also, once our dispatchers take over, we have no say in where we go.  Our protocol says that we HAVE to go where the dispatcher tells us to go.


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## redcrossemt (Jul 28, 2009)

Our medical control authority has set the rules very tightly regarding ambulance diversion.

Hospitals in our area can only divert ambulance patients due to internal disasters, or equipment failure (i.e. no CT capability).


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