How do you decide where to transport?

[ZombieEMT]

I currently volunteer for an organization that has about 6 hospital within a 20 minute transport time. It has generally been our policy that we allow the patient choose where they would like to go. On occassion, if the patient's condition is severe enough, we take the privledge of choice away.

Recently I started working in the southern part of NJ and we only have one hospital in county, meaning the choice does not exist. My question is, does your agency allow patients to choose their destination within reason or simply transport to closest appopraite?

 

[DesertMedic66]

Patient choice unless the patient is critical or does not have what the patient needs (STEMI center, Stroke center, Trauma center).

 

[TheLocalMedic]

Patient choice unless the patient is critical or does not have what the patient needs (STEMI center, Stroke center, Trauma center).

Word. Although I work in an area that has two smallish hospitals within 20 mins of each other. One is really good with ortho surgery, so if we have an ortho trauma we may take a little longer transport to get them to one hospital as opposed to the other, but those cases are few and far between.

 

[Akulahawk]

Patient choice unless we're on system-wide diversion, or if the patient needs a specialty that their choice of facilities doesn't have.

We call that system-wide diversion "round robin." When we go to that status, all ED's are "forced" open and each transport is given a specific destination, no choice.

 

[med51fl]

Patient choice unless the patient is critical or does not have what the patient needs (STEMI center, Stroke center, Trauma center).

This is what we do.

 

[Veneficus]

Think of a hospital and consult the magic 8 ball.

:rofl:

Sorry, couldn't resist. One of those days.

 

[Akulahawk]

Think of a hospital and consult the magic 8 ball.

:rofl:

Sorry, couldn't resist. One of those days.

I've had those days too... Especially when the magic 8 ball seems to answer: "Try Again" every time. :glare:

 

[Veneficus]

I've had those days too... Especially when the magic 8 ball seems to answer: "Try Again" every time. :glare:

Probably best if you are not working codes today.

 

[Akulahawk]

:unsure:

Probably best if you are not working codes today.

:rofl:

 

[Tigger]

Patient choice within reason. If I am in Boston, I don't really want to transport out of Boston. If I am in southern Massachusetts and the patient wants more than a community ED, I have no problem driving to the city.

Company motto is "The answer is yes." so I am not getting any crap from management either.

 

[WuLabsWuTecH]

80% of my patients are not actually emergent so we will transport to patient choice within reason. Our 200 square mile district is divided up into 7 zones and based on where we are we'll usually offer 3 hospitals (which differ based on which zone we are in). This usually is 2 community hospitals and the closest big city hospital.

If a patient needs a specialty center we will go the closest one even if it's not one of the ones on the list. There are a couple of hospitals in the big city that are 10-15 minutes further that we have transported to in extenuating circumstances such as patient just discharged from there, just has surgery there, etc.

Of an interesting note, if we're going to the big city, we actually have a non-diversionary agreement in both big cities that we transport to. The second closest big city hospital and our department have an agreement that if we have been diverted once already, (whether it be by the community hospital or by the closest big city hospital), they cannot divert us based on workload (they can still divert us for something catastrophic like ER flooded or no electricity and generators are off-line, but can't divert us just because they have too many patients.)

This prevents us from hunting for a hospital at the conclusion of what is already a 45 minute-1 hour transport.

 

[Tigger]

Of an interesting note, if we're going to the big city, we actually have a non-diversionary agreement in both big cities that we transport to. The second closest big city hospital and our department have an agreement that if we have been diverted once already, (whether it be by the community hospital or by the closest big city hospital), they cannot divert us based on workload (they can still divert us for something catastrophic like ER flooded or no electricity and generators are off-line, but can't divert us just because they have too many patients.)

This prevents us from hunting for a hospital at the conclusion of what is already a 45 minute-1 hour transport.

Massachusetts state regulations now only allows hospitals to go diversion as a result of internal emergencies and workload is not one of them. Now hunting for an open ED is rare and makes things much easier, I've heard some stories of crews going through two or three EDs to find an open one (call ins are rare and the hospitals did a poor job of alerting ambulances that they were closed apparently).

 

[WuLabsWuTecH]

Oh, another interesting point. The department that covers the 450 miles squard to the south of our 200 miles squared does not offer transport destinations--they will only transport to the community hospital in that region (which happens to own the ambulance service). The reason for that is ostensibly to keep their units nearby and they are exempt from Ohio Trauma Triage Laws due to the fact that they can claim resource hardship if a unit were to go out of the county, but the real reason we believe is that they can bill for the ER stay and a second trip to take the patient to the big city after a trip to the community ER (since they use the same units to do the out of town trips).

The problem is that they are not a very good hospital and people know it. (We actually got yelled at for bringing them a patient who was intubated...)

This has resulted in people calling our dispatcher directly instead of 911, or calling our station line to try and get us out there. We used to still respond when called directly, but now we transfer the call to our dispatcher and wait to make sure the dispatcher picks up. So now people have gotten even more creative--they drive to the boundary between our districts, and then call 911 when they are a few feet inside our district lines. They know that we always offer more than just their community hospital and so if they have a parent who gets treatment in the big city for cancer or something, some people have started doing this...

 

[DrParasite]

I currently volunteer for an organization that has about 6 hospital within a 20 minute transport time. It has generally been our policy that we allow the patient choose where they would like to go. On occassion, if the patient's condition is severe enough, we take the privledge of choice away.

Recently I started working in the southern part of NJ and we only have one hospital in county, meaning the choice does not exist. My question is, does your agency allow patients to choose their destination within reason or simply transport to closest appopraite?

Your agency will dictate what hospitals are within their transport area. In the former, your volunteer organization allows for 6; for your south jersey job, it's only 1. If you only have 1 hospital in the county, and the next nearest hospital is 2 hours away, than everyone goes there, because otherwise the ambulance is unavailable for other jobs.

otherwise, if your volunteer agency picks me up, i want to be take to Columbia Presbyterian in NYC.

I used to work for an urban city agency that would only transport to the hospital in that city. exceptions were traumas went to the trauma center, and peds went to the hospital two towns over. there was a 3rd hospital we would transport to if we were on that side of town, but to be honest, I wouldn't know how to get there without lost. But for 90+% of the time, they went to the local city hospital. it's hard to transported 20 minutes to and back, with there are other calls going on while we one truck was unavailable.

 

[WuLabsWuTecH]

Massachusetts state regulations now only allows hospitals to go diversion as a result of internal emergencies and workload is not one of them. Now hunting for an open ED is rare and makes things much easier, I've heard some stories of crews going through two or three EDs to find an open one (call ins are rare and the hospitals did a poor job of alerting ambulances that they were closed apparently).

Interesting. We have a system here where they have to call a dispatcher to go on diversion and have to give a few minutes notices (I think it's 5). That way, any medics that are already transporting that were about to give report can still give report. I don't mind having hospitals on diversion, but that info needs to be available to me at the time the destination determination is being made.

 

[Bullets]

Tigger how can an ER be closed if the hospital itself is still open?

Depends on your service, they will let you know. Our trauma centers are 20-30 minutes by ground, so i will transport to any hospital within that radius, including Staten Island hospitals.

In NJ, diversion is just a notification, they cant refuse a patient if they present

 

[Medic Tim]

Tigger how can an ER be closed if the hospital itself is still open?

Depends on your service, they will let you know. Our trauma centers are 20-30 minutes by ground, so i will transport to any hospital within that radius, including Staten Island hospitals.

In NJ, diversion is just a notification, they cant refuse a patient if they present

Not sure how it works there but when we are on divert we can only take level 1 and 2 pts to the er. The level 3,4 and 5 go to another. We triage our pts by CTAS .... The hospital uses the same criteria when they triage.

 

[Tigger]

Tigger how can an ER be closed if the hospital itself is still open?

Depends on your service, they will let you know. Our trauma centers are 20-30 minutes by ground, so i will transport to any hospital within that radius, including Staten Island hospitals.

In NJ, diversion is just a notification, they cant refuse a patient if they present

Not sure I understand the question. If the ED is lockdown, the hospital can be still open but the ED will not accept patients. The same would be true of fire or a HAZMAT incident.

My point was that in EDs in Massachusetts rarely go on divert status since they can only declare a diversion in the event of an "internal disaster." If they have too many patients, tough luck. In the last few years the hospitals have come up with solutions to prevent crews from holding the wall and finding a place for every patient (often times the waiting room if indicated).

 

[Simusid]

Tigger how can an ER be closed if the hospital itself is still open?

Depends on your service, they will let you know. Our trauma centers are 20-30 minutes by ground, so i will transport to any hospital within that radius, including Staten Island hospitals.

In NJ, diversion is just a notification, they cant refuse a patient if they present

Southern MA here. One of our ERs flooded (twice actually) and the hospital stayed open. We were diverted up the road a few miles till it was clean and dry.

 

[Veneficus]

Not sure I understand the question. If the ED is lockdown, the hospital can be still open but the ED will not accept patients. The same would be true of fire or a HAZMAT incident.

My point was that in EDs in Massachusetts rarely go on divert status since they can only declare a diversion in the event of an "internal disaster." If they have too many patients, tough luck. In the last few years the hospitals have come up with solutions to prevent crews from holding the wall and finding a place for every patient (often times the waiting room if indicated).

Unfortunately, this is an obvious problem of EMS not understanding the hospital problems.

While every effort is made by EMS to return to service or take another call as that is part of their responsibility, it really does harm patients.

I have personally been in a busy ED when a patient was found dead and nobody even saw that patient prior to their death.

As the hospital staff gets stretched thin, patient care suffers in all areas. The standard of care degrades into "the best we can do."

It is an interesting conundrum. The only 2 viable solutions is for EMS to accept a hospital divert and sometimes transport hours out of coverage area or remove the hospital as the only destination of EMS.

In addition to the training and education problems with this, there is also significant economic interest on the part of both the emergency doctors (who often get paid by the patient) and the hospital itself. (Which is why you get both a doctor bill and a hospital bill when you go to the ED)

But no matter what, any temporary solution will have to involve both parties.