No more diversion in Massachusetts

[Meursault]

http://hosted.ap.org/dynamic/storie...AOL-?SITE=MAHYC&SECTION=HOME&TEMPLATE=DEFAULT

Original bulletin here:
http://www.mass.gov/Eeohhs2/docs/dph/quality/hcq_circular_letters/hospital_general_0807494.pdf

Thoughts?

It seems as if OEMS is trying to solve a very real problem in a backwards and counterproductive way. EDs fill up because there are too many patients getting too much care. Turning away patients is probably a bad idea and isn't possible anyway. Cutting back the amount of time and money spent on ED patients is essentially impossible without changes to the medical and legal climate here.

Mandating that hospitals accept ambulance patients isn't going to solve either of those problems, nor is it going to magically increase the number of beds. OEMS has dumped the responsibility for that on individual hospitals instead. This might not impact quality of care, but it is going to increase wait times.

 

[So. IL Medic]

Here's a thought for discussion: we are required to take patients to the closest appropriate facility.

What if "appropriate" involves a facility with available room in the ER?

 

[reaper]

Any where I have ever worked "Diversion" means they are asking you to go to another hospital. We inform the pt of a long wait time. If the Pt still wants to go to that hospital, then they are taken there. The hospital cannot refuse them, just make them wait. Some states may have other diversion rules in affect.

 

[medicdan]

Below was a post I made last night without doing a complete search, hoping to spark some more debate:

Although I work on an ambulance in Boston that responds to some emergencies, I have to admit, I don’t understand what’s going on.

Boston has the possibly unique situation that we have several Level I trauma centers all within close proximity, with several more Level IIs not far away. Beth Israel and Brigham and Women’s are literally blocks apart (and both Level Is), as well, Children’s Hospital Boston is another block away (a Pedi Level I). We have Mass General (A Pedi and adult Level I) less then three miles from that. In addition, there is Tufts Medical Center (and its floating hospital for children) that stands as a Pedi level I, and is fighting to receive accreditation as an adult level I. Lastly, there is Boston Medical Center (the old City Hospital, which merged with BU medical center East Newton campus, a block away), that is both an Adult and a Pedi Level I. Above is just what is within the city limits.

This super-saturation of medical capacity attracts many patients from outside MA looking for specialized care, but we still have a lot of acute beds to play with in the Boston area.

Mass General is the most often to go on divert, and according to the Boston Globe article cited below, it accounts for 35% of the over 1800 diver-hours last year.

In August, OEMS put out a directive saying that EMS crews no longer have to honor divert status from hospitals. See link below for more details:
http://www.mass.gov/Eeohhs2/docs/dph...entry_plan.pdf
Here is a Boston Globe Article from a few days ago giving a little more detail:
http://www.boston.com/news/local/art...lt_diversions/
and here is what a few medical bloggers have to say:
http://www.kevinmd.com/blog/2008/09/emergency-care.html
http://www.impactednurse.com/?p=553
http://tooldtowork.blogspot.com/2008...iversions.html


Again, I am looking to other Boston area EMTs to understand this problem. Is the end of diversions a good thing for patients? There has been discussion of what happens to medical records? How about for crews, who may have to wait at triage? How about for floor patients, who may be discharged prematurely to clear beds? How about ICUs?
How do other regions deal with this? Is this phenomenon specific to Boston? Is this a direct result of the move towards mass-insurance? Who is to blame here? Is this all because of ER misuse?
I know I am asking a lot of questions here, but I hope to spark some discussion and debate…

 

[boingo]

All I see it doing is stacking patients in the hallway on my stretcher awaiting a bed, which means I will be out of service much longer now. The MGH has the biggest problem as they are the ones constantly on divert. For some reason the general public believes MGH=Man's Greatest Hospital. The ED is constantly overcrowded, and I think there is much better ED level care to be had elsewhere, but thats just a personal opinion. I much rather go to the Brigham, or the Carney for that matter, assuming not a STEMI or trauma case.

 

[medicdan]

Although I particularly hate the Carney, which I neglected to mention above (its a Level II within the city limits), I do bring a lot of patients there-- although its unfair to compare with MGH-- they are on opposite sides of the city.
I do have to say, I like as a part of their recent construction, that MGH has enclosed that long hallway leading to the ambulance triage area-- we can now stay warm and dry as opposed to some of the temporary options that required waiting in chairs or outside....

At what point are all the Boston trucks going to be tied up in triage, and the privates covering city calls? I wonder when BostonEMS is going to intervene in all of this, or what hand they had in it to start...? Any ideas?

 

[boingo]

I foresee city units avoiding the MGH based on wait. We have had supervisors respond to the hospital to speak with admin about moving patients off stretchers and onto hospital beds, be they at triage or in a hallway. I think the hospitals are going to need to put a few extra beds in the ED hallways, and figure something out.

 

[medic258]

Mass Diversion

I see this as a good and bad thing for Mass EMS providers. As far as patients go, that is another story.

I know that many view Boston hospitals as being the most affected but I assure you those of us in other parts of the state will be more greatly affected. Lets face it, you can't swing a dead cat without hitting a level I trauma center in Boston. http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/trauma_region_map.pdf The problem has been too many hospitals taking advantage of diversion. For example, I have worked in 2 specific systems where the local community hospital will go on diversion for 12-36 hours at a whack with complete disregard to the rest of the community. Unlike other regulations in other states we do not take patients to hospitals if they are on diversion with the exception of specialty centers i.e. trauma, pedi and cardiac.

I understand the theory behind safe staffing levels but if one facility goes on diversion all of those diverted patients start taxing other area hospitals. In my case this adds about 20-25 minutes to my transport. Tack on waiting for a bed at the facility, getting demographics and returning to town these calls go from taking 15-20 minutes to taking 60-90 minutes. One thing that many forget, Boston is not all of Massachusetts.

Let the beating begin!