Jim Augustine, MDAs the nation’s health care system undergoes its’ stress test, and the nation’s population ages gracefully, the emergency system buffers the rough waters like a solid breakwater.  But in many metropolitan areas, the system has been severely tested by the destructive process known as “diversion” or “rerouting”.  Whatever it is called, or whatever local rules come to guide the process, it results in compromised patient care and angry emergency department staff.

Congratulations to the Emergency Department staffs and patients in the system that voluntarily developed and implemented a “No Diversion” program.  That occurred October 1, 2009, in Washington, DC.  The leaders of that city’s emergency departments and hospitals offered to develop a “no diversion” process after a couple years of discussions, and had the courage to implement the program in the face of the H1N1 outbreak.  The commitment to the trial of “No Diversion” came in June 2009, at a regular meeting of the Emergency Department leaders, a monthly session where the multi-disciplinary group shares data, and solves the problems which challenge all emergency systems.  The ED leaders then garnered the support of the hospital “C-suites”, with the backing of the President of the DC Hospital Association, Robert Malson.  The timing of the process was independent of the flu, which was completing its first peak, but the influenza threat allowed some hospital leaders to complete internal planning with more expediency.

The DC hospitals are busy.  The 8 acute care civilian hospitals have EDs that see about 500,000 patients a year, or about 1,500 patients a day.  There are an additional 6 hospitals in the bordering areas of Maryland and Virginia that see significant volumes of walk-in and ambulance patients from the District of Columbia, and participate in regional emergency system planning with the DC emergency leaders.  Across these hospitals, about 23% of their volume arrives by ambulance.  So in DC, about 400 patients a day arriving by ambulance or helicopter must be accommodated. 

Over the summer months of 2009, the nurse and physician leaders met to develop internal processes that would accommodate the daily and weekly fluxes in both low acuity and critical patients.  As in other metro areas, Mondays, Tuesdays, and Fridays get crazy.  There is uniform recognition that boarded patients are a huge contributor to ED stress that leads to diversion.  So at least two paths of process development needed to occur to facilitate a no diversion program.  First, the ED leaders developed support for the process within the staff of the Emergency Departments, and identified the bottleneck issues.  Second, the ED managers led meetings with hospital staff members responsible for inpatient flow, and established critical links to allow admitted patients to move out of the ED.  The work on the second process was essential to gaining buy-in from the ED staff on the whole process, because most ED physicians and nurses find the boarded patients the most frustrating part of the job.

Outside the ED, the District of Columbia Fire and Emergency Medical Services Department (DC Fire EMS) simultaneously developed programs for communication, patient distribution, and hospital reporting.  The DC Fire EMS ambulances serve all the 911 response demands in the District, and transport policy has been developed over years that allow patient transports to occur in normal operational circumstances, and during “big events”. 

Prior to October, 2009, when too many hospital EDs had requested diversion or closure, the ambulance system would go to “Code Red”, which forced all patient transports to be coordinated by one individual.  The instances of “Code Red” status had been steadily increasing through 2009.  While in Code Red, the Fire EMS “EMS Liaison Officer” or “ELO” would receive a report from each ambulance crew readying a patient for transport, and would specify the hospital that would receive the patient.  The ELO is in place 24*365, and in regular communication with the ED charge nurses and physicians, so is aware of the degree of “busyness” of each ED.  This monitoring process is done by phone or radio.  There are no computer dashboards or other status management systems that link the EDs to each other or to the Fire EMS communication center. 

To facilitate the No Diversion program, Fire EMS does continuous monitoring and active management of patients that are being transported to appropriate receiving facilities, while balancing the distribution of patients such that each facility is processing EMS transports with optimal efficiency and minimal congestion.  The ELO is responsible for assigning all patient transports.   Those assignments are based on the patient’s needs and the real-time status of all local and regional receiving facilities. To manage the two way communication, a second ELO was placed in the Communication Center.  Radio communications were sharpened for all parties, and each hospital now serves as its own Medical Control.

When the program was initiated, it was a trial process.  But it quickly hardened into the full-time policy of the District hospitals.  Incredibly, the month of October was when the H1N1 influenza peaked, and the patients were distributed effectively.  No system breakdown occurred.

A voluntary program of “No Diversion” that is driven by ED leaders is more likely to be successful, and features the talents of emergency department managers in getting a community problem solved.

In DC, no diversion is no problem.