Patient Flow Enewsletter
Volume 2, Issue 2
Thursday, April 7, 2005
Resources in this article:
With 21 emergency departments (EDs) to accommodate a population of 2.8 million, San Diego County is fairly typical of similar regions across the country. The county's average age and overall population has climbed in recent years, bringing with it increased demand on the area's already strained healthcare system. At the same time, the facilities to provide acute care are decreasing, with at least four ED closures in the last several years.
By 2002, ambulance diversions were becoming so frequent that the county's emergency care staff repeatedly experienced situations in which nearly all of their EDs were simultaneously on ambulance diversion. While the day of the week and the time of day weren't always predictable, there was an indicator that typically foreshadowed this event.
"The system would be functioning just fine until one or two of the county's larger hospitals could no longer accept ambulance patients," said Gary Vilke, M.D., medical director of San Diego County EMS and associate professor of clinical medicine, University of California at San Diego. "As soon as this would occur, the county's smaller EDs would quickly begin to go on bypass as well, because they simply couldn't handle the shifted volume. Before you knew it, with the domino effect, we'd have 14, 15 or more of our 21 EDs on ambulance bypass."
| The problem in San Diego County eventually became so commonplace that hospitals were on diversion status an average of one out of every four hours. |
In an effort to address the issue before a political mandate - which has occurred in some parts of the U.S. - became a reality in the region, the San Diego County Medical Society recognized that it was time to take action. The Society established an EMS Medical Oversight Committee co-chaired by Roneet Lev, M.D., emergency physician at one of the local hospitals, and Dr. Vilke.
The committee consists of representatives from each receiving hospital ED (including nurse managers and ED directors), paramedic agencies, paramedic base hospitals, the County Division of EMS and the local health care association which represents chief administrative officers and directors from community hospitals, to identify and present potential solutions.
Implementation
When the committee met for the first time, they anticipated it would be many months before they'd be ready to unveil and implement a new system. Committee participants were instead pleasantly surprised to find that they were all able to get onto the same page relatively quickly.
The committee collectively outlined the program's three core parameters:
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"Personally, I was hoping that it wouldn't get started until the spring of 2003," said Dr. Vilke. "December, January and February are usually our highest volume months for area EDs. I was concerned that we'd run into a particularly bad flu season two or three months into the trial and that participants would quickly get discouraged and lose enthusiasm."
That didn't happen. First, although participation was voluntary, all hospitals in the county participated. Second, the program was so successful during the busiest time of the year that the committee decided not to stop or extend the trial after the first three months, but to instead officially implement the program's parameters as standard operating procedure beginning in January 2003.
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Results
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See all program results
Lessons Learned
One of the program's strengths was the committee's positioning of the two goals they set for San Diego County. The primary goal was to ensure more patients got to their requested destination hospital, while reducing diversion hours was a secondary goal.
"We've been trying to minimize diversion hours - fairly unsuccessfully - for years," said Dr. Vilke. It's hard to tell a doctor that his or her emergency department has to stay off of diversion when they're watching other hospitals go on. It's easier, instead, to say the goal is to make sure a higher percentage of patients reach their desired destination. This makes practical sense to ED physicians who realize that if they accepted their own patients and each of the other hospitals did the same, then the time- and resource-consuming process of obtaining old records, contacting primary physicians and transferring patients for admissions back to other hospitals where they should have gone originally would occur less frequently. This is how we got community buy-in on the process."
Although there were no mandates or penalties, hospitals adhered to the committee's parameters relatively well - sometimes almost too well, which inevitably led to off-load delays. "Some of our hospitals were so determined not to go on bypass that they'd keep accepting ambulance patients - even if they didn't have beds," said Dr. Vilke. "It became a 'we'll work it out when they get here' approach that resulted in ambulances and paramedic teams stacking up, waiting to turn over their patients before they could take the next emergency call."
Protocol is such that paramedics are allotted a 20-minute turn-around time from the moment they pull up to a hospital's ED. In theory, this should give them enough time to off-load the patient, turn his or her care over to ED staff, complete necessary paperwork, clean out their vehicle and get organized and ready for their next call.
Next Steps
Ongoing data was reviewed regularly and discussed during the committee meetings, which took place weekly, at first, then biweekly. Non-compliance of the program parameters - resulting in patient off-loading delays, diversion status of greater than an hour, etc. - were brought to the attention of the ED nurse manager and the ED director of the involved hospital, which allowed each facility to address its own challenges.
Although the program is now running smoothly, the committee continues to meet each month and plans to do so indefinitely.
"While we're pleased with results to date, we all know that this is only a Band-Aid, not a cure," said Dr. Vilke. "Our population is continuing to grow, and no new hospitals are opening in the area. Eventually we're going to hit a critical point when we'll need another more permanent solution."
When the time comes, San Diego has a committee ready to tackle finding one.
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For more information about the San Diego County Patient Destination Trial, see the October 2004 issue of Annals of Emergency Medicine.
Gary Vilke, M.D.
Medical Director, San Diego County EMS
Associate Professor of Clinical Medicine, University of California at San Diego
San Diego, CA
