Friday, May 22, 2009

Diverting Diversion

On September 26, 2001, I worked a PM shift in the OSF-SFMC Emergency Room.

I thought that the ER was overcrowded and dangerous for my patients.

I wrote the letter documented in this post to OSF's Administrator, Keith Steffen.

The next day I was put on "probation" and then fired from OSF-SFMC in December, 2001.

The following article appeared in Emergency Medical News this month (May, 2009).

It stresses that hospital administrators have to be "on board" with overcrowding and long waits in their Emergency Rooms and seek to find solutions.

Simply, in my opinion, OSF-SFMC was and is mismanaged, caters to elective insured admissions, which puts patients coming to the ER at risk.

From Emergency Medicine News:

EMN Diversion
May, 2009

Diverting the Diversion Diversion

SoRelle, Ruth MPH

Paul Dreyer, PhD, the director of Health Care Safety and Quality at the Massachusetts Department of Public, was coming out of a task force meeting on rules for ambulance diversion more than 18 months ago when he had an epiphany. Diversion was not the problem.

In fact, it was diverting attention and resources away from the real problem plaguing the state's emergency departments. The real issue was crowding.
I discussed it with a number of the members of the committee who were chatting. Instead of talking about diversion rules, I suggested we eliminate diversion. I circulated the idea informally among the members, and at the next meeting, we discussed it formally, and came to a consensus decision that was essentially policy, he said.

On Jan. 1, 2009, Massachusetts eliminated ambulance diversion within its borders except when an internal emergency closes a hospital to all patients. It gets diversion off the table as a potential solution, and enables us to focus on the real issues, said Dr. Dreyer. And it focuses the attention of hospital CEOs and others on the issue of crowding itself. They can't say 'go on diversion' when the emergency department is crowded.

In fact, many emergency experts have long criticized diversion because it simply pushes the problem from one hospital to the next until too many hospitals are on diversion and the system has to open again. Historically, the situation has been that in areas that went on diversion, the situation that led one hospital to go on diversion would lead all hospitals to be on diversion, said Dr. Dreyer.

In two conference calls prior to the no-diversion policy taking effect, he was struck by the steps hospitals had taken to address patient flow issues in anticipation of the new rules. One prior worry had been that the policy would increase the turnaround time for ambulances taking patients to the hospitals.

We heard from the head of a large municipal ambulance service in Boston that contrary to his expectations, the turnaround time had gone down in every single Boston hospital, Dr. Dreyer said. It was a sort of clearing of the decks. Now the focus is on crowding, and the solution to crowding is upstream. Diversion was a diversion so we just got it off the table.

Alasdair Conn, MD, the chief of emergency services at Massachusetts General Hospital in Boston, said diversion created a number of problems for patients and physicians. Patients tend to come to the hospitals where their physicians are. If we were on divert, it created an enormous issue for the patients. They had to see a strange specialist, and the hospitals tried to transfer them later in the day. We all sort of bit the bullet on this, and decided to see how it goes. His hospital and Brigham and Women's Hospital accounted for the highest number of divert hours in the city. We said we had to step to the plate here. We did a pilot of 'no divert' for two weeks a year and a half ago. That went okay. There were no giant catastrophes. Now it looks a though some of our fears have not been realized.

In fact, the length of time ambulance crews had to wait in the emergency department decreased. One downside is that it has put a lot of pressure on the emergency departments, he said. Comparing January 2008 (when the hospitals could divert) with January 2009 (when they could not), he found that while ambulance arrivals went up 17 percent at his institution, the total volume was up only six percent. Thirty percent of patients come by ambulance, but the rest are walk-ins, he said, noting that ambulance arrivals do often generate hospital admissions and stress the hospital's inpatient units.

Because his hospital's leaders knew that the no-diversion policy was in the works, they have changed the way their emergency department works, Dr. Conn said.

Physician-led triage for eight hours a day has dropped the walkout rate from seven percent to two percent, he said, and decreased door-to-doctor time. We implemented this with our existing physical plant and the redesigned the triage area and four screen rooms last October, he said. It has certainly helped. We have sent patients from triage directly to observation or an inpatient bed.

While the emergency department's boarding time has decreased, it is still high, he said. Patients were waiting an average of ten and a half hours for a hospital bed. Now it's down to seven hours. We have also speeded throughput on the inpatient units and boarded more medical patients on the surgical units. All of these have been possible by a hospital administration that agreed that this was the hospital's issue and not just limited to the emergency department.

When Massachusetts General went on divert in previous years, the neighboring hospitals got the overflow and often within 30 minutes went on divert themselves, Dr. Conn said. Now everybody is open. If there is an equal distribution of patients throughout the system, then we all can bear the pain. If the distribution changes slightly, then one hospital suffers more than the others. His department's volume is up six percent month-to-month, but another facility's volume is down and others are only slightly increased.

If you built an emergency department for 70,000 visits annually, and you are now dealing with 80,000, then a change in referrals or ambulance destinations pushes your volume up to 85,000, it will cause a problem long-term, Dr. Conn said. And if one hospital closes its doors, increasing his emergency department volume by 18 or 20 percent, we can't take that, he said.

Opening more hospital beds seems the easy answer, but it will not happen overnight. His hospital is in the process of constructing a new building and opening 150 more beds, but making the inpatient side more efficient over the long term also reduces pressure. If the average length of stay is 5.8 days, reducing it to 5.6 days is the equivalent of opening 24 more beds, he said. A length of stay of 5.5 days is the equivalent of 36 beds.

Changing the timing of elective admissions might also help, Dr. Conn said. Sometimes, a hospital goes on divert because surgeons do most of their cases on Tuesdays and Wednesdays, taking up the inpatient beds and causing others to be boarded in the emergency department. If the admissions were spread out more equitably across the week, the pressure would be reduced and the need to divert goes away. Such plans not only reduce emergency department stress, they also reduce health care costs, he said.

We absolutely have no plan to go back, Dr. Dreyer said. One emergency department director in Boston said things had been busy and in previous times, he might have been tempted to press the divert button. They managed, and he thinks things are better because patient flow is smoother. Because no one goes on diversion, no one gets an excess load.

Dr. Dreyer's ED is also collecting data on patient boarding to track the progress in patient flow over time. In future meetings, they will broach improving patient flow in greater detail. We didn't expect the elimination of diversion to solve anything, but we took diversion as a bad solution off the table, he said. It seems to have had positive consequences because it forced hospitals to take serious measures to improve patient flow. We made it a hospital problem, not just one of the emergency department.

And the state group that previously dealt with diversion? They've renamed it, said Dr. Dreyer. It's now the Boarding and Crowding Task Force.

© 2009 Lippincott Williams & Wilkins, Inc.

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