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Results of Implementation of a Contemporary Model for Ambulance Diversions in an integrated Healthcare Delivery System
m RESULTS OF IMPLEMENTATION OF A CONTEMPORARY MODEL FOR AMBULANCE DIVERSIONS IN AN INTEGRATED HEALTHCARE DELIVERY SYSTEM Abstract This brief report contains a description of a contempora?y, coordinated new system for ambulance diversions, which was implemented in Edmonton area’s Capital Health Region in January 1999. The development of this new system was precipitated by the combination of increasingpressures within the acute care system especially being felt within our emergency departments, and mounting evidence that the existing system for ambulance diversions was ineffectual in providing temporary relief of these pressures. The nature o f the Drevious and the new svstem are comDared and contrasted, and data in the number of ambulance diversions experienced regionally.
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n 1993, Alberta reduced expenditures in acute care by approximately 25%. This reduction led to increased pressures on acute care resources, particularly during periods of peak utilization’. Emergency departments frequently experiented overcrowding. In response to these pressures, Capital Health (a large Integrated Healthcare Delivery System) engaged in the practice of ambulance diversions. Ambulance diversions involve the temporary redirection of ambulances from an emergency department experiencing serious pressures to a less busy site. As resources became increasingly constrained, ambulance diversions became more frequent, as evidenced during February 1998 when ambulances were on diversion for 20.2% of all available hours impacting service delivery and Emergency Medical Service (EMS) agencies (Table 1).This precipitated a regional review of the existing system and the development and implementation of a more contemporary one.
TABLE 1 PERCENTAGE OF ALL AVAILABLE HOURS SPENT ON AMBULANCE DIVERSION IN CAPITAL HEALTH (PREVIOUS SYSTEM)
Previous System In the previous system, an emergency department on status ‘Green’signified that it was able to accept all ambulances. An emergency department on status ‘YeZZow’ signified that it was becoming increasingly busy and requested, where possible, ambulances be diverted. An emergency department on ‘Red’ signified that it was unable to accept any ambulances and requested all ambulances be diverted to another hospital.
Healthcare Management Forum Gestion des soins de santb
bY Erin Anderson, Kent Riddle and Robert Bear In each emergency department there was a terminal displaying the diversion status of the other emergency departments in the region; these data were linked to dispatch at the city’s EMS agency, permitting coordination of ambulances to emergency departments not on diversion. Data available from this system was limited to the type,
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duration and reason for the diversion, and the name of the facility calling it. Acceptable reasons were: 1) lack of stretchers, 2) lack of resuscitation beds, 3) nursing workload, and 4)physician workload. Limitations of this system included: a) a lack of standardized criteria for initiating a diversion, b) non-selective diverting of all patients, c) absence of information on exact emergency department conditions at time of diversions, d) lack of full integration with EMS agencies, e) no constraints on the duration or frequency of diversions, f) no incentives to improve emergency efficiencies, and g) no integration of responses to pressures in emergency with hospital-wide responses designed to concurrently lessen these pressures.
New System A Regional Task Force with representatives from EMS(s) developed a new system, which was implemented in January 1999. In this system, the types of diversions are a Total ReDirect (TRD),and a Critical Care Bypass (CCB). A TRD, which lasts up to sixty (60) minutes is called by an emergency department when all resources are at capacity (all but one designated staffed space is occupied, or is expected to be occupied within the next hour). Only the administrator of the hospital, in consultation with the designated Physician and charge nurse can initiate a TRD. A CCB, which lasts up to thirty (30) minutes is called when all critical care resources are at capacity (all but 1 designated staffed Critical Care space is occupied or is expected to be occupied with the next hour). Only the designated emergency physician, in consultation with the charge nurse can initiate it. The new system aligns the functions of EMS services and emergency departments by permitting them, through a System Alert, an
override of hospital diversion status (after discussion) if EMS resources are temporarily strained. Before any diversion can be called, staff from emergency and designated areas within the hospital initiate a set of pre-designed actions to forestall the need for a diversion (he-Diversion Only after these actions have been initiated and proved unsuccessful in eliminating the need for a diversion can one be called. Every deficiency associated with the previous system (see above) has been addressed.
Results of Implementation of the New System Implementation of the new system has resulted in a marked reduction in the percent of available time the region is now spending on diversion (Table 2). In June 1999 there was a 66% reduction in this number regionally compared to June 1998. TABLE 2 PERCENTAGE OF ALL AVAILABLE HOURS SPENT ON AMBULANCE DIVERSION IN CAPITAL HEALTH (NEW SYSTEM)
being on diversion in Capital Health for an unacceptable amount of time. The development of a new, contemporary system for ambulance diversions in January 1999 which integrated pre-hospital service providers with emergency departments, and which established clear accountabilities and responsibilities throughout the entire organization has dramatically reduced the amount of hours Capital Health is now spending on diversion. We hope that this brief report has demonstrated the advantages of working within an integrated health delivery system. More details on our new Ambulance Diversion Policy and Pre-Diversion Guidelines2in use in each of our hospitals are available on the Capital Health Website.
References 1. Bear, RA,Frame, G, Weatherill, S. The last critical care bed in Western Canada. Healthcare Management Forum 1998;11(4)45-46. 2. Capital Health Authority Website.
www.cha.ab.ca/site/info/departments/default.htm
Summary and Conclusion In Alberta, funding reductions in acute care have resulted in serious system pressures, the focal point of which has been emergency departments. As a means of coping with emergency department pressures, an inefficient and uncoordinated system for ambulance diversions was over-utilized resulting in ambulances
Healthcare Management Forum Gestion des soins de sant6
Erin Anderson, MN, is Project Director, Clinical Affairs, Capital Health Authority. Kent Riddle, EMT-P is Acting Supervisor, Emergency Response Depament, City of Edmonton. Robert Bear, MD, FRCE FACE CHE, is Executive Vice-President,Chief Clinical Officer,Capital Health Authority, and Associate Dean, Faculty of Medicine and Dentis@, Universityof Alberta.
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n 1993, Alberta reduced expenditures in acute care by approximately 25%. This reduction led to increased pressures on acute care resources, particularly during periods of peak utilization’. Emergency departments frequently experiented overcrowding. In response to these pressures, Capital Health (a large Integrated Healthcare Delivery System) engaged in the practice of ambulance diversions. Ambulance diversions involve the temporary redirection of ambulances from an emergency department experiencing serious pressures to a less busy site. As resources became increasingly constrained, ambulance diversions became more frequent, as evidenced during February 1998 when ambulances were on diversion for 20.2% of all available hours impacting service delivery and Emergency Medical Service (EMS) agencies (Table 1).This precipitated a regional review of the existing system and the development and implementation of a more contemporary one.
TABLE 1 PERCENTAGE OF ALL AVAILABLE HOURS SPENT ON AMBULANCE DIVERSION IN CAPITAL HEALTH (PREVIOUS SYSTEM)
Previous System In the previous system, an emergency department on status ‘Green’signified that it was able to accept all ambulances. An emergency department on status ‘YeZZow’ signified that it was becoming increasingly busy and requested, where possible, ambulances be diverted. An emergency department on ‘Red’ signified that it was unable to accept any ambulances and requested all ambulances be diverted to another hospital.
Healthcare Management Forum Gestion des soins de santb
bY Erin Anderson, Kent Riddle and Robert Bear In each emergency department there was a terminal displaying the diversion status of the other emergency departments in the region; these data were linked to dispatch at the city’s EMS agency, permitting coordination of ambulances to emergency departments not on diversion. Data available from this system was limited to the type,
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duration and reason for the diversion, and the name of the facility calling it. Acceptable reasons were: 1) lack of stretchers, 2) lack of resuscitation beds, 3) nursing workload, and 4)physician workload. Limitations of this system included: a) a lack of standardized criteria for initiating a diversion, b) non-selective diverting of all patients, c) absence of information on exact emergency department conditions at time of diversions, d) lack of full integration with EMS agencies, e) no constraints on the duration or frequency of diversions, f) no incentives to improve emergency efficiencies, and g) no integration of responses to pressures in emergency with hospital-wide responses designed to concurrently lessen these pressures.
New System A Regional Task Force with representatives from EMS(s) developed a new system, which was implemented in January 1999. In this system, the types of diversions are a Total ReDirect (TRD),and a Critical Care Bypass (CCB). A TRD, which lasts up to sixty (60) minutes is called by an emergency department when all resources are at capacity (all but one designated staffed space is occupied, or is expected to be occupied within the next hour). Only the administrator of the hospital, in consultation with the designated Physician and charge nurse can initiate a TRD. A CCB, which lasts up to thirty (30) minutes is called when all critical care resources are at capacity (all but 1 designated staffed Critical Care space is occupied or is expected to be occupied with the next hour). Only the designated emergency physician, in consultation with the charge nurse can initiate it. The new system aligns the functions of EMS services and emergency departments by permitting them, through a System Alert, an
override of hospital diversion status (after discussion) if EMS resources are temporarily strained. Before any diversion can be called, staff from emergency and designated areas within the hospital initiate a set of pre-designed actions to forestall the need for a diversion (he-Diversion Only after these actions have been initiated and proved unsuccessful in eliminating the need for a diversion can one be called. Every deficiency associated with the previous system (see above) has been addressed.
Results of Implementation of the New System Implementation of the new system has resulted in a marked reduction in the percent of available time the region is now spending on diversion (Table 2). In June 1999 there was a 66% reduction in this number regionally compared to June 1998. TABLE 2 PERCENTAGE OF ALL AVAILABLE HOURS SPENT ON AMBULANCE DIVERSION IN CAPITAL HEALTH (NEW SYSTEM)
being on diversion in Capital Health for an unacceptable amount of time. The development of a new, contemporary system for ambulance diversions in January 1999 which integrated pre-hospital service providers with emergency departments, and which established clear accountabilities and responsibilities throughout the entire organization has dramatically reduced the amount of hours Capital Health is now spending on diversion. We hope that this brief report has demonstrated the advantages of working within an integrated health delivery system. More details on our new Ambulance Diversion Policy and Pre-Diversion Guidelines2in use in each of our hospitals are available on the Capital Health Website.
References 1. Bear, RA,Frame, G, Weatherill, S. The last critical care bed in Western Canada. Healthcare Management Forum 1998;11(4)45-46. 2. Capital Health Authority Website.
www.cha.ab.ca/site/info/departments/default.htm
Summary and Conclusion In Alberta, funding reductions in acute care have resulted in serious system pressures, the focal point of which has been emergency departments. As a means of coping with emergency department pressures, an inefficient and uncoordinated system for ambulance diversions was over-utilized resulting in ambulances
Healthcare Management Forum Gestion des soins de sant6
Erin Anderson, MN, is Project Director, Clinical Affairs, Capital Health Authority. Kent Riddle, EMT-P is Acting Supervisor, Emergency Response Depament, City of Edmonton. Robert Bear, MD, FRCE FACE CHE, is Executive Vice-President,Chief Clinical Officer,Capital Health Authority, and Associate Dean, Faculty of Medicine and Dentis@, Universityof Alberta.
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