GUIDELINES FOR AMBULANCE DIVERSION POLICIES

GUIDELINES FOR AMBULANCE DIVERSION POLICIES

To ensure access to emergency care, the American College of Emergency Physicians has developed the following guidelines for establishing a diversion policy:

1. All hospitals in the EMS system must work together to ensure appropriate bed utilization for all patients, including emergency patients.
2. All hospitals and EMS agencies in the EMS system must have working agreements among themselves regarding patient diversion policies and criteria.
3. The EMS system must have a plan for categorizing receiving facilities and protocols for determining patient destination.
4. Diversions must occur only after a prospective decision has been made by medical direction (on-line and off-line) and after receiving official information from approved hospital representatives (administration, nursing, and physician) with diversion decision-making and notification authority. These authorized personnel must be identified and their names communicated to the EMS system’s lead agency prospectively.
5. Categories of selective diversion must be defined prospectively. Such selective diversion categories may include critical care divert, routine admission divert, selective divert (i.e., pediatrics, reimplantation, cardiac, trauma, burns, neonatal, spinal cord, neurosurgery, psychiatry), and emergency department divert.
1. Criteria for making diversion decisions must be prospectively established by the EMS system with input from all components of the system (prehospital and hospital).
2. Diversion criteria must be based on exceeding the capacities or services of the hospital.
3. Diversion criteria must be consistent across the EMS system.
6. Ambulance diversion should occur only after the hospital has exhausted all internal mechanisms to relieve the overcrowding situation. Variations from protocols or problems with diversion must immediately be referred to the EMS lead agency and/or medical or administrative director.
7. Hospital diversion decisions must not be based on factors such as protection of beds for elective cases, protection of significant numbers of beds for unforeseen needs (deterioration in condition of floor patients, walk-ins), or desire not to call in “overtime” staff. No diversion decision should be made based on the financial resources of patients.
8. If a service or patient-care capacity is limited or not available at a hospital and if the patient transport can be safely accomplished in a timely fashion with available EMS resources, and if the decision is made in consultation with on-line medical direction, it is appropriate that a patient be taken directly to another hospital that can provide definitive care for the patient.
9. The EMS system must ensure that all components of the system (prehospital agencies and personnel and system hospitals) are notified when changes in the status of any resource occurs. This notification must occur through the EMS lead agency or a designated communications-coordinating center.
10. When diversions are necessary, policies must exist to ensure appropriate patient distribution to other hospitals, to avoid overloading other hospitals.
11. Mechanisms must exist for denying a hospital’s request for diversion or for overriding a hospital’s diversion status when, in EMS personnel’s judgment in consultation with on-line medical direction, a patient’s condition may be jeopardized by bypassing a facility.
12. When on diversion, hospitals must make every attempt to transfer patients (out of critical care units, to home), screen elective admissions, and use all available personnel and facility resources to minimize the length of time on diversion.
13. The EMS system must closely monitor the diversion status of hospitals. Regular review (eg., every shift) and updating of hospitals’ diversion status must occur.
14. Diversions must be temporary (for a limited period of time). The system must return to normal operations as quickly as possible. Automatic return to normal status, unless notified, is the preferred mechanism.
15. A written report of diversion should be made by the hospital after each episode and must include record of administrative approval, type of and reason for the diversion, and times of diversion initiation and completion.
16. W hen the entire system is overloaded (many hospitals on diversion), all hospitals must open. The system then may be operating in a disaster mode.
17. The system must ensure that interhospital transfer agreements exist among all participating hospitals within the EMS system, to ensure adequate resources for patient care.
18. Any interhospital transfer must occur in compliance with local, state, and federal (including COBRA/ OBRA) laws and regulations/rules.