Patient Flow Enewsletter
Volume 1, Issue 5
Thursday, April 29, 2004
Resources in this article:
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Using data and ingenuity, the Massachusetts Department of Public Health has made improvements in decreasing ambulance diversion throughout the state. Ambulance diversions have a long history in Massachusetts first emerging as a problem during the late 1980s, when there was an acute labor shortage in hospitals and nursing homes statewide. At that time, there was a centralized radio system in place through which each hospital could alert all ambulances within its region when it went on diversion.
Although adherence to the radio system to alert ambulance services when local emergency departments were diverting was voluntary and variable statewide, it helped many EMS providers to better manage the impact of ED diversion on patient transport. In the early 90s, two additional factors temporarily, at least, curtailed the need for hospitals to divert ambulances the labor force increased when the economy weakened, and the health care environment changed with increasing managed care reducing both hospital inpatient and emergency department utilization.
The five state regions continued to monitor ambulance diversion through the radio system, however, and beginning in 1998 began to see another upswing with hospitals reporting record numbers of hours on diversion particularly in the metropolitan Boston area. The trend continued, so in the spring of 1999, the Department of Public Health convened the first meeting of a designated Ambulance Diversion Task Force, representing hospitals, emergency physicians, ambulance providers, emergency nurses and others.
See Task Force Participants and Best Practices Recommended.
| "Timing was good, because by the year 2000, the diversion problem was no longer limited to the largest urban centers during the busy winter months," said Charlotte Yeh, MD, FACEP, regional administrator for the Centers for Medicare & Medicaid Services, based in Boston. "It was happening across the state year-round. Soon it became commonplace for multiple hospitals within or across one of the five regions to request diversion simultaneously." |
Getting Hospital Buy-In
The Task Force knew that proposed solutions could only succeed with the buy-in of hospital leadership, so the state Public Health Commissioner met with hospital CEOs in January 2001. The following month, the Department conducted an ambulance diversion survey with 76 out of the 77 hospitals in the state responding. The survey found what many anticipated no hospital was immune to ambulance diversion, and diversion itself correlated with hospital occupancy. Several findings were enlightening particularly that the majority of hospital respondents felt enhanced coordination among hospitals was a necessary first step.
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Click here to download presentation on survey findings.
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In reviewing the survey’s findings, there was universal recognition that the health system needed a tool that could immediately report which hospitals were on diversion in real-time. After looking into a number of commercial, ‘off-the-shelf’ products, the Task Force realized that what they were looking for didn’t exist.
“What we wanted was really simple, so we designed it ourselves,” said Paul Dreyer, PhD, director, Division of Health Care Quality, Massachusetts Department of Public Health. “What gave it teeth was making it state regulation. We placed requirements that hospitals participate in the system right into the Department’s hospital licensing regulations, then announced and promoted this new regulation at a public hearing.”
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Click here to view a larger image of the online tool for reporting diversion status of all hospitals.
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Implementation
The tool itself was developed and piloted in subsequent months, then rolled out in its final form in December 2002 – with online systems operational in every hospital emergency department across Massachusetts. Before long, it became apparent that the new system was an improvement from the older radio version for both hospitals and ambulances. Being online in real-time also allowed each of the five regions to individualize the system to best suit their region’s needs – which varied significantly between metropolitan and more rural areas.
“A hospital’s diversionary status suddenly became public, with everyone able to see the status of how others were doing. It meant everyone’s challenges became transparent for the community at large,” said Yeh. “Previously, certain hospitals were going on diversion considerably more frequently than others, but that wasn’t widely known and recognized. This new technology created a level playing field for all. In fact, just knowing this new system was coming led some hospitals to begin rectifying their internal problems.”
Because demand for emergency services can be seasonal, Massachusetts has learned that it’s best to measure results by looking month-to-month across years. From August 2002 to August 2003, the team saw a 50 percent drop in the number of total hours on diversion statewide. However, the system remains fragile. Under certain circumstance such as the flu, diversion requests still spike.
See the statewide grid of diversion hours.
Next Steps
One and a half years later, the original plan remains in place, but the Task Force continues to work on enhancements. Following September 11th and the subsequent Rhode Island nightclub fire of February 2003, the team realized they needed to add real-time information on available beds in order to manage catastrophes. By the time this modification is complete, one broadcast will result in all hospitals statewide immediately posting the number of available burn unit beds, for example.
“Probably the greatest lesson for us is that just because you develop such a tool doesn’t mean you can turn your back on it,” said Yeh. “You have to continually monitor everyone’s adherence to the tool. The statewide Ambulance Diversion Task Force must continue to meet regularly and review diversion reports. It has to be an ongoing process.”
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Charlotte Yeh, M.D., F.A.C.E.P.
Rgional Administrator
Centers for Medicare & Medicaid Services
Boston, MA
Paul Dreyer, Ph.D.
Director, Division of Health Care Quality
Massachusetts Department of Public Health
Boston, MA
