Policies Regarding Bed Delays and Radio Reports

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mediclauren

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I'm a paramedic in San Diego and I'm part of a research project (along with other paramedics, senior staff and physicians) that is trying to improve the efficiency of our system. We are focusing on delays to get our patient in a bed and delays in radio transmission between us and our base hospital. As it stands right now, we have to contact a base, find out if our intended receiving facility is open and give a full radio report before we can clear. There is been a huge increase in "base shopping" (skimming through all the bases until you find one that answers their radio and is willing to take a report) and it's been hindering patient care and delaying transport. What kind of policies does your system have in place regarding bed delays at hospitals and/or transmissions with base hospital? Any feedback would be great and a link to where this policy is stated would be EVEN better.
 
We transport the patient to the hospital they want to go to, or we can over rule them to go to the most appropriate facility.

When we go en route dispatch advises us if the hospital we are transporting to is on divert or not. We attempt to call them on the radio 3 times, if we can't contact them, it is their problem, not ours and we transport to that facility anyway. Since it is a recorded line the charge nurses can only make so much of a fuss because it isn't hard to prove that we really did call, and they didn't answer.
 
All of the hospitals in our area got together and decided some general guidelines for diversion (ie, the trauma center can't go on adult trauma diversion, at least one of the psych hospitals has to be receiving patients, at least one facility with OB services has to be receiving patients, etc.)

This works fairly well. The bed management supervisor of each hospital changes the status of the hospital on a website, and if the hospital is closed to all ambulances, they have to re-evaluate that position at least every 12 hours. The trauma center (biggest hospital) sort of polices the situation because if all the hospitals are on diversion, ALL of the patients are coming to that one.

The system was started about 8 years ago after a 2-week period in the summer time when the situation was like you described...crews on scene begging for a hospital to take their patient. The hospitals were forced into negotiations when the EMS supervisors just had the crews take the patients to any hospital, because once the patient is in the facility, EMTALA takes over and the facility is stuck.

Our situation was never as bad as I've heard out of California, where you wait for hours with the patient on the stretcher. A long wait for us, then and now, is about 20 minutes.

The system is administrated by our regional office of EMS, who got a rep from each hospital to sit down at the table with reps from the 3 or 4 biggest EMS systems in the area. It was a very collaborative effort, and seems to work pretty well.

Now, with MDTs on the trucks in the system I used to work in, when you go to mark your unit transporting to the hospital, the MDT prompts you if your hospital is on diversion, tells the type, and allows you to override it, in case you have a special case. It's pretty cool, and completely hands-off as far as system admin is concerned...the MDT is linked to the website. Super high-tech, :). I'm easily impressed.
 
A few years back we had an issue with almost all the hospitals going to divert. Caused a big fuss and more or less, they are now no longer allowed to go on divert. Our county will sometimes advise us if a particular hospital has lots of patients inbound and we can adjust our transport decision. However, the patient is generally transported to wherever they want to go -- regardless of hospital status.
 
Where I work (two counties in NJ), hospitals NEVER go on Divert. they could have no beds available, patients on stretchers in hallways, and a line of people waiting to be admitted, and they will not go on divert. EVER. It isn't a good system, it overworks the nurses and ER staff.

As for giving a report, our BLS crews don't give any heads up, unless it's a critical patient. In those cases, a note may be given by the dispatcher center, but it's more of a courtesy than a requirement. for the rest of the BLS crews, it's show up and surprise!! never said it was a perfect system. and all crews are expected to be clear of the ER within 20 minutes.

for ALS patients, the medical control (for each ALS project) gets a report, and (in theory) the doctor will call the hospital that the ALS crew is transporting to.

hospitals can't refuse patients under normal situations. Situations like power failures, fires, hazmats and other emergencies that occurs INSIDE a hospital can result in it not accepting any new patients, but there isn't an issues with trying to find an open hospital.

When I worked in NYS, it was a little different. hospitals could close, and go n divert, in which case you shouldn't take them because they have no beds available. once all the hospitals closes, they went on "forced rotation" where every patient was taken to one of 5 hospitals on a rotating basis. All dispatch centers (there were 3 of them county wide) had access to the system, so every time a patient was transported, a chief complaint was given to the dispatch center, and the receiving hospital got a note (to an alpha pager for the charge nurse and on an LCD screen in the ER) so they knew what was coming to them. but if the patient wanted to go to a hospital on divert, the patient went to said hospital.
 
In the city where I work, for years (decades, actually) there was a 3 color system: green, yellow, red. Green was open, yellow was slow, red was slammed. What most of the staff failed to realize is that these were courtesy colors. Being red was not diversion. It was not uncommon to have a nurse berate you in front of the patient for daring to bring a patient to their faclility.

Then, 2 of our hosptials closed, leaving 6 hospitals system wide, 2 of which are small, rural outlying hospitals. (One is in a bordering county.) That left us with 4 hospitals. Going red was happening more and more. Some were known to abuse it. If they had 2 nurses call in, they would go red for the shift. Or, they would go red and "forget" to go back when they cleared out.

Finally, some patients were being diverted that shouldn't have been, and some specialty care physician groups had had it and raised hell. The big push was the largest, busiest cardiology practice in the city, and perhaps one of the best practices to get cardiac care from in Upstate NY, had some of their cardiac patients diverted to hospitals from competing health systems. There was other issues, like post-op surgical patients with complications being forced to go somewhere that their surgeon didn't practice, or the 3 week post op MI and CABG with chest pain going to a different hospital than the one where they were treated for their MI, but this big cardiac group pushed the issue, and the color system went away. There was a 3 month trial, and the EMS providers BEGGED for it not to come back. Nurses suddenly had no ammunition to give us a hard time for bringing the patient to their hospital. Patients were being transported to the appropriate facility, and EMS drop times went down.

In New York State, there still is diversion, but it's not easy. The hospital has to involve the local State Department of Health representative, they must call in extra staff to ease the burden, they must cancel all elective (cash making) procedures, and they must arrange for another hospital to accept their patients. Cardiac arrests and unstable airways don't count. They still go to the closest facility, regardless. You get a specific amount of time on reprieve, usually 4 hours, and then you are re-evaluated to see if you still need it.

There still is code black, for things like power AND generator failure, someone shooting up the ED, someone driving a car through the doors, an ambulance catching fire 10 feet from the entrance, or a haz mat, but those aren't for patient loads.

We don't do any call ins on probably 90% or more of our patients. Sometimes you have a reason to call medical control, either for orders or notification of an acute patient (we call point of destination) or you can call the charge nurse directly on her cell phone for a heads up.

It's not perfect. Far from it. I work full time nights, and probably spend, on average, 30-45 minutes per patient waiting to get triaged and into a bed. It's worse at some hospitals more than others. But it is better.
 
Hospital diversions usually lead to hilarity for me. The system I work in does hospital diversions through a website, which lists the statuses of each hospital, what type of diversion they are on, and how long they will be diverting. When we go enroute to the hospital, dispatch gives us a heads up if our destination is on diversion.
Unfortunately, charge nurses or cocky staff nurses like to hop on there high horse and decide that there to busy to stop gossiping and intake a pt, and will tell the receiving crew they're on diversion and refuse to take the phone report. I've had nurses hang up on me thinking "were on diversion" is the magic pill to get their union break.
If its not listed on the website, which is run by the hospital commission, we don't have to recognize the diversion status. Even when it is listed, pt choice can largely override it unless its an acute condition.
Most of the time I continue to the hospital regardless of what the nurse says. It leads to a argument frequently but its usually resolved by asking dispatch to confirm a diversion status in front of the nurse or writing the pt's report and history on the back of an emtala pamphlet.
 
mediclauren said:
I'm a paramedic in San Diego and I'm part of a research project (along with other paramedics, senior staff and physicians) that is trying to improve the efficiency of our system. We are focusing on delays to get our patient in a bed and delays in radio transmission between us and our base hospital. As it stands right now, we have to contact a base, find out if our intended receiving facility is open and give a full radio report before we can clear. There is been a huge increase in "base shopping" (skimming through all the bases until you find one that answers their radio and is willing to take a report) and it's been hindering patient care and delaying transport. What kind of policies does your system have in place regarding bed delays at hospitals and/or transmissions with base hospital? Any feedback would be great and a link to where this policy is stated would be EVEN better.
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I have never nor will ever work in California, but I doubt with what I have learned about the whole EMS system from this website, I doubt the issue is going to be reconciled by the hospital or an EMS agency.

When the system is set up for failure, then failure is the only outcome.

There needs to be less layers to it.

There is no reason to call in a report unless you need special orders or resources. Patients who walk in to the hospital through the front door don't call report before they come.

There is no reason to call a nurse for orders. If a nurse has to give orders to a medic, the medic, the doctor who is medical control, or the system is a failure.

During my time in the ED, I have noticed that it is the other areas of the hospital that hold up patient flow. You can have 20 patients in the hallway beds in the ED because one lazy nurse on a floor has "too much work" or feels they can't have a patient wait in a hallway for any length of time.

Nurses aren't the only staff to blame, I have seen residents try to delay accepting a patient. At one institution one of the IM attendings actually reprimands residents working nights from accepting too many patients on their shift, consequently they have all kinds of delaying tactics.

What you are experiencing is basically the end of a long line of inefficency.
 
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Here in a LA county we have a computer based system that hospitals can update to show closed or not. We have a lot of facilities so this allows us to make a transport decision without delay. It seems to work well from what I have seen. There are of course diversion policies in place for specialty centers. The patients we take ALS wait 10-15 minutes at the most in my parts.
 
If it is a very busy night, all of the hospitals go on a rotation (which EMS gets notified by command). Once we are on rotation, then the pt. does not get to choose the hospital b/c it means that the hospital does not have a bed. Otherwise we are on a color system of like 5 or 6 colors.

If it is really busy and there are calls holding, then we have a support unit which carries extra stretchers. They can meet us at the hospital, we give the report to the nurse that will take that pt eventually, then transfer the pt to the extra strechers and return to service while the EMT or Medic on support waits with the pt until a bed clears.
 
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feldy said:
If it is really busy and there are calls holding, then we have a support unit which carries extra stretchers. They can meet us at the hospital, we give the report to the nurse that will take that pt eventually, then transfer the pt to the extra strechers and return to service while the EMT or Medic on support waits with the pt until a bed clears.
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I hope you guys are billing the hospital for this. The ambulance service is doing the hospital's job. If patient volumes are that high on a regular basis, then the hospital needs to adjust: more inpatient beds, more ED beds, more nurses, better flow etc. Them overflowing does not mean EMS should have to hold the bag. Hospital diversions, for the most part, are nothing more than pushing the problem onto the shoulders of EMS, and not dealing with the problem.

"Failure to plan on your part does not constitute an emergency on my part."
 
I agree that the hospitals should not be making us wait so long. Im actually not sure about the billing the hospitals. The fact is it is New Orleans and we are still in a recovery period after the hurricane especially in our hopsital systems where most of the EDs are understaffed, and could use more beds. ED beds, but obviously those go hand in hand since the nurses can only handle so many pts at one time.
 
Im pretty lucky where i work. The hospitals arent allowed to go diversion (except the trauma centers, which still have to remain open to trauma patients). Our waits are pretty short (10 minutes is a LONG wait for us. If we wait >20 minutes our Commanders come to the hospital). We have a lot of hospitals (16 that we can choose from). We let patients pick what hospital they want to go to (as long as its an "appropriate facility" for their condition {i.e. Stroke/STEMI Center}). If we notice that one hospital is getting slammed then we tell the patient that, and try to get them to go to another hospital.
 
In the New Orleans area we have a color-coded system which gives estimated wait times for a bed. Hospitals are not allowed to go onto diversion and refuse EMS patients. We go by patient request for facility and, if the hospital is on an extended wait, advise the patient of the wait time and hope for the best. If it's critical then we transport to the nearest appropriate facility.

This means that we don't have to shop for a hospital but also means we have to sit on the wall for hours at a time. I spent 5 hours waiting at our Level 1 for a peg tube replacement because that's where the patient wanted to go and they were on, "Purple".
 
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