Hospital Diversion/By-Pass Policy

Purpose

It is imperative that patients in Northeastern Pennsylvania have access to expedient and appropriate emergency medical care twenty-four hours a day, seven days a week. This document is to provide guidance to pre-hospital providers, BLS and ALS, during times when the resources of a hospital(s) are taxed.

 

This document will provide:

  1. Standard definitions for determining a hospital's status;
  2. Standard methodology for notification of a hospital's status through the appropriate communications center;
  3. Protocol for pre-hospital providers, BLS and ALS, to use in making a determination to honor a hospital's request for diversion.

 

Background

From time to time, the resources of a hospital may be come taxed. In an effort to provide optimal patient care, a hospital may request that patients by ambulance be diverted to another facility so that care may be expedited. In doing so, many times this places an undue responsibility upon the pre-hospital provider and a burden upon the patient.

From a legal standpoint, a hospital cannot close its emergency department. It is obligated to, at a minimum, complete a patient assessment, provide stabilization and then if necessary transfer a patient. This applies to all patients who present themselves to an emergency department, regardless of how they arrived there - personal vehicle, walk-in or ambulance.

Because hospitals are able to exercise a certain amount of control over patients being transported by ambulance, they are able to inform prehospital personnel of their status and go on diversion. This is actually a request of the hospital. This document establishes a protocol for prehospital personnel to use honoring the diversion request.

 


Transportation To Hospital Not in Immediate Proximity


When presented with patients proximate to one hospital, but desirous of transportation to a more distant hospital; or when family or professional staff request such arrangements on behalf of the patient the following guidelines should be applied.

  1. Class I patients are to be transported to the nearest facility unless otherwise stipulated (i.e. trauma) or unless the patient is competent and alert and refuses transportation to that facility.
  2. For class II and III patients receiving pre-hospital ALS and for which the requested (more distant) hospital is a Medical Command Facility, the EMT Paramedic should complete the patch to the more distant hospital and request direction from that Medical Command Facility. If approved, that (more distant) facility will maintain Medical Command throughout the duration of transport. This procedure should also be applied for class I patients refusing transportation to a local facility.
  3. For patients transported at the BLS level, contact medical command to obtain medical direction.
  4. For patients desirous of transportation to a non-proximate facility, the patient should be provided full explanation that the desired receiving facility is further distant than another facility, thereby potentially delaying definitive medical care. If, after this explanation the patient continues to desire transportation to the more distant facility, the patient should complete and sign the appropriate release of responsibility section of the release form.

This procedure in no way obligates long distance transportation such as to out-of-area hospitals. Transportation to these hospitals is a matter of squad policy and/or discretion.

* Class I refers to unstable patients suffering immediate life-threatening injuries or illness. (refer to regional Pre-Hospital Classification)


Hospital Status And Diversion

Hospital Status

The following terms will be used to describe hospital bed status:

  1. Critical Care Beds Full - indicates no critical care/cardiac monitored beds are available.
  2. Non-Critical Care Beds Full - indicates no regular hospital beds are available.
  3. All Beds Full - indicates no hospital beds are available (except trauma beds in a trauma center).
  4. Emergency Department By-Pass - indicates the resources of the hospital's Emergency Department are completely involved in patient care presently.
  5. Trauma By-Pass - indicates the resources at a trauma center are temporarily and completely involved with trauma patients presently in the Emergency Department. Diversion of trauma patients to another trauma center should be considered if practical.
  6. Any hospital reporting their bed status as set forth in "1" through "5" above must reconfirm that status to the Communications Center at least every 4 hours. Those hospitals not reconfirming their status within the prescribed time will have their status automatically changed back to fully operational. Renewal is for a 4 hour period, also with automatic termination unless renewed.

Diversion Criteria

  1. No class I patients are to be diverted regardless of bed status. Such patients require stabilization prior to any diversion.
  2. Class II and III patients may be considered for diversion based upon a hospital status in "1 thru 5" above. (see above). Contact medical command for guidance.
  3. If all hospitals in a reasonable proximity are on divert status for a given type of patient (i.e. cardiac), an EMT or Paramedic may take a class II patient (potentially unstable) to the nearest hospital for further stabilization regardless of bed status. Hospitals must respect the judgment of the EMT or Paramedic in such circumstances.
  4. Trauma centers are never closed to trauma regardless of hospital status, though the Emergency Department may be on temporary "Trauma By-Pass" status when fully involved with current trauma cases.