Streamlined operations mean fewer cases of diverting ambulances somewhere else.
Inside Upstate University Hospital's emergency room, registered nurse Cassandra Griffin checks the vital signs of 17-month-old Markayla Washington. The hospital did not disclose the nature of the girl's health problem.
Syracuse, NY -- Upstate University Hospital was turning away ambulances about one-third of the time a year ago because its emergency room could not handle additional patients.
Now it’s trying to take on all comers.
In April, the hospital’s emergency room closed its doors to ambulances for one hour, down from 217 hours during the same month a year ago. The about-face reflects a concerted effort by the hospital to eliminate “ambulance diversion” — a process that occurs when an ER cannot care for any more patients and redirects ambulances to other hospitals in the city.
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» Excellus: Many Central New Yorkers flocking to ERs with sore throats and other minor illnesses“The front door of the (ER) ought to be open all the time,” said Dr. John McCabe, the hospital’s CEO.
Dr. Gary Johnson, Upstate’s chief of medicine, agrees.
“I’m embarrassed when the place is closed,” he said.
While Upstate has made the most progress, Syracuse’s three other hospitals that serve the general public have also reduced ambulance diversion. The four hospitals’ total hours on diversion in April were about 75 percent lower than year-ago levels. (Regional hospitals such as Auburn Memorial and Oneida Healthcare Center do not divert ambulances.) Cutting diversion makes it easier and quicker for patients to get care at the hospital of their choice, said Ron Lagoe, of the Hospital Executive Council, a planning agency that monitors ambulance traffic at Syracuse hospitals.
It also may save lives. A study published in the latest issue of Inquiry, a journal published by Excellus, found that high levels of ambulance diversion in New York City were associated with increased heart attack deaths.
Making sure ERs are easily accessible is important because they are often the only places providing care at night and on weekends, Lagoe said.
Paramedics bring in a patient into the emergency room at Upstate University Hospital. The hospital has reduced the number of hours its emergency room was on ambulance diversion.
Ambulance crews are legally required to take patients to any hospital they request, even if it’s on diversion. Patients and their families, however, often follow the advice of ambulance crews who know which ERs are open and where they are most likely to get the fastest care.
“If you have someone who’s having a heart attack that wants to go to Upstate, but they really don’t have the room, it’s just trying to explain to them they will get better care elsewhere because they are hanging people from the rafters,” said Ed Moser, supervisor of public education at Rural/Metro, the ambulance company.
While reducing diversion is a laudable goal, it must be balanced against a hospital’s ability to provide safe, high-quality care, said Dr. Paul J. Kronenberg, president and CEO of Crouse Hospital. Reducing diversion is not necessarily good if it leads to crowds of patients stranded in ERs, waiting for beds to open up in the hospital, he said.
Ambulance diversion is a controversial practice. It is supposed to be used sparingly, when a hospital ER has so many critically ill patients it cannot safely take on any more. But it has become more commonplace nationwide at hospitals where combinations of too few beds and not enough staff can result in overcrowded ERs. Massachusetts banned the practice last year.
Sometimes all four ERs in Syracuse go on diversion. When that happens, ambulance patients are parceled out in rotation to each hospital. That means ambulance crews cannot immediately tell patients and their families what hospital they will go to because the crews don’t know themselves until they talk to a radio dispatcher en route.
McCabe said diversion tends to be overused. “It becomes a crutch,” he said.
The four Syracuse hospitals monitor the same computer data which shows which ones are on diversion. Situations sometimes arise where a hospital will go on diversion just because the other three are on diversion and the one still open does not want to get all the ambulances, he said.
“All of a sudden there’s a lot of gamesmanship and a lot of moving parts without any real benefit,” McCabe said.
Diversion can be eliminated only when it’s the focus of the entire hospital, not just the ER, he said. Everyone has to be working to move patients through the system efficiently. That means getting lab tests and X-rays done quickly, discharging patients when they are ready and promptly cleaning rooms to prepare for the next patients, McCabe said.
Upstate recently installed an electronic bed board system, a computerized system that lets staff monitor the status of every bed in the hospital. A color-coded screen shows which patients are ready to be discharged, which rooms need to be cleaned and which rooms are dirty. That’s dramatically speeded up the movement of patients, McCabe said.
“People used to roam the halls looking for empty beds,” McCabe said.
Emergency room crowding is a symptom of hospital-wide problems, he said.
“When you use diversion to turn the valve off, you are missing the point,” he said. “You are fixing the hospital problem by shutting the front door instead of cleaning house. We’ve worked hard to clean house.”
St. Joseph’s Hospital Health Center, which handles the largest ambulance volume of the four hospitals, has increased staffing of doctors, nurses and physician assistants in its ER to reduce diversion. It is also streamlining all the processes that take place between the time a patient enters the ER and is seen by a doctor.
“It’s the unpredictable nature of emergency department flow that makes that a challenge,” said Mark Murphy, a St. Joe’s vice president.
Community General cut its diversion hours from 243 in April 2009 to just nine hours last month.
“It’s adhering to the true concept of diversion,” said Dr. James Ciaccio, chief and director of emergency medicine. “You only really go on diversion when one additional patient significantly jeopardizes the care of other patients.”
Community’s reduction in diversion reflects in part a change in its ER staff, Ciaccio said. The same doctors who staff Upstate’s emergency room have been staffing Community’s ER for the past 18 months. There are more doctors in the ER and they are skilled at managing large volumes, he said.
Although it has cut its diversion hours in half over the past year, Crouse had the highest level of diversion among city hospitals in April.
Kronenberg, Crouse’s CEO, said the hospital is taking steps to get diversion down to the levels Upstate has achieved. Crouse recently installed a computerized information management system in its ER to better manage the flow of patients.
“If we can do this right and go to zero diversion and be able to deliver the same outstanding care, it’s a home run,” Kronenberg said.
--Contact James T. Mulder at 470-2245 or jmulder@syracuse.com.