HVHC On Diversion?

[DonMoose 3]

Just wondering if anyone heard about this. I just heard some chatter about it, curious as to what's going on.

[ems-buff 81]

Not from what I can see. It look's open to me!!

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[Guest alsfirefighter]

HVHC is on full diversion. Nothing out of the ordinary due to numerous holds in the ER...13 in fact when they first went on diversion.

The bigger issue are the couple of agencies that disregard the diversion request and still bring patients there which often further extends the need to be on diversion. Remember its not about whether you agree that they should be...its about your patient whom needs to be brought to a facility that they can get prompt, proper treatment. The one specific agency who is the worse with that concept..hopefully you will figure this out one day.

[mfc2257 464]

When I was in South Central, PA / Northern, MD this happened all the time. Gettysburg Hospital, York Hospital, Hershey Medical Center, Waynesboro, Chambersburg, etc. on any given day one or two would be on divert.

Most of the time Gettysburg would go on divert for just class 2 patients who typically would be seen and admitted. If there were no beds upstairs, they would be diverted. A class 1 however would be seen to stabilize and then transported to a better facility like York or Hershey. Class 3's which were treat and release were the second to get the boot. Finally, Class 1's would be the last to not be seen. This was somewhat rare, although the we were usually pretty in tune with the patient levels at the hospital and if they were already on Class 2/3 divert we would probably not take a Class 1 there unless it was a working code. Whenever possible we'd air medical them to York or Hershey because in theory that's where they'd end up any way after Gettysburg ER further stabilized them.

[INIT915 1,119]

Westchester area hospitals use diversion as a fairly common practice, especially during the winter months.

The problem often is convincing patients to go to a different hospital, and pitting you, the provider, between a rock (patients wishes) and a hard place ('unhappy' ER nurses).

If a patient wants to go to HVHC, and your efforts to talk them into Phelps, NWHC, Putnam, etc., are unsuccessful, its off to HVHC you go.

[Guest alsfirefighter]

If a patient wants to go to HVHC, and your efforts to talk them into Phelps, NWHC, Putnam, etc., are unsuccessful, its off to HVHC you go.

I have rarely, rarely had this happened to me. What I do find is that there are many providers who steer their patients to what they want which is to just go to the nearest hospital and they feed off of that. I have had patients/family express intently that they wanted to go to HVHC and after simple, informative discussion as to why (or any provider in most instances should) its better to go to another area hospital is usually more then enough to get them to understand. Its all about being professional and informative and not being lazy in most cases.

Starting off a conversation about transport "xyz is on diversion, but if you still want to go there, we can't deny that and we'll be more then glad to," doesn't help much.

"While we would normally transport you to xyz hospital, they are currently asking that we divert from bringing patients in due to (insert issue here.) The reason I want to bring you (your loved one) to another hospital is because xyz hospital is so overcrowded, I want to ensure that you (your loved one) will be able to get the care you need and deserve promptly. If I take you to xyz, chances are you will be waiting in the hallway and you may not get the same level of care you may be used to nor deserve."

Its about the patient and making informed decisions.

[INIT915 1,119]

I have had patients/family express intently that they wanted to go to HVHC and after simple, informative discussion as to why (or any provider in most instances should) its better to go to another area hospital is usually more then enough to get them to understand.

Usually, yes. Always? No.

Seems to especially be with the older crowd who have used the same hospital and/or PCP for years.

Edited January 25, 2008 by INIT915

[ONEEYEDMIC 68]

Now obviously the PT's condition depends on this, but just out of curiousy what AMB's go to HVHC on a regular basis? Prob the only Hospital in WEST/PUT that I am not familar with. Then given that the PT is stable enough to go to another hospital what are the TXP times? How long will that take the AMB out of service? I mean from Yorktown to Phelps is prob a GOOD 10 min ride. I remember from NORTH SALEM to NWHMC was a long time or what seemed like a long time especially when I had to leave the fly car there. Sorry, that is for another topic that has been bothering me.

I always said that DIVERSION was a COURTESY to the HOSPITAL. If the PT wanted to go to "ABC" hospital then that is where they were going. Most of the time the PT and Family members were more worried that their PRIVATE DR affiliated with their normal hospital would not be able to take care of them. I would tell them once that the HOSPITAL that they wanted to go to was on DIVERSION. If they didn't care, that is where I went.

Then of course you get the ER's ATTITUDE. I can still hear the NURSES now. Like it's my fault the hospital doesn't have any room. Thank God I don't have to deal with that BS anymore.

[INIT915 1,119]

Now obviously the PT's condition depends on this, but just out of curiousy what AMB's go to HVHC on a regular basis? Prob the only Hospital in WEST/PUT that I am not familar with. Then given that the PT is stable enough to go to another hospital what are the TXP times? How long will that take the AMB out of service? I mean from Yorktown to Phelps is prob a GOOD 10 min ride.

Peekskill

Cortlandt

Mohegan

Putnam Valley

Garrison

Philipstown

Verplanck

Yorktown

Mahopac Falls (on occasion)

Croton (on occasion)

And many parts of Yorktown would be well over 10 minutes.

[Oswegowind 17]

With the projected expansion of the hospital to occur in the near future, I am sure that this problem will be reduced. Of course, my wife being an ER nurse at a local facility (St. John's - Yonkers), I continuously bust her about diversion. In fact this week has been ridiculously busy all around!

And as ALS is saying...sometimes we all have to play "Politician" and use our charm to help patients make their decision to go elsewhere...this won't work all of the time, but this is the real world.

[ckroll 101]

If the emergency health care provider is committed to respecting diversions, the patient usually will be OK with it. No one likes being told that they will not be going to their favorite hospital, but no one likes waiting hours for treatment or spending 2 days warehoused in an ER hallway either. At the very least, a direct discussion of probable outcome--extended delay in treatment-- will manage the patient's expectations.

I've had good luck calling the ER to ask the nature of the diversion. If the problem is beds upstairs or a particular piece of equipment isn't available, and I've got a 'treat and release', then I've never been given a hard time for calling first and bringing it in. If the ER just can't handle another patient, then the patient or his family needs to know that. Knowing what the hospital can do is part of an informed decision and as advocates for the patient, we ought to be guiding the patient to what will be a good decision for that patient. It's certainly easier to advocate for a longer drive and out of service time when I'm on the clock than when it's volunteer time I'm giving up, but if we are putting the needs of the patient first, then an extra 30 minutes of our time that saves the patient hours is a small inconvenience to us.

A couple of things would make the decision process easier, better dispatch information and updates and agency policy. If I don't know about a diversion, I can't plan around it. What also would be useful would be for volunteer agencies to have a policy on respecting diversion requests. As an ALS provider, I find myself in the position of not knowing what a vollie ambulance will say when it gets there. I can tell a patient that a hospital is on diversion, but they don't know what that means and if a transporting agency shows up and says that they don't care, it gets complicated. If I've just coaxed a family into using a different hospital and the crew says they don't do it, usually quoting 'it's policy', well we all end up looking like idiots in front of the family, which does not inspire confidence in prehospital care. Neither does telling a family that I don't know where we will be taking the patient until I know who the crew is. Individual crews should not be setting corps policy. If agencies don't want to honor diversions, then come on out and say it. If agencies choose to honor diversions, it should not be up to individual crews arbitrarily to say yes or no, absent some other crisis.

I remember an auto accident, with a whole bunch of bumps and bruises, HVHC was diverting because the ER was jammed up, I was willing to go to another hospital, the other ambulance from my corps was not and it would mean splitting a family, so we all went to HVHC after a tense discussion in the middle of the street and caught some grief for it at the hospital, which I thought was well deserved. It's not like the ER has control over patient load. Nurses have a right to be grumpy if you've just left another patient to sit in a hallway with scant hope of ever seeing a bed. My understanding, and if anyone knows details, please chime in, that the number of hospital beds in a given region is regulated and that this region is already thought to have too many. I was told by someone I trust that the HVHC 'expansion' will not result in a significant number of new beds for this reason.

[smwells 7]

Unfortunately HVHC goes on diversion far to frequently ("Boy that cried wolf").

I have seen the faxes at my VAC from HVHC indicating 4-8-12 hour diversions at a clip. I can certainly understand if a piece of equipment is off-line like Cat-Scan that will limit thier capability, but they never explain the reason, in turn as a provider it makes it hard to make an informed decision about the best location for the patient.

As Ckroll indicated if they are short on beds upstairs, why force the patient to a hospital 30+ minutes away for a treat and release issue?

Is it any quicker for the patient to go to Putnam Hosp, or WCMC 30min away, so they can sit 30 minutes less in the waiting room?

For an ALS call it may make sense to call ahead to the hospital, but as a BLS provider, calling on every job makes no sense, and will quickly tick off the ER staff .

[NWFDMedic 58]

The last thing I want to do is bring a patient to a hospital that is on diversion. Not only is it bad for patient care, it is bad for my blood pressure when having to deal with facility staff that thinks diversion means that they are all of a sudden no longer a receiving hospital.

My first comment about diversion is that it's very rare that a hospital in the Hudson Valley is actually legally allowed to go on diversion and they rarely do it properly anyway. Hospitals are not allowed to go on diversion because there aren't any beds upstairs. They also aren't allowed to do on diversion if there isn't another nearby appropriate hospital (unless of course the ER is on lockdown or potentially contaminated, etc.). They should really stop issuing diversions and start issuing "high volume alerts."

With that being said, my job is to take the patient to either the closest appropriate facility or the facility of their choice if the patient condition allows. I will inform my patients that the hospital of their choice is on diversion if (1) I happen to know about it, (2) the patient's condition will allow me to take them to a further hospital, (3) the hospital on diversion is not the only appropriate hospital in the area (ie. Vassar for heart issues, Horton for suspected acute surgical cases at night, etc.). I will inform my patient what is going on and why it's going on and explain to them that another facility would be the best option for their prompt and acute care and they could arrange transfer later if necessary. I've actually had charge nurses come to me in some facilities and ask that we try to take patients to another local facility because of the high volume, but they weren't going on divert and I will do my best to help.

Lately, I've taken quite a few patients to Putnam Hospital and we don't get informed that they are on diversion until we make a radio report to the facility. After I've driven from East Fishkill or further, informed the patient's family we would be going to Putnam, and now am within minutes of the hospital, they're getting the patient. I've had the same issue with HVHC transporting patients from the Highland Falls/Fort Montgomery area. I've also walked into a hospital or two that will have an empty ER with floor nurses handling the holds and the ER complains that we bring them a patient. Sorry, but there is NO reason that a patient cannot receive appropriate and acute ER care in that situation.

[emt301 4]

A couple of things would make the decision process easier, better dispatch information and updates and agency policy. If I don't know about a diversion, I can't plan around it.

Ah yes, once again something that we can blame the dispatch center for. Just in case you're not aware - many times dispatch isn't notified in a timely manner either. If we don't know about it, we can't pass along the information.

Edited January 29, 2008 by emt301

[helicopper 1,050]

Now obviously the PT's condition depends on this, but just out of curiousy what AMB's go to HVHC on a regular basis? Prob the only Hospital in WEST/PUT that I am not familar with. Then given that the PT is stable enough to go to another hospital what are the TXP times? How long will that take the AMB out of service? I mean from Yorktown to Phelps is prob a GOOD 10 min ride. I remember from NORTH SALEM to NWHMC was a long time or what seemed like a long time especially when I had to leave the fly car there. Sorry, that is for another topic that has been bothering me.

I always said that DIVERSION was a COURTESY to the HOSPITAL. If the PT wanted to go to "ABC" hospital then that is where they were going. Most of the time the PT and Family members were more worried that their PRIVATE DR affiliated with their normal hospital would not be able to take care of them. I would tell them once that the HOSPITAL that they wanted to go to was on DIVERSION. If they didn't care, that is where I went.

Then of course you get the ER's ATTITUDE. I can still hear the NURSES now. Like it's my fault the hospital doesn't have any room. Thank God I don't have to deal with that BS anymore.

It may be a courtesy to your patient too and you should be an advocate for their appropriate and timely care. If the hospital is on diversion because of no critical care beds and you bring them there anyway (knowing that they're a potential critical care admission) you're not acting in their best interest. If the hospital is on diversion because their CT scanner is down and they're a trauma patient, again not in their best interest. They may end up in a hallway for hours (days?) or require an additional transport to a facility that can handle their needs.

ALSfirefighter and ckroll are right on the mark. Educate your patient, make a phone call, find out what the real deal is and then you and your patient can make a more informed decision about where to go and why (or why not). You'll get far less attitude if you actually communicate with the ER staff about what's going on than if you just roll in with a patient.

And for many of the 'regular' EMS agencies that transport to HVHC, it can be a 10-20 minute ride there (Cold Spring/Putnam Valley/Eastern Yorktown/Somers/Croton).

[Guest alsfirefighter]

Unfortunately HVHC goes on diversion far to frequently ("Boy that cried wolf").

I have seen the faxes at my VAC from HVHC indicating 4-8-12 hour diversions at a clip. I can certainly understand if a piece of equipment is off-line like Cat-Scan that will limit thier capability, but they never explain the reason, in turn as a provider it makes it hard to make an informed decision about the best location for the patient.

As Ckroll indicated if they are short on beds upstairs, why force the patient to a hospital 30+ minutes away for a treat and release issue?

Is it any quicker for the patient to go to Putnam Hosp, or WCMC 30min away, so they can sit 30 minutes less in the waiting room?

For an ALS call it may make sense to call ahead to the hospital, but as a BLS provider, calling on every job makes no sense, and will quickly tick off the ER staff .

What is far to frequent? I know of hospitals that go on diversion at least once a day in areas that I've worked. In the system I was in down in Virginia our local hospital would go on diversion for 12 to 24 hours clips and once during a a strong flu outbreak for 2 straight days, leaving the Fredericksburg area with going to Prince William or Fairfax Counties or Richmond. It happens...when I'm at work and I get a job and come into HVHC I can see why they are on diversion. So to say they go far to frequently is a bit of a strong statement. You can only control patient influx to a certain degree and you can't control how many need to be admitted. The only control you have is to slow the ambulance arrival flow.

As far as calling as BLS...yes call. It won't tick them off as bad if you keep coming in. Same thing as I've said though, I even tell the BLS ones that they will be waiting with the rest in the waiting room and it could be hours. Informed decisions making, you wouldn't expect anything less and neither should your patient. No one "forces" a patient to a hospitial "30+ minutes away," you let them know that the 30+ minute hospital might get you in and out quicker. I'll drive the 30 minutes if I know I'll get taken care of and get home faster then sitting around. Most wait times when hospitals are full and the ER is stacking up is nowhere near 30 minutes, those prompt rooms end up being ER beds for higher triaged patients.

The only time I call with an ALS patient is if I need orders being I know my medical control the best at that facility.

In most cases I do not care why they are on diversion. I know they are requesting relief. The simplest answer is to try to take patients elsewhere. The more other agencies keep disregarding it and bringing people in the longer it keeps them on diversion while they are trying to clear out as much as they can, making it harder on the providers and agencies who work with them during that time. Provider personal opinion on diversion, the facility on diversion, the reason why they are on diversion and travel time to and from, have nothing to do with patient care decision making and informed decisions. Most cases with adequate ALS care will make it to the next hospital, and BLS certainly will. If that was the case for some of the arguments some of you are trying to make, we wouldn't ground transport to trauma centers and everyone would be considered for medevac.

Diversion isn't the end of the world. In fact in some parts its a daily occurance.

[ckroll 101]

Ah yes, once again something that we can blame the dispatch center for. Just in case you're not aware - many times dispatch isn't notified in a timely manner either. If we don't know about it, we can't pass along the information.

Yes, I am aware. There was no criticism actual or implied of dispatchers. Better dispatch information would help, but I did not blame dispatchers for its absence. Perhaps we need better communication all around. The first agency to deliver a patient to a hospital on diversion gets told about it and that agency should be telling dispatch, who should be passing it along to the rest of us. If there isn't a system in place to do this, then let's make one.

Trying to cut everyone a little slack here, EMS agencies living in the shadow of the hospital do feel a much larger increase in transport time, at least on a percentage basis, when they go out of town than do those of us who practice in the outlying areas. It would be nice, especially with a redesign of the hospital on the boards, to have decreasing diversions as a priority, but in the mean time those of us in outlying areas who can divert our patients have an ethical obligation, at the very least, to try to honor it.

It goes back to how we approach EMS in the first place. We are constantly given rules and then told to use good judgment. Our response to this freedom can be to take the position that 'I don't have to. You can't make me.' or we can ask what we can do to help. I've seen crews that would not make a peep over going to WMC for a trauma patient pitch a fit over going to WMC for diversion. Same distance, same down time, just different reason. If a hospital says they need it and they ask you not to bring in a patient, that ought to be compelling reason to find a better place to park the patient.

[emt301 4]

Yes, I am aware. There was no criticism actual or implied of dispatchers. Better dispatch information would help, but I did not blame dispatchers for its absence. Perhaps we need better communication all around. The first agency to deliver a patient to a hospital on diversion gets told about it and that agency should be telling dispatch, who should be passing it along to the rest of us. If there isn't a system in place to do this, then let's make one.

Trying to cut everyone a little slack here, EMS agencies living in the shadow of the hospital do feel a much larger increase in transport time, at least on a percentage basis, when they go out of town than do those of us who practice in the outlying areas. It would be nice, especially with a redesign of the hospital on the boards, to have decreasing diversions as a priority, but in the mean time those of us in outlying areas who can divert our patients have an ethical obligation, at the very least, to try to honor it.

It goes back to how we approach EMS in the first place. We are constantly given rules and then told to use good judgment. Our response to this freedom can be to take the position that 'I don't have to. You can't make me.' or we can ask what we can do to help. I've seen crews that would not make a peep over going to WMC for a trauma patient pitch a fit over going to WMC for diversion. Same distance, same down time, just different reason. If a hospital says they need it and they ask you not to bring in a patient, that ought to be compelling reason to find a better place to park the patient.

No offense taken. You're 100% correct, better communication all around would be a big help.