WREMS DIVERSION POLICY

For a facility to request diversion status, the Emergency Department needs to be operating beyond it's capacity to provide quality patient care, with resources so limited that the acceptance of an additional patient would either endanger the life of that patient or another patient.

There are four possible statuses of the Emergency Department which clearly need to be identified:

1. Open Status - which means no delay in patient care.
2. Open Status with Delay in Patient Care - This is left up to the individual facility to determine what the "delay" actually means. The intent of this status is to allow EMS services to consider alternative destinations when they advise patients that there will be a delay in care. The delay in care must be explained to the patient and must be documented on the PCR.
3. ALS Diversion - When an ED is in this status, all patients from the CIPS status definitions of unstable or potentially unstable are diverted.
4. FULL Diversion - This relates to diverting all patients who from the CUPS status are unstable, potentially unstable, as well as stable.

The use of the CUPS status replaces the ALS and BLS statuses which are somewhat ambiguous.

STEPS FOR A HOSPITAL TO GO ON DIVERSION:

1. The decision to divert must be made by the CEO or designee of the facility in conjunction with the Emergency Department Physician.
2. Once the hospital finds it necessary to go on a diversion status, the Regional Office of the Department of Health is to be notified immediately.
3. The hospital is responsible for notifying the Regional Dispatch Organization/Dispatch Centers that can alert the pre-hospital care community the hospital is on diversion.
4. The hospital must have selected alternative facilities that incoming patients are to be transported to.
5. The hospital must, according to 405 Standards, ensure that the following has occurred:
   1. Additional staff are called in.
   2. A discharge team has evaluated patients in the Emergency Department, as well as on the floors, for early discharge.
   3. Cancel elective surgeries
   4. Open additional certified beds, which may not have been kept staffed and open.

With those in place, diversionary status may be instituted.

Diversion status needs to be enacted for the minimal amount of time feasible, which is defined as the maximum 4 hours for ALS Diversion, 2 hours for FULL Diversion unless renewed.

EMS personnel may transport patients to a hospital on diversion in the following situations:

1. All critical patients, those that are too unstable to bypass the nearest facility, are ALWAYS brought to that facility whether or not it is on diversion. Examples include those with airways that cannot be maintained, those in shock, those in cardiopulmonary arrest, etc.
2. Those patients in which on-line medical direction directs patients to the facility despite it's diversionary status.
3. Specialty hospitals, those that offer services not readily available at other facilities, such as trauma, hyperbaric medicine, etc. may not refuse patients requiring these services, regardless of their diversionary status.
4. Patient refusal. The patient always has the right, once explained the risks and benefits of the decision, to go to a facility on diversion.

These are listed in descending order of priority.

A statement will be read to all patients when diversion is discussed. See statement which follows. This will be done by the pre-hospital care providers attending the patient.

DIVERSION STATEMENT:

The following is to be read to all patients when requesting a given facility when the facility is on diversionary status. The patient's condition, his/her insistence on a specific facility destination, and the hospital status need to be fully documented on the PCR.

The statement to be read to the patient is as follows:

YOU HAVE REQUESTED TO BE TRANSPORTED TO _______________ HOSPITAL. AT THIS TIME, THE HOSPITAL IS OVERCROWDED, LIMITING ITS' ABILITY TO PROVIDE YOU WITH OPTIMAL CARE.

_______________ HOSPITAL RECOMMENDS THAT WE TRANSPORT YOU TO _______________ HOSPITAL (THE ALTERNATE SITE). THE STAFF THERE WILL BE ABLE TO TREAT YOUR MEDICAL NEEDS IN A MORE TIMELY MANNER.

The following paragraph is to be read only if the patient continues to insist to go to the diversionary hospital:

IF YOU INSIST WE TAKE YOU TO _______________ HOSPITAL, YOU NEED TO UNDERSTAND THAT YOU MAY EXPERIENCE DELAYS IN YOUR CARE WHICH COULD CAUSE YOUR CONDITION TO WORSEN.

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