Be Well: Cleveland's Hospitals To Stop Diverting Ambulances. But How?
By Sarah Jane Tribble
It’s about 4 p.m. on a Thursday in East Cleveland and Anthony Savoy is the head medic for one of the city’s two EMS squads.
When a call comes in for a man whose nose is bleeding, the squad arrives within minutes on a tree-lined street with well-kept houses.
Once the patient is checked over and walked woozily out to the ambulance, Savoy follows protocol and calls ahead to University Hospitals. It’s the closest emergency department and he needs to make sure they have room to take him.
“Our job is to stabilize them and get them to the hospital alive, to the best of our ability and knowledge as EMTs and medics,” Savoy says.
For years, it’s been common practice for UH to go on diversion. That means when the call comes from Savoy, the hospital says they don’t have the space or staff to handle the patient.
But that practice is expected to change. Earlier this month, UH and Northeast Ohio’s other large hospital systems announced they would begin limiting diversions now and completely stop them within two months – by Feb. 15, 2016.
Savoy is skeptical.
“My concern is all of the sudden you guys are willing to put this in paper and say that you’re going to do this. What was stopping you guys before? You know, why now?”
Savoy and others on the squad are worried that the emergency departments will stay crowded and patients will end up waiting longer.
On the other hand, he says, no diversions will be welcome.
“If we get diverted and then we get a call while we’re at the hospital, our response time will be lengthened by maybe a minute maybe two minutes,” Savoy says.
Dr. James Feldman, an emergency medicine practitioner and researcher in Boston, says that minute or two – or what he calls time to treatment – really matters for some patients.
“I think we have strong evidence that people who have critical illness or injury who have a delayed time to treatment, do worse,” Feldman says.
One 2011 study published in the Journal of the American Medical Association found that lengthy periods of diversion were associated with higher mortality rates among patients with a time-sensitive condition, such as heart attacks.
And before that study came out, the Institute of Medicine had taken a look at the increasing use of diversions by hospitals nationwide, recommending against them.
Yet, emergency departments across the country, including those in Cleveland, continued the use – often making it even more commonplace.
Jane Dus, chief nursing officer at University Hospitals, says that’s because of more patients and more ambulance squads going to emergency departments, including hers.
“If you go back and you look at just the squad volume, we’ve seen a 56 percent increase in our squad volume over five years,” Dus says. “So we’re getting many more squads coming to us.
Dus is one of the hospital leaders in town who negotiated the recent verbal agreement to stop going on diversion. Indeed, all four major health systems say they will stop going on diversion in two months – on Feb. 15, 2016.
And there are few in town like Dus who know exactly how difficult it will be to abide by the ban.
Just this year, UH has been the top utilizer of diversions, with more than 500 hours in which ambulances couldn’t take certain patients to their main campus doors, according to county data. The second highest user of diversions has been MetroHealth System, with more than 400 hours clocked this year.
To stop diversions, leaders at both hospitals say they will add beds and staff.
“We just opened up one floor and we will be building more ICU beds, we’ll be building more inpatient beds and building a clinical decision unit right in our ED to take the low-risk admissions and just keep them down there overnight,” Dus says.
MetroHealth’s Chief Clinical Officer Dr. Alfred Connors says there are actions the hospital can take to be better prepared.
“This does obligate us to take steps to correct problems that are correctable that will allow us not to go on diversion,” Connors says. “It’s not just simply we’re not going to go on diversion and everybody just sits and hopes that everything will be better.”
Adding beds and refocusing on staff are part of the solution, he says.
“It's an issue of do we have enough beds open, do we have the proper staffing, do we have the capacity in the emergency room,” Connors says.
MetroHealth is frequently the busiest emergency department in the city and it has struggled with diversions before, logging nearly 1,000 hours in 2013. Connors says the hospital worked to decrease those hours, getting them down to less than 150 hours in 2014. But, this year, they have been on the rise again.
MetroHealth and UH leaders said they will also make sure everyone at the hospital, from the start of the day, help in the effort to move patients out of the emergency department and up into open beds on the floors.
At St. Vincent Charity Medical Center, the hospital’s chief nursing executive Bev Lozar says the small downtown hospital hasn’t gone on diversion since 2012.
“It’s a matter of working together as a team. It starts every morning at 8:30 we have a huddle of all the nursing directors and all of the other clinical and support directors just to kind of review the day,” Lozar says.
On a recent Thursday morning, nearly 20 people ranging from intensive care staff to the facilities leader, are ready to start at 8:30 sharp.
Lozar pulls out a spreadsheet and points: “So this is kind of the score sheet we start with.”
The title at the top reads “Bed Report, Date 12/10/15, Census: 161”
“So it tells us, shows the various units and their capacity and the census. Who we expect to go home, who we expect to come in. It helps us start the plan.”
A version of this morning operations meeting happens at all of the local hospitals, leaders say.
The Cleveland Clinic’s leaders credit the same kind of operations meeting and communication among the staff as with their recent cut in diversions at main campus.
“What it does is drive people to actually address efficiencies throughout the day and not use diversion as a crutch, to not be doing the work they should be doing,” Meldon says.
Cleveland’s hospitals certainly aren’t the first to try to ban diversions. There are some voluntary bans across the country. And in 2009, the state of Massachusetts passed regulations to ban ambulance diversions after voluntary attempts failed.
Boston’s Dr. James Feldman was a co-author on a study reviewing the ban:
“Overwhelmingly people have felt that this was a positive experience both for patients, the EMS system and actually the emergency department staff as well, some of whom were skeptical about this.”