Ambulance Diversion Project Comes to Successful End

Nearly a year after the end of a 90-day pilot project aimed at ending ambulance diversion in King County, Wash., hospitals, all 18 hospitals continue at or near zero-divert status.

“I think King County is off divert for good,” says David Carlbom, MD, associate director of emergency services at Harborview Medical Center, the Level 1 trauma center in Seattle. “There have been times when it would have been convenient to go on divert, but we haven’t; we worked through the challenges instead.”

The pilot project was the culmination of 18 months of preparation by the hospitals, private and public EMS agencies, and the Central Region EMS Council (see “Ending Ambulance Diversion,” EMS World, April 2011). During the March through May 2011 pilot period, divert hours declined to less than 6 total per month for all 18 hospitals. Since the pilot ended, ED diversions hours in King County have remained between 11 and zero hours per month, including zero for both November and December 2011.

EMS agencies operating in King County have all noticed and appreciated the move toward zero diversion. Kaylee Garrett, operations manager for American Medical Response (AMR) in King and Snohomish Counties, reports: “We at AMR have been ecstatic with the work King County hospitals have done to make these changes, because we see they do work.”

Eastside Fire and Rescue (EF&R) serves a population of 120,000 in 193 square miles of urban, suburban, rural, wilderness and mountainous areas. In 2010 it logged more than 5,000 EMS responses. Transport times in such a large and diverse geographic area always factor into EMS operations. Deputy Chief Wesley Collins appreciates how zero diversion has helped solve some of their transport issues. “In general, the improvement is being able to go to the hospital that is the most appropriate for the patient, meets the patient’s wishes, and does not cause confusion for the family members who may end up at a different hospital than the patient due to diversion,” Collins says.

Pilot Kick-off

Merrili Owens, executive director of the Central Region EMS & Trauma Council in Seattle, described the reason to engage hospitals in the 90-day pilot program as, “We needed to dip their toes in the water.” In other words, just do it.  By the end of the second month of the three-month test, the hospitals had met both primary goals:

1. Will it work?
2. Can everyone do it?

Pilot project manager Clark Hartley said no critical issues occurred to compromise operations or patient care. Anticipated problems were addressed by prepared work-arounds already in place, with no unpleasant surprises. According to Hartley, most problems were related to timely and accurate data reporting, which continued to suffer from lack of up-to-date training due to turnover.

There were minimal hitches along the way, Hartley said, but they were mostly hospital-specific, where pilot project procedures were not followed, rather than system-wide issues. Busy hospital EDs faced a new reality: We’re saturated, we can’t divert, now what do we do? Hartley said managers dealt with problems by using existing but little-used policies, rather than defaulting to diversion.

Zero diversion has been sustained because everyone understands it has become the new norm. Hartley recalls an example of the new paradigm: “One evening a supervisor in one hospital announced they were no longer participating and placed their ED on divert. The next morning the supervisor’s manager was horrified to find this out, solved the problem, and that hospital has never gone on divert since.”

Carlbom said that at Harborview initially there was some concern from front-line staff, but once they experienced no-divert, they recognized they really could do it. He says, “It turned into more of a pride issue for staff, as in, ‘Look what we did!’”

Jennifer Graves, RN, MS, ARNP, nurse executive at Swedish Medical Center’s Ballard campus, echoes observations of staff pride in the Swedish Hospital system. “I raised the issue of ED diversion at a multidisciplinary shared leadership meeting in late January, and it was wonderful to see the visible sense of the pride everyone displayed.  I believe one of my most important roles as a leader is to remind staff of how far we have come and that together, we have accomplished things that were at one time perceived as impossible,” she says.

During the pilot, all hospitals had immediate access to project leaders, including Hartley, Owens and Chris Martin, executive director of Airlift Northwest. Hospitals were initially concerned about not ever being able to divert. Nobody wanted to be the first to fail. Many had internal struggles to deal with. Project leaders were available for phone consultations any time, offered continuous reports back and reinforced efforts with positive feedback.

Routine conference calls were held where participants could share their statuses, get advice and hear positive feedback from others. Six calls were scheduled to help everyone through the process, but the last two were canceled due to lack of need.

Martin says the information-sharing calls disproved false impressions created from rumors and assumptions. “We had confessions at every meeting,” he says. Managers from hospitals self-reporting issues were brought together with others experiencing the same problems. Martin says this collaborative effort made everyone seem more equal and took a lot of negative energy out of the system.

In addition to the conference calls, written reports were sent out monthly to all hospitals. These reports enabled everyone to see what everyone else was doing. By the third month, participants felt they had the means to complete the trial period and continue on indefinitely.

Another key to success, according to Hartley, was EMS being given ongoing and accurate data hospitals were feeding into the WaTrac system. “The fact that they were given that data was eye-opening. EMS managers for the first time saw real divert data and the efforts hospitals were putting into zero-divert,” Hartley says. “Sharing information broke down some misconceptions of things that were believed to be happening, but really weren’t.”

ED/EMS Interactions

As a second benchmark, the pilot project group set a 35-minute ambulance offload standard that was met 70% of the time during the pilot. EMS agencies and crews noticed the difference.

AMR’s Garrett remarked on how the feedback from AMR’s 300+ responders in King County has changed. “We used to hear crews complain about having to wait 40 minutes to offload a patient. Now what we hear is more like, ‘We were there close to an hour, but you should see what they were doing to find us a bed.’ Our crews see the efforts that have gone into achieving zero divert and have really noticed hospitals putting effective procedures into practice.”

EF&R Deputy Chief Collins also reports a reduction in the friction between hospital staff and EMS crews, saying that feedback from crews has been silence, as in no more frustration. “There used to be increasing frustration about diversion that has suddenly disappeared,” Collins says. “I realize a lot of work went into making this happen and continue to happen; however, for the crews this almost seems like magic.”

Sharon Mow, RN, MS, CNAA-BC, director of emergency services at Virginia Mason Hospital in Seattle, says, “We’ve created a process to direct EMS with a patient on arrival to our ED to go to a room and give a hand-off so they can get back in the field sooner.”

At Harborview, Carlbom has seen improvements in the interaction between ED staff and EMS crews. “ED staff may appear harried when EMS is handing off patients, but it is clear that it has nothing to do with EMS. ED staff recognizes EMS providers as fellow professionals who are doing their jobs,” he says.

Graves reports that at Swedish, “We have built very positive relationships between our EMS providers and ED staff, and we feel as if communication is strong and continuously evolving. To my knowledge, there are no unresolved issues, and we are certainly open to any improvement suggestions our partners propose.”

Remaining at Zero

Since the pilot, ED diversions hours in King County have remained between 11 and zero per month. What was the norm is no longer the norm. “Everybody has stepped up to bat. We made it through the 90 days, there’s no reason we can’t keep it up,” says Owens. At a meeting held two weeks after the pilot project officially ended, participants described their operations as continuing as if the pilot had never really ended, even with nobody being forced to continue.

Graves said the Swedish system intends to remain at zero-divert. “Our commitment is to our community, and keeping access open to all patients is one way we can deliver on this commitment to excellence. I can say that at all levels of the organization, we are aligned and intend to remain divert-free,” she says.

At Virginia Mason, Mow says, “The zero-divert pilot has actually enhanced our ability to identify our flow needs and make improvement. We learned that ED flow is predictable.  We can plan for discharge on arrival to the ED. Now, we anticipate what resources are needed and when so we can prepare for the unexpected.”

Carlbom says it's all a matter of focusing on the positives: “No matter how bad it gets, it’s never as bad as it could be. You may think it’s the worst situation possible, but it never really is.”

Hartley says this successful pilot and the ongoing effort to remain diversion-free means “Zero diversion saves lives, saves money, improves EMS status and improves hospital status.”

Ed Mund began his fire and EMS career in 1989. He currently serves with Riverside Fire Authority, an ALS-level fire department in Centralia, WA.  His writing and photos have been published in several industry publications. Contact him at ems@emedstrat.com.