Missouri State Regulators Make Few Inquiries into Diversions

Hospitals are required to report to the Missouri Department of Health and Senior Services when they go on and off ambulance diversion, via a Web-based communications system. Computer monitors in emergency departments, dispatch centers and ambulance districts list area hospitals and display which ones are on bypass status.

The system is operated by the Missouri Hospital Association. Individual hospitals do not have to consult the health agency before they decide when to reroute ambulances.

"I would like to see no diversions at all," said Dr. J. William Jermyn, Missouri Emergency Medical Services medical director. "Is it acceptable, in that we're managing it on a day-to-day basis? I think so."

Emergency rooms are "forced open" if all the hospitals in a defined geographic area, called a catchment area, are closed to ambulances at the same time, according to health department rules. Emergency rooms were forced open 11 times over three different days this year, according to the Missouri health department.

However, a Post-Dispatch analysis found instances when all of the hospitals in a catchment area were on diversion, but not forced open. For example, all the hospitals in the Jefferson Memorial Hospital catchment area were diverting ambulances for two hours -- starting at 11 p.m. April 21 and 12 a.m. April 22. No forced opening occurred. In the hour before and hour afterward, three of the four emergency rooms were closed.

As part of its disease surveillance system, the health department calls hospitals that have redirected ambulances for prolonged periods -- eight hours or longer -- to find out if a disease outbreak or bioterrorism event is under way that could be bringing an influx of emergency cases.

If no unusual event is occurring, staff members do not inquire any further.

The health department does not investigate why an individual hospital regularly declines to accept ambulances.

It does not investigate why multiple emergency rooms were on diversion at the same time, or why some hospitals divert ambulances for lengthy periods of time.

Nor does it analyze the data it receives in monthly reports from the hospital association.

"The raw fact that emergency department capacity was exceed- ed, and they had to redirect patients for a time, in and of itself, is not a violation," said David Durbin, the Missouri health department's director of the division of regulation and licensure.

Jermyn said health regulators were not interested in becoming involved in an individual hospital's staffing and administrative issues.

"It's a fine line, as far as regulation goes, in how do we regulate the problem and not take over the running of the individual business," Jermyn said.

Several looks at the computer screen this summer revealed that some hospitals had not updated their status in days, even weeks.

Durbin said health department staff were not aware of any time when the communications system had not been updated. He said it was monitored all the time.

Some hospitals turn away ambulances but are not listed as being on diversion, said Helen Sandkuhl, director of nursing for emergency services at St. Louis University Hospital.

"If you look on the screen, they are not on diversion," Sandkuhl said. "I have a huge beef with that."

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