Joy, Theresa BSN, RN; Blue, Leeann MSN, RN; Fecher, Alison MD; Gomez, Gerardo MD; Simons, Clark MD; Kemp, Heather MBA
Authors' Affiliations: Trauma Program Manager (Ms Joy), Chief Nursing Officer (Ms Blue), Wishard Health Services, Indianapolis, Indiana; Assistant Professor (Drs Fecher and Simons), Associate Professor (Dr Gomez), Clinical Research Manager (Ms Kemp), Department of Surgery, Indiana University, Indianapolis.
Corresponding author: Ms Kemp, 545 Barnhill Dr, EH 527, Indianapolis, IN 46202 (firstname.lastname@example.org).
Hospital diversion, sometimes referred to as "ambulance bypass," is a critical issue in hospitals across the country that affects patient safety and public health.1 When patients are diverted from hospitals to facilities that are farther away or do not have the resources necessary to accommodate the patients, as can be the case with critically injured trauma patients who are diverted from a trauma center, their health and safety can be compromised.2-5 Relevant journal articles published in the last 5 years reveal that the majority of research and policy discussion is focused on the problem of emergency department (ED) overcrowding,6-17 which is only a small element of the diversion problem. There is ample research being done on how emergency medical services' protocols affect diversion, but few hospitals and public health systems are focusing on the systems issues that need to be addressed.18-24
In November 2005, following the triannual level I trauma center reverification site visit from the American College of Surgeons (ACS) where our institution, a public hospital serving Marion County (Indianapolis), Indiana, was cited with a weakness for excessive hospital diversion, the chief of trauma services and the trauma program manager initiated a period of performance improvement aimed at this issue. The first project completed was a survey of the staff groups (ED physician coordinators, ED nurse managers, and house supervisors) responsible for making decisions to go on hospital diversion to determine what factors precipitated initiating diversion. This survey revealed that all 3 decision-making groups considered holding too many inpatient admissions in the ED as a significant factor in deciding to initiate diversion and the importance of opening additional inpatient beds was a 9 on a 10-point Likert scale.
In January 2006, data regarding ED census (including total volume, number of admissions, and number of patients requiring acute care in the ED) were analyzed to determine objective criteria for when to initiate diversion. These criteria, shown in Figure 1, were implemented in June 2006, after approval by the chief of trauma services, director of emergency medicine, and the ED nursing management group.
After those activities were completed, the trauma program staff partnered with representatives from hospital administration, ED nursing administration, inpatient nursing administration, operating room administration, nursing house supervisors/bed coordination, case management, and environmental services, all of whom became champions of decreasing hospital diversion at Wishard Memorial Hospital. In November 2006, an additional 20 inpatient beds were opened. The cost to open this additional 20-bed unit that could accommodate telemetry and medical patients who were admitted to the hospitalist service was $800,000, and the hospital pays an additional $1 million annually in staffing and maintenance costs for this unit. In January 2007, this unit was converted to an open observation unit to accept all non-acute-care patients, including those admitted to surgery services and other medicine services.
Beginning in January 2007, hospital administration initiated a twice-daily "bed huddle" meeting (8:00 am and 3:00 pm) where stakeholders (nursing directors, nursing managers, as well as bed control, case management, and environmental services staff) met to review the current inpatient and ED census and develop plans for hospital decompression and patient throughput. All critical parties were present to make decisions that maintained a safe and efficient hospital bed control system by reviewing obstacles to patient discharges and patient movement. The agenda for these meetings is seen in Figure 2. Bed placement priority is given to admitted patients waiting in the postanesthesia care unit and the ED prior to any patient transfers of currently admitted patients. If there are no open beds at the initial meeting, an additional meeting at noon is held and diversion may be initiated. Following the "bed huddle" meeting, the trauma program manager reviews all inpatients admitted to a surgery service (including trauma surgery, general surgery, vascular surgery, orthopedics, and neurosurgery) to determine if patients can be discharged or their acuity downgraded.
In February 2007, representatives from the trauma program began presenting data on diversion trends at the monthly hospital leadership forum. This was initiated to ensure that all leaders in the hospital had up-to-date diversion statistics and were aware of progress being made toward eliminating diversion and how this affected ACS trauma center verification status, using 5% annual diversion as the threshold for measuring diversion.
The following month, March 2007, Wishard Memorial Hospital implemented the "diversion-avoidance plan," modeled after the Stony Brook University Medical Center's "Full Capacity Protocol,"8 to relocate admitted patients from the ED into the ward hallways to decompress the ED and avoid diversion. This placement of patients in the ward hallways is restricted to 6 patients (2 per inpatient medical/surgical ward unit) who are not on cardiac monitoring.
In November 2007, the hospital purchased an automated bed control system that allowed better tracking in real time and allowed the hospital to more thoroughly review case management metrics. In addition to accessing numbers of beds available, administrators can see if the beds have been cleaned by environmental services and the level of nursing staff and their level of education. This allows hospital administration to create a system of accountability for patient throughput among all of the individual directors. The BedReady software (Innovative Workflow Technologies, Evansville, IN) cost the hospital $300,000 to license and install. The hospital authorized the expenses for opening additional inpatient beds and the software based on medical necessity for our institution, which is a safety-net hospital. The hospital has not done a financial study to evaluate the cost/benefit of these additional open beds; however, the analysis presented in this article demonstrates the effectiveness is addressing the problem of diversion from an efficacy perspective.
The costs to open and maintain the additional inpatient unit and to license and install the bed monitoring software were justified by the chief nursing officer because they were critical to the community served by the public hospital. It was logically foreseeable that if these improvements were not made, then diversion would continue to be a problem, likely causing the hospital to be cited with a criteria deficiency at their next ACS level I recertification visit, which could result in the hospital being unable to retain those trauma surgeons (who also served as the hospital's general surgeons), and the community requires access to general surgeons for the maintenance of public health.
Figure 3 provides a timeline of the hospital-wide changes that were implemented at Wishard Memorial Hospital compared with hospital diversion. Wishard experienced an initial drop in hospital diversion when they began to research diversion, which raised awareness regarding the importance of addressing this issue in the ED; however, these solutions were only temporary, and the downward trend lasted for only 6 months. Diversion again began to increase, and hospital administration began to take drastic hospital-wide measures to address this issue systemically. In the first quarter of 2007, after diversion was put on the leadership's high-priority agenda, diversion began to precipitously decline and remain below the ACS's 5% threshold.
Results of Systemic Changes
We analyzed our historical hospital diversion rates from 2004 to 2009 to determine which efforts resulted in a statistically significant drop in hospital diversion. Because this research did not involve accessing or using health information, this study did not meet the criteria for human subjects research, and review was not required by the institutional review board.
The institution saw steady increases in annual hospital diversion rates from 7.5% (659.58 hours per year) in 2004 up to 11.2% (979.37 hours) in 2006. After the hospital directed its diversion-avoidance efforts beyond the ED, the amount of hospital diversion took a precipitous drop in 2007 (0.8%, 68.02 hours) and remained at this point in 2008 (0.8%, 68.57 hours) and has remained under the 5% threshold for the first 3 quarters in 2009 (1.4%, 88.83 hours in 9 months) despite our hospital closing its on-site acute rehabilitation center, which had been consistently used as a discharge location for trauma patients. Table 1 includes the annual hospital diversion rates for the period of review. The average annual hospital diversion for the period of increase (January 2004 to December 2006) was 9.85% (862.45 hours), with an average of 113 incidences of diversion per year. The average annual hospital diversion for the period of decrease (January 2007 to September 2009) was 1.0% (75.1 hours), with an average of only 22 instances of diversion in this period. This represents a decrease of 9.0% (787.35 hours per year).
The data were broken down by quarter and analyzed using a Wilcoxon rank sum test; use of this nonparametric test was required because the sample size was so small (12 quarters of data in the period of increasing hospital diversion and 10 quarters of data in the period of decreasing hospital diversion). This resulted in a z score of 3.96 (α = .01, 99% confidence interval), demonstrating that there was statistically significant less diversion after the hospital-wide systems processes changes were implemented.
Changes to the diversion policies and procedures were successful because the decisions being made were (1) championed by hospital administration, making this a hospital-wide issue; and (2) based on objective information from multidisciplinary sources. The hospital has cultivated a culture where all disciplines, departments, and units understand that the hospital must run as a team to serve the patients efficiently and effectively; open sharing of information and dialogue at least twice daily creates an environment of cooperation and multidisciplinary participation in problem solving to meet the needs of the community.
Hospital diversion is a critical problem for public hospitals that provide essential care as a safety-net provider. To successfully decrease hospital diversion, it must be placed on the programming agenda of hospital administration and requires a top-down commitment and system-wide accountability before any significant decreases can be seen. To be effective, public hospitals must move hospital diversion beyond the scope of the ED.
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