Effects of ED Diversion on Trauma Care As Perceived By EMTs Who Provide Basic Life Support Services for Morristown Memorial Hospital’s Geographical Region

Abstract

Emergency departments are affected by overcrowding, which may lead to diversion and cause delays in emergency services. In the past decade, overcrowding has become a significant national problem, with critically ill patients being diverted because of a lack of space and resources. Diversion of ED patients also is problematic from an administrative perspective, as it is a loss of potential revenue for the institution. The decision for diversion is made when it is deemed that the emergency department is at capacity or the hospital does not have sufficient bed capacity. A similar decision-making process is applied to critical care diversion and is contingent on the lack of available critical care beds. Also affected by ED overcrowding and diversion are EMTs, who transport the ill and injured. EMTs are challenged with finding alternative hospitals and dealing with prolonged transport times, which is a burden for the EMTs and potentially puts patients at risk. According to a study by Begley and colleagues, there could be a correlation between diversion and death rates among the most severe trauma patients transferred from lower-level hospitals. The state of New Jersey has a 2-tiered emergency response system consisting of Basic Life Support (BLS) and Advanced Life Support (ALS). BLS care is provided by either professional providers or volunteers and conducted under the direction of the local government. ALS operates under the auspices of the New Jersey Department of Health and Senior Services and is provided by a hospital-based Mobile Intensive Care Unit; while the volunteer BLS services generally are freestanding and nonregulated. All requests for EMS receive a BLS response, and patients with critical medical conditions additionally receive an ALS response; as a result, 2 vehicles are dispatched. Within our catchment area, BLS providers are EMTs or First Responders, and ALS providers are paramedics. Word Net Book defines diversion as sending on a course or direction different from the one that was planned or intended. In New Jersey, diversion cannot be mandated by a hospital; it is only an advisory status. Therefore, ambulances with critically ill patients have the discretion to utilize a diverted emergency department (see Table 1 for descriptions and definitions of diversion). Emergency service providers can be affected dramatically by hospital diversion. The decision of which emergency department to utilize often is not clear because of geographical distance between hospitals. Available resources and prolonged transport times factor heavily in the decision making. The authority to utilize an emergency department or hospital that is on diversion may be heavily scrutinized by a hospital staff that is already stretched to capacity. This situation creates a potential source of conflict between the EMTs and the ED staff. The purpose of this study was to identify the perception of hospital diversion by EMS providers and how these perceptions affect their management. This study specifically evaluates how diversion affects comfort level of care providers, reception of ED personnel, EMS, and patients, along with barriers to the continuum of care. This issue is important, because EMS providers are critical members of the emergency service team and have Gayle Walker-Cillo, New Jersey ENA, is ED Clinician, Morristown Memorial Hospital, Morristown, NJ.