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Cooperation, expansion keep diversion rate low
City cuts overcrowding, beats national averages
"Overcrowding? What overcrowding?" That could well be the slogan of EDs in Fort Wayne, IN, where diversion rates in its five hospitals are consistently below national averages. The last time Lutheran Hospital had to divert patients was February 2006, and Parkview Hospital and Parkview North had only two instances in the past 18 months when patients were diverted — and then for only an hour or so.
These impressive statistics have been made possible by a number of factors, including a significant expansion at Lutheran, and use of a single ambulance provider. But perhaps above all, it is the communication and cooperation between the community's EDs that has helped keep things flowing smoothly.
When Lutheran Hospital goes on diversion, administrators let Parkview know, says Joe Dorko, chief operating officer for Lutheran. "Even before they go on, they tell us they are at capacity and probably will go on diversion in an hour or so," he says.
This effective communication is due to the fact that the systems now share the same diversion policy, first developed by Parkview Hospital. When volumes were growing from 55,000 annually in 1995 to 82,000 in 2000, they developed a Code Purple, recalls Deb Richey, MPA, director of emergency services at Parkview. "That means the ED is at capacity, and it's a signal that goes to the house and allows us to partner with our critical care and meds/surg units," Richey says.
When either Parkview hospital (the second facility is Parkview North) goes on Code Purple, the ED calls the other hospitals in the community and establishes what their status is — i.e., whether they are full or have capacity. "If we do get to the point where we are unable to take more critical patients in, we can triage those patients to Lutheran or St. Joseph's," Richey explains. "If they didn't have the capacity either, our executive decision would be to go to Code Orange, not diversion."
Shortly after Parkview adapted that policy, says Richey, Lutheran was at capacity "and we shared our policy with them, and they adopted it."
A 'great system'
Dorko and Richey agree the community's single ambulance provider makes a big difference as well. "It's a great system," Dorko says. "We have great communication with pre-hospital care."
They have a public utility model ambulance service, The Three Rivers Ambulance Authority, which is in charge of all EMS service provided within the county, adds Richey. American Medical Response is the contracted provider and provides the bulk of the transportation, she says. "It's easier for us to communicate because there aren't multiple providers — everything is patched through a central system," she explains. "Since EMS is provided by that one organization, they are able to strategically place ambulances and meet our needs during peak demand times."
Most diversions that do arise involve dealing with patients who may be coming from a nursing home, says Dorko. "Our local ordinances say the ambulance must take critical care cases to the closest ED," he says.
The shared diversion procedures also have served the city well when working with the ambulance system, Richey adds. "We fax a copy of our [code] information to the ambulance authority when we go on and off diversion," she says.
This keeps ambulances from having to go to one hospital and then to another, Richey explains. "I'm going to say we had fewer than 10 hours of diversion between both organizations in the last year," she says.
Both systems have added bed capacity, which also helps take the burden off the EDs. For example, both systems opened new hospitals in recent years. In addition, Lutheran doubled the bed size of its ED (from 17 to 34) in 2003, and Parkview recently added six surgical intensive care beds and reopened four medical ICU beds to relieve ED pressure.
In February 2006, Lutheran opened the 77-bed Lutheran Musculoskeletal Center, which freed up bed space in the ED. Prior to its opening, up to 30 beds in the ED were being used for patient overflow.
The final piece of the puzzle is a series of five outpatient centers, called RediMed, which the Lutheran system runs in Fort Wayne. Level I and II cases are handled in these facilities, which also help reduce the volume in community EDs.
"If you look at our conversion rate, something like 28% of our ED patients go on to be admitted, while the national average is probably more like 16%," says Dorko. "How do we address that? We offer these alternatives to ensure we have sufficient capacity."
Of course with the best of systems, diversions cannot be entirely avoided, but Fort Wayne seems to be as close to the ideal as a community could get. "There are times when more than one facility has had to go on diversion — but fortunately, never at the same time," says Dorko.
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