Cleveland hospitals increase capacity, hire additional staff to help end ambulance diversion
With pressure from EMS to curb ambulance diversion, the four hospital systems serving metropolitan Cleveland have made a pact to bring diversion to an end. The agreement is voluntary, but all sides were determined to make the ban on diversion stick as of mid-February 2016. To get there, the health systems are increasing capacity, adding staff, and taking steps to tackle deeper hospital throughput issues.
- In 2015, reports noted that University Hospitals logged more than 550 hours on diversion, and MetroHealth closed its doors to new ambulance traffic for more than 400 hours. The Cleveland Clinic went on diversion for only 10 hours last year.
- To prepare for the ban on diversions, MetroHealth is adding more inpatient and ED beds, and it is also hiring additional staff. University Hospitals is taking similar steps while also building on the success of its medical access clinic, a lower-cost setting where patients can be screened, stabilized, and connected with primary care for future low-acuity needs.
- Hanging over the effort in Cleveland: Voluntary efforts to ban ambulance diversion in Boston failed repeatedly. However, once regulators mandated a ban on diversion statewide in 2009, the hospitals all fell into line with few signs of any adverse consequences. The city has now operated diversion-free for seven years.
Most EDs have some experience with ambulance diversion, the practice of turning away ambulances for a period of time so that emergency staff can better manage surges in demand. However, while this tactic may help clinicians better care for patients who are already in the ED, few argue with the notion that diversion likely delays care for incoming patients who must now travel to a second- or third-choice facility that may be farther away. Further, there is no question that delays in care can adversely affect outcomes, and cause problems for EMS providers as well as other hospitals in the area that must pick up the slack.
In short, nobody likes diversion, and yet the practice persists in many communities around the country when ED administrators determine that they don’t have the capacity or staff to accommodate incoming ambulance traffic. A handful of communities have determined that ambulance diversion is a practice they can do without. At least some of these efforts have clearly demonstrated that when the issue is addressed collectively as a community, diversion can not only be eliminated, but looking more closely at the problem can also force hospitals to finally address the deeper throughput issues that often prompt the need for diversion in the first place. (See below: “Cleveland can learn from Boston.")
Consider effect on incoming patients
Hospital leaders in Cleveland are the latest to come to the realization that ambulance diversion must end, and that they have the tools and the capacity to make it happen.
“Our local emergency transport system called a meeting in late November , and said that this was really not working well for them,” explains Alfred Connors, MD, chief clinical officer for MetroHealth Medical Center, one of four health systems in the Cleveland metropolitan area. The other three systems are the Cleveland Clinic, University Hospitals, and St. Vincent Charity Medical Center.
According to Connors, EMS providers urged hospitals to unite and craft a system or process that wouldn’t be so disruptive to its operations or patients requiring emergency care.
“They pointed out that … when we were closing [to ambulance traffic] we were thinking about what was best for the patients in our ED right at that point, and they agreed that is important,” Connors says. “But their point was that what you don’t want to do is a good job for the 50 people in your ED, but then put a larger group in the community at a disadvantage because now it is harder for [EMS] to coordinate and arrange transport for everybody.”
It wasn’t one thing, but rather the accumulated effect of multiple small things that brought the issue to a head, Connors explains.
“There wasn’t enough communication among the systems as we were closing, so we would see that we had a problem and we would close, but we weren’t taking into account who else was closed at the time,” he says. “What [the EMS providers] wanted was something where we worked together, we communicated with each other, and we did a better job managing this to minimize the effect on the community.”
Contributing to the problem is the fact that ED volumes have been on the increase in Cleveland in recent years for many reasons, observes Jane Dus, DNP, RN, NE-BC, chief nursing officer at University Hospitals Case Medical Center. “Some of this can be attributed to Medicaid expansion, but we have seen an increase in patients presenting to our EDs, which resulted in MetroHealth and [University Hospitals] increasing our number of diversion hours so that we could maintain the care of the patients in our EDs,” she says. “When that happened, patients would end up at the Cleveland Clinic.”
Collaborate with hospital providers
In response to the discussion with EMS providers, the chief medical officers (CMOs) of all four health systems decided to partner and find a solution. In addition to CMOs, the city commissioner for EMS, the director of safety for the city, and the director of the board of health for the county were invited to participate as well, Dus recalls.
“I was brought along because I manage our ED,” she says. “It was an interesting dialogue.”
Cleveland is somewhat unique in that there are four hospitals that are all located within a 10-mile radius, Dus observes, adding that an ambulance will always travel to the closest, most appropriate hospital, so if the ambulance is transporting a trauma patient, it will not arrive at the Cleveland Clinic because that is not a trauma facility. However, if the patient is not a trauma patient or not in acute distress, the ambulance will often travel to the patient’s hospital of choice — unless, of course, that hospital’s ED has closed its doors to new patients. For instance, reports note that University Hospitals logged more than 550 hours on diversion in 2015, and MetroHealth closed its doors to new ambulance traffic for more than 400 hours.
During the meeting, the participants all felt compelled to see what they could do to alleviate the diversion problem, Dus explains.
“We recognize that there are times when, if we are closed and MetroHealth is closed, the squads need a place to go; or if a patient wants to go to University Hospitals and they have to go to the [Cleveland] Clinic because we are closed, they don’t get to go to their hospital of choice,” she says. “We just decided to make an agreement. It is a verbal agreement that by the middle of February , let’s try to not go on diversion hours at all.”
The pact between the hospitals is voluntary. There are no regulations that would force compliance, but participants are convinced they can put an end to ambulance diversion in Cleveland.
“We made the decision collectively that, yes, this is the right thing to do for our patients, and so we are going to do what we need to do to make this happen,” says Bradford Borden, MD, chairman of the Emergency Services Institute at the Cleveland Clinic. “It’s just the right time to come together with the other health systems in our city and in our area, and get everybody on the same page.”
Look at throughput hospital-wide
In fact, as all participants acknowledge, the task will be somewhat easier for the Cleveland Clinic than for the other hospitals involved, given that the Cleveland Clinic has already taken the steps necessary to all but eliminate ambulance diversion on its main campus.
“We were only on diversion for 10 hours in 2015, and so we have already done some things on our end,” Borden notes. “A big thing is that we have great support in our institution [for the concept] that emergency medicine throughput is not just ED throughput, it is hospital throughput, so the whole hospital needs to be on same page in terms of trying to make sure we are being as efficient as we can be for all of our beds.”
With this organizational support, the Cleveland Clinic has implemented a number of interventions to improve efficiency. For example, Bordon notes that the hospital now holds a series of hospital “huddles” throughout the day to quickly identify and effectively manage any concerns, such as patient surges, that occur.
The hospital also has instituted Saturday morning surgeries so that bed utilization is more evenly spread over seven days rather than just five, and it has begun to make better use of some of the health system’s regional ICUs to ease demand on the main campus.
While Cleveland Clinic is ready to go, other health systems are taking steps to improve efficiency and build up capacity so that diversion will not be necessary. For example, MetroHealth will soon take over the operation of two additional EDs, which are staffed to manage 20,000 to 25,000 patients a year, Connors explains.
“We think this will unload our main campus ED to a degree,” he says. “We will have more sites to go to if needed.”
The health system is also building a satellite ED in a suburb of Cleveland that should be ready for patients in August, and it will soon complete renovations to the ED on its main campus.
“We have redesigned our waiting room and tried to make it more efficient. We also have added additional exam rooms and evaluation rooms,” Connors says. “We did it so that we could handle additional patients, and with the very idea of trying to improve our throughput process so that we have fewer people waiting.”
Also, while expanding emergency care capacity, the hospital is adding two floors to its critical care pavilion to create more ICU space and step-down capacity.
“One of the problems that keeps people waiting [in the ED] is that we get someone who needs an ICU bed, so we need to move someone from the ICU into a step-down unit before we can move [the emergency patient] up to the ICU,” Connors explains. “We are doing this so that we will be more likely to have an open bed so that we can take the patient [up to the ICU] right away and we don’t end up with backlogs. The [new critical care capacity] will open in July and that will help us in dealing with [the ban on ambulance diversions].”
Prioritize staffing, efficiency
The construction projects are key, but Connors observes that the most important step MetroHealth is taking to adhere to the new agreement relates to staffing.
“We see about 100,000 to 105,000 patients in our central ED per year. We’ve got a busy ED and … [the staff] don’t mind being busy,” he says. “Often times when they get backed up, it is not because we don’t have enough beds available in the hospital … it is because we don’t have enough staffed beds.”
To resolve this problem, MetroHealth hired a sizable number of nurses in the summer of 2015, but the hospital system is only just beginning to feel the effect.
“They are steadily coming out of their orientation and training process,” Connors explains. “They should be ready to staff our EDs and floors so that we will be more likely to flex up our staff easily because we have the people to do it, and we think they will be in place by Feb. 15.”
In just the past few weeks, MetroHealth has further reviewed its human resource pipeline to take care of any other staff shortages that need to be filled to ensure that staffing is optimal, Connors notes.
“We feel pretty confident we will be OK, and as the nurses have come on board we haven’t had to go on diversion very much in the last two months,” he says. “We are feeling that on Feb. 15 we will be ready for this diversion-free agreement.”
University Hospitals is also taking steps to improve efficiency and increase capacity.
“We are in the process of opening new ICU and division beds, because part of our problem [has been] lack of capacity on the inpatient side,” Dus observes. “We are also looking at our throughput through the ED.”
In addition, administrators are hoping to build on the success of the hospital’s medical access clinic, which opened three years ago to screen and stabilize patients.
“We can send patients to the clinic where we can hook them up to primary care, so they don’t even make it to the back of the ED,” Dus explains. “Many of these patients have insurance, but they don’t have access to primary care, so we arrange for them to have primary care, and what we are finding is that 96% of them don’t return to the ED for low-level care needs.”
Establish a deadline
Dus acknowledges that there are always concerns about patients overloading the ED, but she stresses that the hospital is going to make every effort to abide by the agreement to end diversion by Feb. 15. She adds that there are signs of progress on that front.
“Just by making the agreement, we are already only closing for four-hour increments, and that seems to be going well,” Dus observes. “Instead of going cold turkey, the agreement for Dec. 1 through Feb. 15 was that if any ED needed to close, it could only close for four hours, and then it would need to stay open again for another eight hours.”
While efforts to boost efficiency and add capacity are important, Dus suggests that hospital staff [members] are also realizing that they can handle more patient volume than they anticipated.
“That is part of it, and also knowing that closing isn’t an option anymore,” she says. “It makes you think a little bit more creatively, and work a little bit differently and proactively.”
Connors concurs that the agreement has forced each hospital to focus their attention on meeting the goal, but he notes that the hospitals were working on the problem even before entering into the agreement.
“Two facilities, [Cleveland Clinic and St. Vincent Charity Medical Center], were [eliminating diversion] already, and both MetroHealth and University Hospitals had plans in place to address the issue,” he says. “That is partly what determined the deadline at a time when everyone could do this.”
Also key to the agreement is the fact that competitive issues didn’t enter into the equation, Connors adds.
“The reason this succeeded is we effectively put aside those issues because there is no competitive advantage to closing your ED. Actually, the competitive advantage would be to never close your ED because [that way] patients can always get in,” he says. “We also realized that the things we are doing to fix this problem are also an advantage competitively. It makes it easier for our patients to get in and get services, so there really isn’t an advantage to not doing this.”
Borden has no doubt that the hospitals will succeed in sustaining the ban on ambulance diversion.
“We are going to make sure it works because that is the mentality of the people at the table,” he says. “Everybody bought into the fact that this is the right thing to do. It is not just the right thing to do for the patients; it is the right thing to do for the community.”
- Bradford Borden, MD, Chairman, Emergency Services Institute, Cleveland Clinic, Cleveland. Phone: (216) 445-4500.
- Laura Burke, MD, MPH, Emergency Medicine Physician, Beth Israel Deaconess Medical Center, Boston. Email: [email protected]
- Alfred Connors, MD, Chief Clinical Officer, MetroHealth Medical Center, Cleveland. Email: [email protected]
- Jane Dus, DNP, RN, NE-BC, Chief Nursing Officer, University Hospitals Case Medical Center, Cleveland. Phone: (216) 844-1000.
Cleveland can learn from Boston
While hospital leaders in Cleveland are steadfast in their determination to end ambulance diversion, it remains to be seen whether the ban on diversion will be sustained. The voluntary route was not successful in ending ambulance diversion in Boston several years ago, although the key driver of the process there was different. “Massachusetts had a Boarding and Diversion Task Force for a long time, and they had been trying to voluntarily eliminate it, and it just wasn’t working by voluntary means,” recalls Laura Burke, MD, MPH, an emergency medicine physician at Beth Israel Deaconess Medical Center in Boston.
However, when the task force, which was part of the Massachusetts Department of Public Health, voted to make a ban on ambulance diversion mandatory statewide on Jan. 1, 2009, the hospitals all fell into line. “The [task force] was willing to go out on a limb and do it. They had buy-in from lots of people, but there were also fears that [the ban] would cause harms; that EDs would be overwhelmed with patients, and that patients would die,” Burke says.
Fortunately, such fears did not materialize. Burke co-authored a study on the effect of the diversion ban on nine EDs in the Boston area, concluding that the ban did not exacerbate ED crowding or ambulance availability.1 “We are going on seven years now that we haven’t had ambulance diversion, and no one talks about putting it back,” Burke says. “Diversion is a crutch, and when hospitals are forced not to use that crutch, they make do. It was a crutch that didn’t work anyway.”
Burke praises Cleveland’s voluntarily ban on ambulance diversion, and she acknowledges that every community is different. However, there is no denying that hospitals in Boston clearly needed to know that they could not back out. Her advice to other health systems and communities that are struggling with diversion problems is to keep the pressure on for change and look for a sympathetic ear among policymakers.
“Find the story that makes people care about this,” Burke advises. For instance, she notes that mass-casualty events have received a lot of attention of late, and people are concerned about an effective emergency response. “Having that policy angle that makes people pay attention to what we know is the right way of doing things probably would help,” she says.
- Burke L, et al. The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time. Ann Emerg Med 2013;61:303-312.
Hospital leaders pledge to make a ban on diversions stick, but some outsiders question whether a voluntary pact will work.
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