The practice of temporarily closing hospital emergency departments (EDs) due to lack of capacity — a practice known as going on diversion — has gained national attention in recent years as a symptom of the shortcomings in the US health care system. Camden Clark Memorial Hospital in Parkersburg, West Virginia, USA, used to be a prime example of this problem.
“We were diverting patients away from our ED about 20 times per month,” says Jessica Owens, BSN, RN, CEN, Clinical Specialist and Trauma Coordinator at Camden Clark. “We were spending a lot of time and effort turning patients away.”
Today, the story couldn’t be more different. “Except for during a mass casualty, we haven’t diverted in more than a year,” says Owens. “And even then, it was only for an hour.”
The ED at Camden Clark — with 30 beds and about 48,000 visits per year — is a very busy place. The flow of patients into the ED is steady, says Owens, which used to mean regular bottlenecks as patients filled each room. But as participants in IHI’s Collaborative on Improving Flow Through Acute Care Settings, staff at Camden Clark learned, and then experienced for themselves, that there is no such thing as simply “an ED flow problem.”
“When we analyzed our patterns of diversions over a six-month period, we found that in all but one case we diverted because there were no critical care or telemetry beds available for us to transfer patients to after treating them in the ED,” says Owens. “We were diverting patients not so much because we couldn’t treat them in the ED, but because we couldn’t move them out of the ED to their next destination quickly enough.”
To bring this situation to the attention of staff, the Camden Clark Flow Team compiled data on diversions — how often they were diverting and why — and posted it for all to see. “People were shocked to see how much we were diverting,” says Owens.
The team also posted data on the time it took staff to go on diversion — completing the paperwork, notifying other hospitals as well as the area’s centralized emergency services command center — versus the time it took to check in patients. “We were spending more time and effort just to go on diversion than we would checking patients in,” says Owens.
The data opened the eyes of staff to the realities of their diversion patterns, and laid the groundwork for change. Next would come the hard work of changing policies, practices, and culture.
A Critical Partnership
Located on the western edge of West Virginia, near the Ohio border, Parkersburg is the state’s third largest city, serving a mostly rural county with a population just under 90,000. With 313 beds, Camden Clark is the larger of two acute care hospitals in Parkersburg. The county’s emergency medical service operates out of a centralized telecommunications command center known as WestCom. Owens says her group knew that working in partnership with WestCom would be one of the keys to changing the hospital’s diversion practices.
“We talked with them about wanting to reduce our dependence on diversion,” says Owens. “We asked them what kinds of patterns they were seeing.” Through these discussions, the group learned several important things.
“We were asking the paramedics in the field to make judgments within two or three minutes of seeing the patient if the patient might end up being admitted to our ICU, CCU or telemetry unit,” says Owens. “That’s a very quick decision under the circumstances.” Owens says she and her team members knew that this was not a highly reliable way to determine the patient’s ultimate destination, and that some patients were probably being turned away needlessly.
The WestCom paramedics also were able to paint the bigger picture of what frequent diversions meant to the larger medical system. “They could see that when we divert, the other hospitals in our area start to get overloaded, and then they divert, and it all comes back to us, and it’s just a cycle of diversions.”
And third, Owens says she and her team knew that going on diversion was only keeping a certain category of patient from coming to the ED. “We would still take walk-ins, and that was a higher percentage than ambulance patients. And we would also take ambulance patients who insisted on coming here even when we were on diversion.”
A New Sense of Pride
All this made it clear to the team that reducing diversions was a worthy goal. But they also knew that solving one problem often creates another.
“We knew that first we had to figure out how to improve the flow of patients out of the ED into beds,” says Owens. Because the hospital serves a large elderly population, their admission rate of 28 percent of ED patients was already higher than the national average of 16 percent.
The ED staff implemented bed huddles
during which staff could review the status of patients and determine how many were likely to be admitted. “We started having huddles at 10:00AM and 2:00PM every day, but then we realized it made more sense to let the ED shift leader call a huddle whenever it looked like flow was compromised,” says Owens. The bed huddles include the nursing supervisor and the director of case management, as well as ED physicians. “We hold the huddle right at the grease board where all the ED patients are listed,” says Owens. “The docs will say what they think will happen with each patient, so we can give the units upstairs some idea of how many patients may be coming their way.”
The flow team also developed a high census plan that takes effect whenever the ED has patients in half its beds designated for admission. The plan calls for ED staff to notify the hospital administrator who calls a “major bed huddle” with top management. One of the decisions that only the administrator can make is to open up a special patient overflow area for ED patients who are waiting to be admitted. This area, created as part of the “anti-diversion” plan, is a recovery room that can be staffed when necessary by nurses from the float pool and critical care nurses after the surgical schedule is complete.
The administrator is also empowered to call for rescheduling of elective surgery when necessary. “West Virginia was hit very hard by the flu,” says Owens, “especially with our geriatric population. Elective surgeries were cancelled a couple of times during the height of flu season. It was a tough call to make, but the right decision.”
These tactics have not only allowed the ED to virtually eliminate the need to divert, but have enabled staff to treat more patients without increasing the average length of stay in the ED after admission, which remains about 70 minutes.
Owens says the culture shift in the ED, and in the hospital at large, is noticeable. “Before, diversion was a common practice,” she says. “Now, everyone knows that to divert, it has to be a very big deal. There is a new sense of pride about that.”
Owens says hospital staff also learned a broader and more important lesson during the process of improving flow into and out of the ED. “The single biggest thing we have learned from IHI is that no department acts alone to help the patient,” she says. “Because we are all part of the same system, we are all connected to each other’s work.”