April 30, 2006, 1:11 pm

Diversion Aversion

chest x-ray

“Oh yes, doctor. That is so much better! You see, Billy is so ugly that we couldn’t possibly have put a picture of his face in the yearbook! This picture of his ribcage is much more appealing! Thank you so much!”

Billy: “Yeah, wait until the guys get a load of my widened mediastinum! That’ll show them!”

It looks like they had three-dimensional chest x-rays back then!

If x-rays were that good, even I, one of the radiologically challenged, would be able to read them!

Trust me, if I can see something wrong on your x-ray, you are really sick!

Ambulance diversion.Does it really help emergency department overload?

In the counties I have worked, the emergency departments are allowed to go on “ambulance diversion” status.

This means that anytime the ED cannot safely handle any additional patients, based on specific criteria, they are able to divert ambulance traffic to other area hospitals.

That “specific criteria” usually means one of two things:

  • You have no monitoring capabilities as you have every monitor tied up with a patient who requires it.
  • You ED has maxed out its resources and cannot safely handle another patient. For example, your ED has monitors available, but you have three critical patients in cardiogenic shock and all available staff are required to care for these patients until they can be transferred to the unit.

Lack of staff and/or lack of critical care beds are not, for example, criteria for diverting ambulance traffic.

The status of any particular ED is visible on a county-wide monitoring system; a computer resides in each ED.

(You can also signal the county if your CT scanner is down: patients with head injuries and possible strokes will automatically be diverted.)

Some counties have restrictions on how many hours you are allowed to be on divert in a 24 hour period, some have limits on how many consecutive hours are allowed.

Others have no restrictions, but keep track of the different hospitals and evaluate how much time they spend on diversion.

Too much time on diversion is a no-no.

But what exactly does it accomplish?

  • Well, it might keep elderly, altered and septic patients from nursing homes from arriving by ambulance.
  • It will keep the ambulance-for-the-stubbed-toe folks from arriving.

And that is about it.

  • If you are in cardiac arrest, you go to the nearest hospital, period! Diversion means nothing at this point. Even if you don’t have a monitor and have to perform resuscitation in the hallway, that patient is coming and you will find the means to deal with it.
  • If the paramedics are going Code 3 (red lights and siren) they will come to your hospital. You don’t question the medic’s decision – it is their call. And it should be. You must accept Code 3 traffic at all times. It means the patient is critical.
  • On both sides of the San Francisco Bay, there are hospitals 5-15 minutes apart all down the highways. If two hospitals in a row are on diversion, then neither of them are on diversion, because it would mean passing up two hospitals for care.
  • Diversion does not stop:
    • the walk in MIs
    • the patients with pulmonary edema
    • the decompensating asthmatics
    • the suicidal overdoses
    • the trauma patients laying in the back of their friend’s truck
    • the patient with the CVA whose family managed to get them into the car despite the paralysis of their entire left side.

You get the picture. In addition:

  • Patients who have an HMO plan and are transported to non-HMO hospitals because of diversion have to deal with extra paperwork to make sure their hospitalization is covered or have to deal with the extra trauma of being transferred for admission to the hospital that was diverting at the time of their call to EMS.
  • Some hospitals in our area are well known for certain specialties and patients often request facilities for that reason; requests that cannot be accomodated if the facility is on divert.
  • A patient may be diverted to a facility where their regular doctor does not have admitting privledges, especially distressing if the doctor was planning on meeting the patient at their usual hosptial.

Some of my worst shifts have resulted not from ambulance traffic, but by the acuity and number of walk-in patients to the department.

So while it may be psychologically comforting (and it is) to think that you will not be receiving ambulance traffic, diversion can cause distress to patients, put pressure on the medics in the field and you can never really be sure that the Code 3 ring-down isn’t just a second away.

Ambulance diversion just gives the illusion of control, something that you never get in emergency departments.

It’s the nature of the beast.


  • TC

    April 30, 2006 at 2:51 pm

    You know what I like about you and your site? Oh, besides the blindingly good looks and rapier wit. You really tell it like it is…so many people have a unrealistic idea about what it’s like in the ED-even doctors and nurses. My old hospital would go on divert and every time it seemed like the hospital down the street would too. So we’d wind up taking turns with the medics/EMT’s which is not really divert. And oh, the walking wounded! Nothing like having someone sit in the triage chair and calmly tell you they’ve been shot.

  • Sheepish

    April 30, 2006 at 4:35 pm

    Hi again Kim:

    1. Did you wonder where the kid’s shoulders, arms and neck are on the X-Ray?

    2. Ambulance diversion, or Ambulance Bypass as we like to call it here in Australia, is a last resort option that we take when the ED is so full that every crevice, nook and cranny has a patient in it, usually doubled-up in each bay and sitting out in the hallway. Even then, we don’t do it very often, firstly because there is such a financial penalty in doing so (up to A$20,000 for each 4-hour episode), but secondly because it doesn’t really help.

    You are quite right, the walk-in patients will always walk in, and the true emergency patients will still come. Nevertheless, it still happens.

    What is worse, is when you have a critically ill patient in a small hospital who desperately needs transfer to a tertiary centre. Once I had a patient with an ICH from an MVA in a regional hospital who needed a craniotomy. Every hospital I rang said they were either on bypass or had no ICU beds and refused admission. If I were the neurosurgical registrar none of those would have been valid excuses – the patient goes straight to the operating theatre and the ICU bed is a postop problem. Nevertheless, I allowed myself to be pushed around until we were forced to do a craniotomy locally with a sterilised hand drill from the local hardware store. When I checked a few years ago, the patient was hemiplegic but alive.

  • Susan

    May 1, 2006 at 6:13 am

    Diversion really doesn’t help when we are overcrowded. We often wish we could put up a sign at the door: Closed, try someplace else!

  • missbhavens

    May 1, 2006 at 6:40 pm

    Our L&D department diverts rarely. When we do, it means we are packed to the gills, two-to-a-room, patients having babies in the hallways and conference rooms, ORs maxed out. Usually by the time they divert, it’s far too late. And people keep walking in off the street, anyway. Ours is one of a zillion hospitals all in a row on 1st Avenue. Sometimes I want to put up a sign that says “GO NEXT DOOR!!! THEY ALSO HAVE A BETTER CAFETERIA!”

  • Flea

    May 2, 2006 at 12:12 pm

    Good post, Kim. A nice break from a busy day… you might say diverting.


  • Grunt

    May 3, 2006 at 12:29 am

    About 14 months ago the two “big” receiving hospitals in my fair city bargained to a truce, and now we don’t go on diversion unless we’re forced into “Internal Disaster” mode, meaning it doesn’t happen without approval from a lot of people with manicures and clipboards. Ergo, it’s very very very rare.

    We’ve managed to survive, but we’re also having to get used to permanently-filled hallway beds. Hallway patients used to be a rarity and now, on some of my later-afternoon shifts, they’re the rule.

    Our experience is (I think) a little different from yours: our joint gets (from the last numbers I was privy to) about 60% of the total EMS runs in the county, so diversion did indeed impact our flow. It was a nice break, and let us catch our breath. Now, we’re learning to hold our breath for longer and longer periods.

  • doublediamond

    May 3, 2006 at 9:50 am

    Touche. I work in the OR in Southwest region of the USA. My house is the only major facilty for our state (in the northern region) and the surrounding 3 states southern borders. We are fortunate to have many quailified physicians. I am relieved when one of our specialties closes their service to referrals. The big brohaha happens when the anesthesia group decides that the ED needs to divert. Talk about clipboards and highheels descending upon the underlings wanting the justicficaion and waiving copy of policy. Sometimes the plan comes together. However, most of the time it takes me away from planning care for the patients that are still needing that healing touch.

  • Shannon

    May 4, 2006 at 10:28 am

    Diversion. Now there is a word I never like to hear on my days off. But, I have run into your blog and I have to say… I’m so glad I did.
    I work in the second largest ED in our city. We do not have trauma capabilities, however; we still recieve our fair share of the walking wounded. The larger hospital diverts severeal times daily (2 hour slots)… usually followed by our diversion and sometimes again from the smaller hospital a little north of here. It is one thing to recieve all ambulance traffic. It is an entirely different thing when the ambulatory patients do not stop presenting in Traige. Diversion is frequently the rule right around 6pm daily. Not only are we overwhelmed with ambulances, we also tend to become “standing room only” in our waiting room. New policy within our non-profit catholic hospital is that our primary care area, or “fast track”, cannot take any patients that require labs or radiology. This clogs our ED even more. Patients that simply sprained an ankle have to wait 5 or 6 hours for a bed inside the main.

    You know it’s a bad day when you have three or four Priority 2’s sitting in your waiting area because there are no beds, stretchers or hallways to put them in due to strict JHACO standards, and the line is forming out the door just waiting to register to see a nurse. I’m fairly new to the hospital arena, and on my way to a nursing license, and I find myself so frustrated that the ED is filled to the brim with patients who do not have PCP’s. I really feel that this is a major issue for most ED’s.

  • Erica

    May 4, 2006 at 9:20 pm

    So true. While on paper going on divert seems a feasible answer, it rarely makes a dent in the chaos. Our ED is the busiest in Colorado, and we always operate above capacity, and the other healthcare system in town maxes out considerably sooner than we do. Consequently, if we’re forced to divert, it’s probably only going to last an hour or two until that system forces us off divert. We typically send non-urgent ambulance traffic through triage when we can to offset the flow of toe-stubbers & the rest of those don’t-really-need-an-ambulance folks – but the truly sick still get to us one way or another, and we do what we’re there to do: provide care. In spite of the clipboard-and-manicure set.
    Thanks for the insights!

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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