Testing surge capacity

Community General Hospital tested its emergency preparedness this week when 20 “accident victims” showed up in the emergency department for a first-of-the-kind state exercise.

"Victims" arriving at Community General Hospital

The Exercise Plan (ExPlan) tests a hospital's surge capacity (at least 20% above typical emergency patient volume).

The ExPlan will be required for New York State hospitals in 2010, and Community was the first hospital to test the exercise for the Department of Health (DOH).

A "mass casualty" victim entering the ED

That screaming in our ED came from some of the high school students who played "victims" of a mass casualty event, complete with moulage (makeup simulating wounds). Exercising their vocal chords was part of the verisimilitude.

The training scenario, developed by the State Department of Health, activates a hospital's incident command system, allowing the hospital to practice its its ability to triage victims, to treat them, and to prepare the entire hospital, including surgery, for the influx.

Triaging a "victim"

It was a learning experience for all of us, and we certainly appreciate the help of the DOH in developing the significant resources needed to prepare, conduct, and evaluate this exercise.

Community's incident command center

Diversion hours were 39% lower last year

Last year diversion hours at Community General's emergency department (ED) fell from an average of 6.9 hours per day (2007) to 4.4 hours (2008). That’s a reduction of 39%. And things were better during the fourth quarter when Community's diversion hours dropped from an average 8.5 hours a day to 2.2 hours, a 74% decline.

Syracuse hospitals generally did a better job last year of providing access to emergency care. Collectively the four non-federal hospitals reduced diversion hours by 10% in 2008 -- and by 57% in the fourth quarter.

When a hospital is “on diversion,” its emergency department asks ambulances to “divert” emergency patients elsewhere. If all Syracuse hospitals happen to be on diversion simultaneously, then the emergency medical system (EMS) directs ambulances to each hospital in sequence.

Diversion occurs when there is an imbalance between patient demand and hospital capacity. If too many patients seek care for the size of an ED or its staff, a hospital may request diversion until a balance is restored. Sometimes an internal event (for example, water line break) may prompt diversion status.

When hospitals are on diversion, a patient seeking care at one hospital may end up at another, at a place where her doctors are not available and where her medical records are not at hand. That’s why the American College of Emergency Physicians, among others, has guidelines for ambulance diversion.

Even when on diversion, however, a hospital's ED is not actually closed. Every emergency department will accept a patient who presents herself for emergency care at any time. A patient has the right to insist that an ambulance go to the hospital of her choice, irrespective of diversion status.

Through the Hospital Executive Council (HEC), a planning agency, Syracuse hospitals have worked together to understand and reduce diversion hours. Funded by the hospitals, the HEC shares data, conducts analyses, and helps support cooperative initiatives to improve health care efficiency and quality.

Diversion is not only about emergency department issues. Does a patient remain in the ED longer than necessary while waiting for a hospital bed to become available? Is a hospital’s length of stay extended because of delays in tests or test reports, because of the time it takes to prepare a room for the next patient, or because patients cannot readily be transferred to nursing homes? Diversion is an indicator of the flow and efficiency of, not just a hospital, but of the health care system within a community.

Here’s an interesting note: last month Massachusetts ordered hospitals to stop diversion, except in specific cases. Syracuse hospitals have reduced, but not eliminated, diversion hours, and we’ve done so voluntarily and cooperatively.

It will be interesting to see the experience of Massachusetts with its regulatory approach.