San diego county patient destination trial
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San Diego County Patient Destination Trial. Gary M. Vilke, M.D. Associate Professor of Clinical Medicine Interim Medical Director, San Diego County EMS. Acknowledgements. Edward M. Castillo, PhD Theodore C. Chan, MD Roneet Lev, MD Marcelyn A. Metz, RN Patricia A. Murrin, RN, MPH.

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San Diego County Patient Destination Trial

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San Diego County Patient Destination Trial

Gary M. Vilke, M.D.

Associate Professor of Clinical Medicine

Interim Medical Director, San Diego County EMS


Acknowledgements

  • Edward M. Castillo, PhD

  • Theodore C. Chan, MD

  • Roneet Lev, MD

  • Marcelyn A. Metz, RN

  • Patricia A. Murrin, RN, MPH


Background: The Problem

  • Emergency Department bypass hours up

  • Many patients unable to get to ED of choice

  • On average, it takes 6 hours to repatriate a patient

  • Compounded by fewer beds and increasing population in the county


Background: County population up


Background: Population getting older


Background: Population getting older


Background: Number of ALS Transports up


Background: ED visits up


Background: ED beds down


Background: Acute care beds down


Background: ICU beds down


Need to use our existing ED beds more efficiently

Without the luxury of additional funding!


Background: Previous work

  • Two neighboring hospitals

  • One secured funding to stay off diversion

  • The other made no changes

  • Data collected week before and week after trial period

    Vilke GM, Simmons C, Brown L, Skogland P, Guss DA: Approach to decreasing emergency department ambulance diversion hours. Acad Emerg Med 2001;8(5):526


Background: Previous work

Week Before Test Week Week After P-Value

Hosp A Diversion hrs19.61.4 39.4 p<0.05

Hosp A Diverted pts192 29 p<0.05

Hosp B Diversion hrs27.70 26.3 p<0.05

Hosp Diverted pts240 9 p<0.05


Background: Previous work

The oscillatory phenomenon, when one hospital went on diversion leading to a disproportionate flow of ambulance traffic to the neighboring facility that subsequently was forced to go on diversion, went away during the trial week.


Background: Previous work

  • Five regionally located hospitals

  • Commitment to try to stay off diversion for a week

  • Measurements the week before and after the trial week

    Vilke GM, Loh A: A prospective study of minimizing ambulance diversion and its effect on emergency department census and hospital admissions. Prehosp Emerg Care 2003;7(1):171.


Background: Previous work

Week 1Week 2Week 3

Ambulance runs685717709

Diversion hours112.20.347

No changes in numbers or percents of ED patients, med/surg admissions, ICU admissions.

There were significant decreases in patients being diverted and trends to decreased numbers of patient requiring interfacility transfer out.

No reported “unsafe” events in the ED during the trial week.


Methods: Study site/type

  • San Diego County

    • 2.8 million people (urban, suburban, rural and remote)

    • 150,000 annual ALS transports

    • 21 Emergency Departments (2 military)

  • Prospective observational


Methods: Participants

  • SDMS EMS Oversight Committee

    • Emergency Physicians

    • Nurse Managers

    • County EMS personnel

    • Prehospital Agencies

    • Hospital Association


Methods: Why the study needed to be done

  • Patient care issues

  • System collapsing

  • Previous work supported a county-wide trial

  • Fear of non-medical people “outlawing” diversion


Methods: The Rules

  • An ED can only go on diversion for an hour at a time, then must take itself off

  • It can only go back on diversion after taking an ambulance patient

  • While on diversion, the ED must take its own requested patients

  • All hospitals agreed to participate (n=21)


Methods: Measurements

  • Baseline data obtained

  • Trial started in October, 2002

  • Followed

    • Numbers of patients who requested an ED and could not get there due to diversion issues

    • Diversion hours

    • Duration of diversion events

    • Numbers of ambulance runs


Results: Trial Data


Results: Trial Data


ALS Transfers


Bypass Hours


Diverted Patients


Results: Comparison to historical data


Results: Comparison with historical data


Limitations

  • Observational study

  • Computer database, occasionally, computers went down

  • Cannot account for actual patient or paramedic requests


Conclusions:

  • A voluntary community-wide approach to attempt to get ambulance patients to requested facilities and to decrease ambulance diversion can be effective in attaining these goals.


Follow-up :

  • The committee unanimously voted to stop this as a trial and to continue this as a process

  • Meetings will occur, at minimum, monthly for oversight


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