Hospital Squad Diversion Override Policy

Overview

The HOSPITAL SQUAD DIVERSION OVERRIDE POLICY is an addendum to the CECOMS Operations Procedure: HOSPITAL CAPABILITY RESTRICTION ADVISORY SERVICE. It addresses the special circumstance, which occurs when hospitals in a particular region of Cuyahoga County are simultaneously diverting emergency ambulances. As a result of such widespread diversion, pre-hospital providers may not have a proximate available appropriate hospital destination.

Policy

The following Cuyahoga County Hospitals shall participate in a rotation designed to insure the following:

1. 1. The major guiding principle is to maintain the highest quality of patient care possible given the extraordinary challenges of the overload of our facilities and services.
2. 2. The Override Policy is designed to insure that:
   1. i. Patients in extremis can always be taken to the closest hospital.
   2. ii. Ambulances will always have a hospital within a reasonable transport time where they can take their patients.
   3. iii. Hospitals and pre-hospital providers will equitably share the stresses and costs of patient overload.
3. 3. Participating hospitals shall know in advance what their patient care responsibilities will be so that they will be prepared to receive incoming patients.
4. 4. Barring catastrophic problems, the trauma system will function in its usual fashion when the HOSPITAL SQUAD DIVERSION OVERRIDE POLICY is activated.

Procedure

(see map for hospital pairings and rotation)

Cuyahoga County, for purposes of declaring Override Condition is divided into two (2) regions. These regions are designed to meet the following conditions:

1. 1. Any hospital within the region is likely to be within reasonable distance of the squads who generally use any of the other hospitals in the region.
2. 2. The closure of all the hospitals in the region would pose difficulties in patient delivery to a significant percentage of the squads who transport to the hospitals in that region.

An override exists when all but one hospital within a region simultaneously place the same or encompassing restriction. Encompassing means that some categories due to their breadth automatically include another category and categories. There are five restriction categories in Cuyahoga County. They are: Critical Restriction - Trauma, Critical Restriction - Medical, Full Restriction, Treat and Release Only and Full Restriction Except for Trauma. Please see table below for further explanation on encompassing restrictions:

Please note that the CECOMS system is programmed to automatically factor in the encompassing categories.

An annual Hospital Override Schedule is prepared and placed in the system. Select the “schedule” tab to view hospital override shifts. In December of each year, the upcoming new year schedule will be placed in the system.

During Override Condition, the day will be divided into 4 hour "override shifts" starting at 12am, 4am, 8am, 12pm, 4pm, and 8pm. Hospitals that are “open” due to override shall accept all patient categories.

No hospital will be required to remain open on an override condition for more than 4 continuous hours. Also, anytime override terminates and then is activated again within the same override shift, that group of hospitals previously open due to override will be required to reopen until the end of their preset override shift. Should the override still be in effect at the end of the preset 4-hour shift the hospital grouping shall rotate.

West Region

A. Lakewood Hospital, Fairview Hospital, Parma Community Hospital, Lutheran Hospital
B. St John Medical Center, Southwest General Heath Center, MetroHealth Medical Center

Communities

Bay Village, Rocky River, Lakewood, Westlake, Fairview Park, Linndale, Cleveland, North Olmsted, Brooklyn, Olmsted Township, Olmsted Falls, Berea, Brook Park, Middleburg Heights, Parma Heights, Parma, Seven Hills, Strongsville, North Royalton

East Region

A. Euclid General Hospital, Hillcrest Hospital, South Pointe Hospital, Marymount Hospital, University Hospital
B. Richmond Hospital, Ahuja Medical Center, UHHS Bedford Medical Center, Cleveland Clinic, St Vincent Charity Medical Center

Communities

Cleveland, Bratenahl, Euclid, East Cleveland, Cleveland Heights, South Euclid, Richmond Heights, Highland Heights, Mayfield Village, Lyndhurst, Mayfield Heights, Gates Mills, University Heights, Shaker Heights, Beachwood, Woodmere, Pepper Pike, Hunting Valley, North Randall, Highland Hills, Warrensville Heights, Orange, Moreland Hills, Chagrin Falls Township, Chagrin Falls, Newburgh Heights, Cuyahoga Heights, Brooklyn Heights, Garfield Heights, Maple Heights, Bedford Heights, Solon, Bentleyville, Independence, Valley View, Walton Hills, Bedford,

Additional Assumptions

1. Patients "in extremis" always go to the closest appropriate facility.
2. The order of the rotation is always the same, unless hospitals negotiate a different order, which is agreed upon by all hospitals in the region and provided to CECOMS prior to the Override.
3. The time the Override starts is always the time when all but one hospital in the region is closed to one of the five encompassing categories. The time the Override ends is always the time the first two hospitals in the region opens.
4. CECOMS will notify all hospitals in the affected region when an override condition is activated or terminated.
5. Since this system occasionally requires significantly longer transports than what certain squads currently do, the decision about whether a patient is in extremis, requiring delivery to a nearer hospital, is made in consideration both of the patient's condition and the required length of transport. This concept is intended to protect patients whose care might suffer from a significantly longer transport.
6. Once a hospital on Override status communicates with an incoming squad, that hospital must accept that squad, even if that hospital's Override status changes before the ambulance arrives.
7. Some squads on the periphery of the County may elect to deliver patients to hospitals in other counties or other regions. This will relieve the burden upon squads on the periphery of their regions.
8. Some hospitals have special arrangements with certain squads. As long as all squads have an open hospital destination within reasonable distance at all times, the diversion and Override policies shall have no effect upon individual arrangements specific hospitals have with specific squads.
9. Upon rare occasion, hospitals may have no ability to take all or certain types of patients. This could be due to fires, electrical or plumbing problems, local disasters, etc. Under these circumstances, hospitals may negotiate with other hospitals near them in their region to arrange for another hospital to take the load until the problem is resolved. CECOMS must receive verification of any special arrangements between hospitals from both hospitals before those arrangements are operative. Hospitals should make special arrangements, if any, with very close facilities within their region such that those arrangements do not result in significantly longer transports for any pre-hospital provider.
10. All provisions of the CECOMS OPERATIONS PROCEDURE: HOSPITAL CAPABILITY RESTRICTION ADVISORY SERVICE which may apply to this HOSPITAL SQUAD DIVERSION OVERRIDE POLICY remain unchanged and in effect. The same hospital officials designated to interact with CECOMS with respect to hospital diversion are authorized to interact with CECOMS with respect to Override.
11. Hospitals are encouraged to use a formal process to accurately monitor and report bed availability. Accurate information can optimize hospital bed utilization, thereby decreasing the requirement for diversion override.
12. The Medical Standards Committee (MSC) recommends that all hospitals maintain Quality Management Programs to address issues raised by pre-hospital and/or hospital providers about diversions and patient transports. All providers must know that they can access the Quality Management Program that will hear and appropriately review their concerns. They should have reason for confidence that the Quality Management Program will institute corrective action plans whenever those plans are indicated.

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