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

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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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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

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Background County population up
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Background Population getting older
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Background Population getting older
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Background Number of ALS Transports up
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Background ED visits up
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Background ED beds down
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Background Acute care beds down
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Background ICU beds down
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Need to use our existing ED beds more efficiently

• Without the luxury of additional funding!

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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
  20018(5)526

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Background Previous work

• Week Before Test Week Week After
  P-Value
• Hosp A Diversion hrs 19.6 1.4 39.4
  plt0.05
• Hosp A Diverted pts 19 2 29 plt0.05
• Hosp B Diversion hrs 27.7 0 26.3
  plt0.05
• Hosp Diverted pts 24 0 9 plt0.05

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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.
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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 20037(1)171.

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Background Previous work

• Week 1 Week 2 Week 3
• Ambulance runs 685 717 709
• Diversion hours 112.2 0.3 47
• 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.

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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

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Methods Participants

• SDMS EMS Oversight Committee
• Emergency Physicians
• Nurse Managers
• County EMS personnel
• Prehospital Agencies
• Hospital Association

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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

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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 (n21)

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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

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Results Trial Data
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Results Trial Data
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ALS Transfers
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Bypass Hours
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Diverted Patients
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Results Comparison to historical data
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Results Comparison with historical data
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Limitations

• Observational study
• Computer database, occasionally, computers went
  down
• Cannot account for actual patient or paramedic
  requests

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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.

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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