Strategies to take hospitals off diversion: for many hospitals, diverting patients to other facilities has become routine. But diversion can mean death to certain hospital revenues

Healthcare Financial Management, March, 2004 by Robert Geer, Jim Smith

The majority of hospital emergency departments (EDs) perceive they are at or over operating capacity, according to an American Hospital Association survey (The Lewin Group Analysis of AHA ED and Hospital Capacity Survey, 2002). This ED overcrowding, coupled with a nursing shortage and a history of hospitals closing beds, has created a national healthcare emergency.

The AHA survey also found that ED visits increased 14 percent last year. Experts believe the increase is largely due to the overall population growth, especially among the aged. In addition, increases in the uninsured population may be partially responsible for increased ED visits.

As a result, hospitals sometimes close their doors for significant periods. The AHA survey findings showed that the problem is most acute in urban hospitals, which report their EDs are over capacity 48 percent of the time. However, even rural hospitals report that their EDs are over capacity 19 percent of the time. According to the AHA survey, the number-one reason hospitals go on diversion is a lack of critical care beds.

Decreasing diversion time requires the involvement of staff throughout the hospital, including nurses, physicians, ancillary departments, dietary staff, patient access staff, and ED staff. The importance of garnering support of top management, including the CEO, CFO, COO, and CNO, cannot be overemphasized. Each must understand the issue and be committed to supporting change throughout the organization.

Some Solutions

Ingalls Health System, a large urban hospital with 424 staffed beds in the Chicago suburb of Harvey, Ill., with nearly 19,000 inpatient admissions a year, experienced ED overcrowding and diversion that caused the system to lose potential patient revenue and market share to other facilities. The problem was exacerbated in June 2001 when the hospital experienced 238 hours, or 10 full days in the month, on hospital bypass. In addition to the ED being in a continual state of crisis with patients holding for beds, private attending physicians could not get their patients in the front door. Urgent direct admission requests commonly waited three to five days for a bed. Patients, families, and physicians were frustrated, frequently seeking admission at other hospitals and/or seeking care in the overwhelmed ED. The outcome for Ingalls was physician and patient dissatisfaction and a loss of significant patient revenues.

Ingalls took steps that reduced diversion hours to 51 in June 2002, down almost 79 percent from June 2001. By reducing its diversion hours, the hospital also increased its inpatient revenue, reduced its length of stay (LOS), and eased the stress on its admitting and discharge process. The strategies the hospital used to address its diversion problem ca n be instructive.

Implement an admission and discharge center.

Ingalls introduced an admission and discharge center, with five private treatment rooms, that functions as a staging area for patients who have an order for admission but cannot be admitted because an appropriate bed is not available. The center provides a place to care for patients who are being admitted by private physicians through the admitting area and from the ED for whom a bed is not available. Before the center was created, these patients waited at home or in the overcrowded ED, or were sent to another facility.

The center is located on the first floor, adjacent to both the ED and the admitting area. The center is staffed with nurses, a nurse case manager, and information associates. By providing an area dedicated to caring for patients who are waiting to be admitted, the center allows space to be cleared in the ED for caring for emergency patients.

The goal is to ensure that patients receive the appropriate level of care without delay and within the most appropriate care setting based on their needs and in consideration of third-party payer requirements. The center's staff helps patients complete all necessary paperwork, including consent forms, insurance forms, and medical history. They can perform nursing assessments and coordinate diagnostic testing. While in the center, patients can have lab work and ECGs performed and receive initial doses of medication, such as antibiotics or pain medication.

Upon discharge, patients sometimes are seen in the center. At that time, paperwork is completed, follow-up appointments are scheduled, and prescriptions to take at home are filled.

The center has helped Ingalls achieve the following goals:

* Minimize hospital diversion

* Decrease LOS

* Reduce inappropriate short term utilization of inpatient beds

* Maximize utilization of limited human resources

* Decrease insurance denials

* Increase revenue and payment

* Improve patient satisfaction

* Improve physician relationships

Name a bed czar. At Ingalls, the director of the admission and discharge center serves as the "bed czar" for the organization. She reports to the system's senior vice president and COO. The bed czar continually evaluates strategies and works across multiple departments to focus on patient movement and to decrease diversion hours.