UAMS MEDICAL CENTER POLICIES & PROCEDURES. Number: MS.5.17 Policy Title: Diversion of Trauma Patients

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1 UAMS MEDICAL CENTER POLICIES & PROCEDURES Number: MS.5.17 Source: Hospital Administration Approved By: Executive Administrative Committee Date Approved: November 2016 Review/Revised Date: Replaces Policy: PURPOSE This policy shall provide guidance for notifying the Arkansas Trauma Communications Center (ATCC) of the need for diversion of trauma patients due to circumstances that prevent UAMS from being able to care for additional trauma patients such as Trauma Overload or an Internal Disaster that impacts essential resources needed to care for additional trauma patients. DEFINITIONS I. Trauma Overload The number of trauma patients exceeds available resources despite usual accommodation processes, and activation of Code Green must be considered. I IV. Code Green Hospital Disaster Plan for Mass Casualty events. Emergency Department Overload The patient volume in the Emergency Department has exceeded the threshold of normal available resources and the ED is following usual accommodation processes to provide necessary care. Internal Disaster Fire, flood, loss of utilities, or other condition which impacts essential resources necessary to provide care to patients in the facility. V. Major or Moderate Trauma Major or moderate trauma is defined in the Field Triage Decision Scheme: The Arkansas Trauma Triage Protocol, located at: Documents/trauma/Resources/FieldTriageDecisionScheme.pdf. VI. Trauma Medical Director The Trauma Medical Director, Associate Trauma Medical Director or the On-Call Trauma Surgeon if neither of the above is available. POLICY 1

2 I. Recognizing the role of UAMS as the only Adult Level I Trauma Center for the State, Major or Moderate Trauma patients shall not be diverted unless circumstances exist where, in the judgment of the Trauma Medical Director and On-Call Chief Medical Officer (CMO), it is in the best interest of the trauma patient to be directed to an alternative facility for care because UAMS lacks resources to provide necessary care despite the use of usual accommodation processes. Examples of such circumstances include, but are not limited to, Trauma Overload or an Internal Disaster. Trauma Overload may occur when one or more of the following conditions exist: A. The ED is experiencing Emergency Department Overload and there are no additional resources available to provide care to additional patients. (e.g., there is an excessive number of critical care patients, external disaster, or multiple-casualty event and usual accommodation processes are fully utilized). B. All critical care beds are occupied with critical patients and there are no additional resources available to provide care to additional patients. C. The operating rooms are functioning at maximum capacity and either no surgical suites or surgical teams are expected to become available within a reasonable time frame. D. All available trauma surgeons are in the operating room or cannot safely manage additional cases. E. The ED or the facility has sustained an Internal Disaster and is unable to continue normal patient care operations. F. Other circumstances determined appropriate by the Trauma Medical Director, On-Call CMO or ADON that fully commit available patient care resources and are not expected to resolve within twelve hours. I The need to remain on diversion status should be reviewed at least hourly to provide for the shortest period of diversion that is possible. Diversion applies only to incoming ambulance patients and not to walk-in patients or patients who arrive in an ambulance on UAMS property. Such patients will be evaluated and treated or transferred regardless of the hospital s status. PROCEDURES I. In the event of a Trauma Overload or Internal Disaster, the ED Attending, Trauma Medical Director or designee, ED Charge Nurse and the On-Call CMO or On-Call Administrator will confer to assess the need for diversion status. Upon agreement that diversion is warranted, the ATCC dashboard will be updated with the status of NO CAPACITY by the ED Charge Nurse. The Trauma Medical Director or designee must 2

3 be notified prior to changing the status of the trauma dashboard. I IV. The ADON will be notified of the change in status of the facility by the ED Charge Nurse. The ED Charge Nurse will utilize the Emergency Notification System to notify the agencies listed on Appendix A of the trauma diversion status. All notifications, changes in status and returns to normal operations will be documented on the Emergency Department Delayed Status Worksheet (Appendix A). V. When the Trauma Medical Director, ADON and On-Call CMO determine that the status can be changed to Delayed or Open, the ED Charge Nurse will update the status of the trauma dashboard, and contact all agencies to revert back to Delayed or Open status. VI. Individual specialties may be placed on NO CAPABILITY status at the discretion of the Trauma Medical Director in circumstances where a single specialty or resource is not available. APPENDIX A. UAMS Emergency Department Delayed Status Worksheet REFERENCES Arkansas Trauma System Rules and Regulations (Sept. 6, 2014). 42 C.F.R

4 APPENDIX A UAMS Emergency Department Delayed Status Worksheet Notification ED Attending: ADON: On-Call CMO: Trauma: Required for Trauma Delay Delayed Status Authorization Name Official DELAYED/OPEN Times: Date/Time DELAYED Status Date/Time OPEN Status Patients Holding in ED ICU Floor Reason for DELAYED Status Nurse Staffing Issues OTHER Comments: ED Charge Nurse will: 4

5 1. Call the following agencies in the order listed when possible. 2. Provide the following information for notification of DELAYED STATUS: This is (your name), RN at UAMS Emergency Department. I am calling to notify you that we need to be placed in DELAYED STATUS for all ambulance traffic [except for Major and Moderate trauma (or any other service as determined by the CMO/ADON/ED Attending/Trauma Director)]. We will call back to notify you when we are no longer in DELAYED STATUS. 3. At the conclusion of DELAYED STATUS, notify the same agencies of the return to OPEN STATUS. This is (your name), RN at UAMS Emergency Department. I am calling to notify you that we are now OPEN to all traffic and are no longer in a DELAYED STATUS. 4. If the status change is a change to the Trauma Status, update the Trauma dashboard and notify the dispatchers on the phone of the change in the Trauma dashboard. Any status changes to the Trauma dashboard require approval of the Trauma Medical Director. Agency Phone Number MEMS OR Desk Central RCC EASI Southern Paramedic Jacksonville Fire Allied MEDTRAN Air Evac Med Flight DELAYED STATUS OPEN STATUS Date Time Date Time Life Net Survival Flight This form shall be maintained for a minimum of 5 years. 5