CLINICAL ARTICLE An Accurate Tool for Measuring ED Saturation Levels in an Urban EMS System: Phoenix s Year-long Experience Author: Eric W. Heckerson, RN, MA, NREMT-P, Gilbert, Ariz Eric W. Heckerson is Senior Clinical Manager, Desert Samaritan Medical Center, Emergency Department, Mesa, Ariz. For reprints, write: Eric W. Heckerson, RN, MA, NREMT-P, 1649 E. Palo Blanco Way, Gilbert, AZ 85296; E-mail: eric.heckerson@ bannerhealth.com. J Emerg Nurs 2002;28:427-31. Copyright 2002 by the Emergency Nurses Association. 0099-1767/2002 $35.00 + 0 18/1/128204 doi:10.1067/men.2002.128204 It is 7 o clock on a Saturday night in the Phoenix metropolitan area, and all local emergency departments are at full or nearly full capacity. Staff members of every emergency department are overwhelmed by high-acuity patients, excessive volume, impatient customers, visitors in the lobby, and a seemingly endless flow of new patients through the ambulance entrance. Charge nurses are searching for any new idea that would help manage these various challenges; virtually all of them are opting to place their department on bypass or diversion status. What criteria should be used to place the emergency department on diversion status? What should one facility do when several other facilities in the same area determine that diversion is necessary? How do the facilities determine (objectively) who has the greater need to be on diversion? To answer these questions and to assist managers in quantifying how busy an emergency department is at any given time, a group at Desert Samaritan Medical Center in Mesa, Arizona, as part of a regional committee, developed a form that objectively determines the saturation percentage level. Background As most ED nurses and managers realize, emergency departments have increasingly become the overcrowded safety net for providing vital medical care for communities across the United States. The Phoenix-Mesa area in Arizona is no different. In the past, hospitals were overwhelmed with a high volume of patients and several area emergency departments were competing to be on diversion simultaneously, which, in turn, would leave ambulances with no place to transport their patients. EMS agencies were becoming frustrated with inconsistency in the application of diversion, citing that some October 2002 28:5 JOURNAL OF EMERGENCY NURSING 427
hospitals were going on diversion unnecessarily. Meaningful data surrounding the diversion process were anecdotal at best and frequently inconsistent. Something had to be done to prevent friction over diversion and the broken system. The EMS council in the region, known as Arizona Emergency Medical Systems (AEMS), a long-standing forum for multidisciplinary problem solving, set out to do just that. The AEMS Board created a task force with registered nurse and physician representation from hospitals throughout the region to review and update the diversion guidelines. 1 The group, with cooperation and assistance from the Phoenix Fire Department and the Arizona Hospital and Healthcare Association, implemented the use of EMSystem, a commercially available computer program for tracking the diversion status of all local hospitals (www.emsystem.com). The task force also divided the region into 4 sectors to better aid in communication and monitoring diversion. Finally, the group guided the development and implementation of the ED saturation measurement form. numbers and types of admission holds, and staffing. By completing the corresponding blanks for each factor, totaling the sum, and dividing by the predetermined divisor, an ED manager could identify what level or percentage of saturation the emergency department was experiencing at any given time. The form was then presented to the AEMS diversion task force for discussion and fine-tuning. The AEMS Board of Governors approved the form after several minor modifications and a month-long trial run. The form was designed to be as simple and userfriendly as possible, while at the same time capturing all of the factors that went into the decision to place an emergency department on diversion (Figure 1). Early in the trial, an explanation form was created to assist the users in completing the form accurately and consistently (Figure 2). Additionally, a Saturation Level/Diversion Tracking Form (Figure 3) was developed to summarize and track the data and report the findings to the Department of Health Services. Planning the form The need for an accurate and objective tool was clear. The process began by examining a list of 5 key questions: Could the system objectively quantify diversion criteria? What type of form would be needed for diversion? How could emergency departments compare apples to apples? How could we include such factors as staffing, acuity, and patients being held for admission? How would the system track diversion hours? The ED Senior Clinical Manager (EH) at Desert Samaritan created the first draft of the form as a weighted decision matrix. Some time was then spent debating what weights to assign to what criteria. Much discussion ensued regarding what we would do with the percentages and what they would mean. In other words, once the saturation level was determined, what would the charge nurse do with that information? Because little pertinent literature was available at the time, a management engineer then reviewed the form to ensure reasonable statistical validity. The form was designed to quantify the 4 major factors surrounding the decision to go on diversion: patients in ED rooms, patients in the ED lobby, ambulances waiting or en route, acuity, Program The region adopted the form to be used by virtually all hospitals in the area. The clinical manager or charge nurse in the emergency department typically completes the form when he or she anticipates the need to be placed on diversion. Once the charge nurse determines the saturation level (percentage), he or she can then determine whether to go on diversion. Every facility uses the saturation number differently. There is no predetermined percentage or magic number that must be achieved before an emergency department can go on diversion. In other words, an emergency department does not have to reach X% to go on diversion. Typically charge nurses compare their respective saturation percentages over the telephone to determine who has a greater need for going on diversion. Once a department is placed on diversion status, the charge nurse can then use the form to recalculate the saturation percentage and track the saturation level of the emergency department. This is typically done at 1-hour intervals to monitor any improvements or deterioration related to volume or flow. The calling and the reassessment do not happen as much as they probably should. 428 JOURNAL OF EMERGENCY NURSING 28:5 October 2002
FIGURE 1 Desert Samaritan Medical Center Facility diversion worksheet. Divided by 55 is the sum of the numerators from each of the 5 sections of the form. The bottom portion of the form outlines the 2 criteria for code purple. October 2002 28:5 JOURNAL OF EMERGENCY NURSING 429
FIGURE 2 ED diversion/saturation level worksheet explanation form. This information, provided on the back side of the ED diversion saturation form, explains how to use the form. 430 JOURNAL OF EMERGENCY NURSING 28:5 October 2002
FIGURE 3 AEMS diversion tracking form. This was the initial draft of a form used to track the use and variables of ED diversion. AMB, ambulatory; PTS, patients. Evaluation Thus far, the form and the process of measuring ED saturation levels are working exceptionally well. ED managers, system leaders, physicians, and others have found the form to be invaluable in calculating initial saturation levels and objectively reevaluating the levels after going on diversion. At Desert Samaritan Medical Center, managers have taken the form to the next step and incorporated its policy on high volume response, known as Code Purple, into the form. The policy states that when the emergency department reaches a saturation level of greater than 150% and when the emergency department is holding more than 10 admissions, a Code Purple is declared (see bottom portion of Figure 1). The future of the form and beyond The form continues to evolve, and members from the AEMS diversion group will be evaluating it for reliability and validity based on feedback and data collection from area prehospital coordinators. At some point we are going to computerize the form and work to incorporate the data elements of the form into the EMSystem. In the meantime, Valley emergency departments are uniformly utilizing the basic form to objectively quantify their saturation level and need for diversion. REFERENCE 1. Diversion guidelines. Phoenix: Arizona Emergency Medical Services, Inc; 2001. October 2002 28:5 JOURNAL OF EMERGENCY NURSING 431