CAPABILITIES:

All participating parties will provide all other participating parties and to the Council a statement of capabilities that defines that party's capability to provide first response, EMS and hospital services and the scope (quantity or level) of those services in three types of situations:

1) routine operations levels

2) enhanced call-back levels and

3) mass casualty incidents.

The purpose of this exchange of information is to assist the Council and the parties to plan for optimum performance during diversion periods and in cases of enhanced patient loads or mass casualty incidents. Statements of capabilities will be updated whenever a significant change in capabilities of a long-term or permanent nature is made by any party.

LEGAL RESTRICTIONS:

In entering into this agreement for direction of patients during periods of diversion, it is recognized that the hospital participating members are regulated by state and federal laws and regulations regarding care and transport of patients; including the federal EMTALA law that may not be modified by this agreement. Specifically, this agreement does not modify the obligation of hospitals to comply with one or more of the following EMTALA requirements:

A. Hospital-owned ambulances/air medical services are required to transport from the scene of an accident, injury or illness to the hospital which owns the ambulance unless operating under a central community plan for ambulance destinations that determine the destination hospital for the patient in the field or unless the patient or person acting on behalf of the patient formally requests transport to another destination.

B. Hospital-owned ambulances/air medical services may not be diverted by their home hospital. Diversion by 911 Dispatch pursuant to a community wide plan such as this document is recognized as an exception to this rule by HCFA.

C. Once a patient presents on the campus (as defined by EMTALA), the hospital may not divert the ambulance or refuse the patient, regardless of' diversion status,

D. Hospitals are required to accept transfers of patients under EMTALA when they possess greater capabilities than the hospital seeking to transfer the patient and the requested destination has available space and personnel or the capability of providing care, even if that exceeds licensed beds. Beds may not be held open for anticipated elective admissions or contingent in-house use. All unassigned beds are deemed available.

E. Once a patient presents to a hospital via EMS or other means seeking emergency evaluation and care, the hospital is required to provide care and appropriate documentation within its capabilities, including medical screening, additional care, stabilizing care and/or transfer in compliance with EMTALA standards.

F. In-bound EMS units/air medical units may not be re-directed to another facility if the hospital is not formally on divert status consistent with this system.

Diversion criteria:

A participating hospital will utilize five standard designations for its status reports to the 911 Dispatch Center:

Open Available to receive all in-bound ambulance traffic

ED Divert The Emergency Department of the hospital is unable to safely accept any in-bound EMS ambulance traffic

Specialty Caution Due to unusual circumstances, the hospital is presently unable to care for patients requiring care of this specialty type (i.e., neuro or trauma, etc) that would normally be within the hospital's capability. Ambulances are cautioned to consider this in patients who may be better served at another location.

Critical care Divert After all step-downs and other available means to make beds available, no monitored beds are available and patients requiring monitoring will not be accepted for transfer. In-bound EMS units with probable critical patients will be diverted to other facilities by 911 Dispatch.

Disaster Status The facility is currently involved in a mass casualty incident (MCI) and the hospital has instituted its internal and external disaster plan. All in-bound EMS units not involved in the current MCI are to be diverted to other locations.

Divert Denied Although the hospital declared the need for divert; existing system-wide patient loads require all hospitals to remain open and accepting traffic under a rotating assignment basis.

STANDARDS:

Divert status will be requested only after the hospital has exhausted all internal resources to meet the current patient load, including any necessary call-backs of staff, step-downs, expedited discharges, opening of "virtual" beds, and similar mechanisms to address the patient load.

Hospital diversions will not be based on financial decisions. hospitals will not go on divert status to hold available bed space for anticipated elective admissions or withhold call-backs or delay opening additional resources due to cost considerations. While on diversion, hospitals must make every attempt to maximize bed space, screen and defer elective admissions or procedure, and use all available personnel and facility resources to minimize the length of divert status. Hospital medical staff will cooperate in promptly assessing all current admissions for appropriate early discharge.

Diversion is temporary and the hospital must return to open status as quickly as possible. Diversion except for Disaster Status will automatically terminate within 4 hours of initial divert status request. A second 4 hour period may be requested. A hospital may not be on divert in any status (or combination of status) more than 8 hours in any calendar day unless it is on Disaster Status diversion. Time periods will be monitored and enforced by the 911 Dispatch Center.

Divert requests will be denied by the 911 Dispatch center if two or more hospitals are currently on ED Divert status at the time a third hospital requests ED Divert status. A denied request to go on divert will automatically result in termination of diversion status for all hospitals currently on ED Divert and implementation of a rotating destination assignment system by 911 Dispatch Center to spread EMS patients equally among all hospitals. All hospitals requesting divert status will be placed on Divert Denied status. The Divert Denied status will remain in effect for 4 hours or until earlier ended by the 911 Dispatch Center. At the end of Divert Denied, all hospitals will be returned to Open status. Time spent on Divert Denied status does not count toward the maximum daily divert time allowed any one hospital.

PROCEDURE:

ED divert may only be implemented by the Emergency Physician in charge of the Emergency Department with approval of the house nursing supervisor for that shift and the CEO, COO or senior administrator on call, following internal policies and procedures of the hospital. Other types of diversions may be requested by designated individuals within the hospital following hospital policies and procedures. All persons with authority to act on behalf of the hospital to place the hospital on any diversion status; terminate diversion, or modify status must be designated in writing to the 911 Dispatch Center. The hospital is responsible for notifying all internal departments, services, and leadership.

The 911 Dispatch Center will be notified by an authorized individual representing the hospital and the appropriate divert status requested. The 911 Dispatch Center operations manager or the person acting as such in the absence of the operations manager will personally authorize or deny all requests for diversion consistent with the provisions of this agreement.

The 911 Dispatch Center will be responsible for notifying all participating parties by radio (Frequency: xxx.xx) using a tone alert signal and verbal announcement. tone and verbal announcement will be repeated. /Mobile CAD units will receive an encoded tone and text message on the divert status, Individual units contacting 911 Dispatch Center will be advised of the divert status and re-directed by the 911 Dispatch Center to an appropriate destination. Individual units contacting the hospital directly (but not yet on the campus of the hospital) will be advised of the divert status and instructed to contact 911 Dispatch Center for further instructions,

Individual units contact the hospital directly after crossing into the hospital's legally defined campus/ 250 yard zone, will continue on to the hospital and patient care will be administered regardless of divert status.

The 911 Dispatch Center will be responsible for notifying all participating parties in the same manner when any status change occurs regarding any hospital divert status or when the system goes to Divert Denied status.

DIVERT OVER-RIDE:

An CMS crew in the field is authorized to declare a "Divert Over-ride" and proceed to a hospital currently on ED Divert in the following circumstances:

A. The EMS crew has determined that the safety of the patient would be jeopardized by going to a more distant facility, if the requested hospital is the closest appropriate hospital;

B. After advising the patient of the divert status of the hospital and the likely delays that will be encountered in receiving appropriate care, the patient specifically demands to be taken to the destination hospital regardless of the diversion status.

C. The patient is in a class of conditions designated by the EMS Council's written medical EMS protocol as being "No Divert" cases.

No specific over-ride is necessary for Specialty Caution and Critical Care Divert status because these two classes of diversion specifically place the discretion in destination in the hands of the EMS crew attending the individual patient, and are advisory in nature.

Where a facility is on "Disaster Status" EMS services are strongly cautioned that only patients with the utmost emergent situation should attempt to access the facility. Again, those extraordinary situations are determined in the discretion of the EMS personnel attending the patient.

QUALITY MONITORING:

All hospitals will keep a diversion record on each instance that the respective hospital requests diversion. The record should document the administrative clearance process followed for approval, the type of diversion, and facts supporting the decision to request diversion.

One copy shall be provided to a designated physician reviewer or panel of physician reviewers to determine any quality of patient care issues raised by the situation and possible solutions for resolving or alleviating the situations giving rise to the diversion request.

One copy shall be provided to the 911 Dispatch Center for review and retention to support the diversion. Divert requests deemed improperly implemented by 911 Dispatch Center administrators will be reported to the facility and to this Council for discussion at the next meeting.

Disputes between or among the parties regarding diversion incidents or trends will be resolved by submission to the Council for determination and action. Hospitals will provide the Council with a copy of the diversion record or records in dispute.

All hospitals will provide the council a quarterly report on the number of minutes on diversion during each month of the quarter by type of diversion status.