"Under the commissioner's leadership about a year ago, we convened our Boarding and Diversion Task Force," said Paul Dreyer, director of the Bureau of Healthcare Safety and Quality (HSQ). "While having that discussion, we all came to an epiphany that rather than thinking about what the diversion rules should be, we should get rid of diversion."

Under the old policy, if a hospital's emergency department (ED) was filled to capacity due to a sudden rush of ambulance calls, some of those ambulances could be diverted to other facilities.

"The theoretical con to the new policy is that diversion can give hospitals some relief when they're crowded," said Dreyer. "But in practice, that doesn't happen."

More often than not, Dreyer said when one hospital began sending its ambulance calls to another hospital, the increase in flow was just enough to jam up the second hospital as well. Coupled with the complex particulars of trying to determine just when diversion would be acceptable, Dreyer said the real heart of the problem was not being addressed.

"The problem that was really of concern was hospital emergency department crowding," said Dreyer. "We're saying, you hospitals have to take steps to examine your own processes to improve patient flow. You can't rely on diversion."

The recommendations HSQ has for hospitals are twofold. First hospitals should do what they can to improve patient flow, Dreyer said, and this means discharging patients as early in the day as possible to keep the beds ready.
Second, HSQ recommends increasing the availability of beds. Dreyer said this can include deferring scheduled surgeries when the ED gets over-crowded, or boarding patients in unusual spaces.

Officials at Hallmark Health say their hospitals welcome the no-diversion policy and have already taken steps to get staffers prepared for the change.

"This also came out of the feeling that when people were being diverted, they were being diverted away from their town institutions," said Dr. Steven Sbardella, chairman of Emergency Medicine for the Hallmark Health System.

Sbardella said Hallmark has known about the no-diversion policy for more than a year and has been making preparations. Though a long-term plan could involve changing the structure of Hallmark's emergency departments, hospital officials are focusing now on the most pressing matters.

"We did a study on our emergency department," said Sbardella. "It's not the front door that backs up the ER. It's the back door."

Hallmark's two hospitals - Lawrence Memorial Hospital in Medford and Melrose-Wakefield Hospital in Melrose - are undergoing some changes.

Sbardella said a special observation unit was opened up at Melrose-Wakefield for patients who could be fully processed in under 24 hours.

Also, both hospitals will work to get 80 percent of patients discharged by 10 a.m. after their stay is completed, Sbardella said. A number of other changes include using more monitored critical care beds, increasing ED staffing, having beds available in hallways when things get busy and allocating patient care time more efficiently.

Mark Mahnfeldt, director of Emergency Services and Observation at Melrose-Wakefield, said his department has been setting the stage for the new policy for some time now.

"We've been preparing for this for awhile," said Mahnfeldt. "For the last four to five months, we've pretty much maintained a no-diversion status as much as possible. We didn't want to be blind-sided for this."

Employees needed to be re-educated about the way the ED would function, said Mahnfeldt. It is expected that, while overall yearly numbers of patients seen will remain steady, sudden rushes will be even more taxing on the department.

Sbardella said LMH sees about 22,000 ED patients a year and MWH sees roughly 45,000.

"Since Oct. 1 we've only had 2.04 hours of diversion," said Dr. John Nadolny, director of Emergency Medicine at LMH. "Typically, diversion happened for an hour at a time."

He said this would happen only if a sudden surge makes the ED over-crowded, fills all the beds, jams the waiting rooms and the patients aren't moving.

But Nadolny added he's excited for the change.

"I think it's an extremely positive change," said Nadolny. "Diversion, in my opinion, is really sort of a Band-Aid for the institution that's putting diversion into effect. It provides temporary alleviation, but taxes neighboring hospitals.

"With the no-diversion policy coming into effect, hospitals should be getting their own ambulance calls and their own patients," he added. "I think this will be a positive change for hospitals overall."

Hospitals across the commonwealth will have to deal with sudden ED rushes a little more efficiently now. Patients may be seen in hallway beds, boarded in unusual spaces or given less time to be picked up after being discharged, but patients will now be reassured that they'll always be rushed to the hospital they chose and the doctors they are used to.

While it will tax the system at times, Sbardella said Hallmark's staff is up to the challenge.

"The busier it is, the more excited they are about their jobs," said Sbardella. "And we've searched for people who believe in that."


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