EMSystem and Emergency Department Diversion Overview

What is EMSystem?

EMSystem is an Internet based application which tracks the statuses of various resources within the emergency medical care environment. Emergency Departments must communicate their ability to receive sick or injured patients to the pre-hospital care providers. EMSystem is also used for communication between Emergency Departments, pre-hospital care providers, and potentially public health officials. EMSystem lists the resources within a geographic region and constantly monitors the status of each. EMSystem also has a system alert function to disseminate urgent information to all hospitals simultaneously and a multi-casualty incident (MCI) notification alert used during incidents that have the potential to overwhelm a communities emergency medical system. Due to the nature of emergency medicine and the pre-hospital environment this system must be monitored 24 hours/day, 7 days a week, 365 days a year.

The New Mexico EMSystem Experience

EMSystem was integrated into Bernalillo County on July 1, 1999. Data has been gathered since on the statuses of all Albuquerque area hospitals. This process was facilitated with the assistance of the Bernalillo County/Albuquerque City Medical Control Board representatives and multiple meetings with the individual area hospital administrations. Each facility has designed its own internal guidelines for threshold of status changes and who does the actual updates. All hospitals have agreed on common terminology and the use of algorithms to prompt forced openings when multiple area hospitals becomes overwhelmed. Current system oversight is performed by Albuquerque Base Communication Center and is regionally administered by Dr. Philip Froman. System oversight includes monitoring 24 by 7, tracking statuses, forcing hospitals open when the system becomes overwhelmed based on pre-defined algorithms, posting system and MCI alerts, and routing units to the appropriate facilities based on cautions and closures and during an MCI. The regional administrator’s role is to provide oversight medical direction, work with all hospitals to insure quality of care issues, to design and update protocols as necessary, work with the State of New Mexico IPEMSB and Department of Public Health to best utilize EMSystem, integrate and educate new hospitals, EMS services, and air services, and to review and publish EMSystem data.

The Goals of EMSystem in New Mexico

Goals of EMSystem include:

• Information sharing between hospitals. This helps with staffing concerns as well as transfers between hospitals with scare resources to hospitals with surplus resources.
• Data gathering for trending of hospital cautions, closures, and forced openings. This information helps the hospital systems, EMS systems and local and State governmental officials understand the stresses of the emergency medical care environment.
• Information sharing with EMS transport services to better route ambulances to facilities that can handle addition workloads. This decreases field time, turn-around time, and allows field crews to route family and friends to the open hospitals.
• Rapid dissemination of important information through system or public health alerts.
• Better management if MCI’s
• Cooperation of the hospital systems to develop a safety valve of “forced open” to ensure that no patient has to sit in the back of an ambulance and wait for an accepting facility.
• To develop a single source in the hospital for links to information including infectious disease, bioterrorism, system protocols, State links for patient charting and data gathering.

Definitions

Status Choices: The current status of each facility Emergency Department (ED) is displayed in the Status column of the display screen. This selection represents the status of the ED only. There are five possible statuses to be displayed for each facility.

• Open - ED accepting patients normally
  
• Caution - ED is open - however, there are alerts for other areas of the hospital effecting admission. Can also be used to alert for limitations in an open ED - i.e., ED is approaching capacity. Caution can also be used to signify a status regarding interfacility transports. There will be times a hospital will accept all local ambulances but not be able to accept transports from other areas of the State. When cautions are forced open based on our pre-defined algorithms, this caution can remain in effect because it does not influence local ambulance traffic.
  
• Closed - ED is full - cannot accept patients as normal. Patients should be diverted to another facility. ED’s in this status will still accept Code Blues if they are the closest facility. It is understood that an ED listed as closed will still receive patients for direct admit and pre-arranged transfers. UNMH, as the only Trauma Facility, will, at times, utilize the Closed Status while still accepting Trauma patients. Their status will reflect Closed, with notes stating “accepting trauma only.”
  
• Totally Closed - ED cannot accept patients under any circumstances. Examples: ED is without power or the building is under a bomb threat.
  
• Forced Open - Facility has been forced open from either a caution or closed status based on the algorithm in Figure 1 for a period of two hours.

System Statistics and Trends

EMSystem data allowed for “black and white” documentation of a problem that had up until 1999 only been hearsay. Hospitals and EMS services stated there was a problem with ED overcrowding and divert and EMSystem has generated the appropriate documentation. The number of cautions, closures, and forced openings has steadily increased since we started collecting the data. In March of 2001 we reached the maximum level of forced openings at 185 incidents or 370 hours. The Albuquerque Ambulance Service/University of New Mexico Research Group is in the process of analyzing this data. Figure 2 shows some preliminary data on cautions and closures at University Hospital from January 2000 to February 2001. Figure 3 shows March – July 2001 data for the Albuquerque area hospitals. Also included are a quarterly summery of cautions and closures and the number of forced opening incidents (Figures available on request).

The Future of EMSystem

Current and on-going discussions are taking place regarding the expansion of EMSystem in New Mexico. The integration of the Northern New Mexico region took place in the late spring of 2001. Santa Fe control will play an increasing role in monitoring and activation of system and MCI alerts for areas outside Bernalillo County. Plans are to integrate Southern New Mexico in the fall. University Medical Center-Lubbock has been on the system for several months and other border hospitals are planned this fall. In the fall we plan to continue the addition of the air services in New Mexico. The role of the air services on the EMSystem screen is still unclear. Public Health should play a significant role in EMSystem in the near future. There is a planned Public Health Alert notification so when there is a significant public health concern or emergency, that information can be distributed in a matter of minutes. Through pre-designed links, there is the plan for links to infectious disease sites, WMD/bioterrorism sites, and the New Mexico data gathering system sites. There will be continuing discussions with the IPEMSB and the Department of Public Health to look for more ways to integrate EMSystem into the emergency medical care environment of New Mexico.