EFFECTIVE DATE:	11/17/97	(Original)
	06/23/98	(Revised)
	03/22/00	(Revised)
	08/03/00	(Revised)
	10/11/00	(Revised)
	11/06/00	(Revised)
	02/01/01	(Revised)

OVERVIEW

The HOSPITAL SQUAD DIVERSION OVERRIDE POLICY is an addendum to the CECOMS Operations Procedure: HOSPITAL CAPABILITY RESTRICTION ADVISORY SERVICE. It addresses the special circumstance, which occurs when hospitals in a particular region of Cuyahoga County are simultaneously diverting emergency ambulances. As a result of such widespread diversion, pre-hospital providers may not have a proximate available appropriate hospital destination.

POLICY

The following Cuyahoga County Hospitals shall participate in a rotation designed to insure the following:

1. The major guiding principle is to maintain the highest quality of patient care possible given the extraordinary challenges of the overload of our facilities and services.
2. The Override Policy is designed to insure that:
   1. Patients in extremis can always be taken to the closest hospital.
   2. Ambulances will always have a hospital within a reasonable transport time where they can take their patients.
   3. Hospitals and pre-hospital providers will equitably share the stresses and costs of patient overload.
3. Participating hospitals shall know in advance what their patient care responsibilities will be so that they will be prepared to receive incoming patients.
4. Barring catastrophic problems, the trauma system will function in its usual fashion when the HOSPITAL SQUAD DIVERSION OVERRIDE POLICY is activated.
   

PROCEDURE (see map for hospital pairings and rotation)

Cuyahoga County, for purposes of declaring Override Condition is divided into 3 regions. These regions are designed to meet the following conditions:

1. Any hospital within the region is likely to be within reasonable distance of the squads who generally use any of the other hospitals in the region.
2. The closure of all the hospitals in the region would pose difficulties in patient delivery to a significant percentage of the squads who transport to the hospitals in that region.
3. The Central Region is one region in terms of hospital groupings; however it is divided into 2 regions for the purpose of activation.

An override exists when all but one hospital within a region simultaneously place the same restriction. There are five restriction categories in Cuyahoga County. They are: Critical Restriction - Trauma, Critical Restriction - Medical, Full Restriction, Treat and Release Only and Full Restriction Except for Trauma. For example, if all but one hospital in a region place a "Critical Restriction - Medical" the override condition will activate.

Determining which hospitals open first is based on whether it is an "A", "B", or "C" week. These weeks correspond with fire department "A", "B" & "C" shifts. For purposes of this Override Policy these shifts will be for 24 hours beginning and ending at 12:00 a.m. Whichever "A", "B", or "C" shift is in effect at 12:00 a.m. each Monday morning will determine the 4-hour override shifts for hospitals. For example:

If Override is activated

"A" shift week -	"A" group hospitals take the 12am-4am and 12pm-4pm shifts. "B" group hospitals take the 4am-8am and 4pm-8pm shifts. "C" group hospitals take the 8am-12pm and 8pm-12am shifts.
"B" shift week -	"B" hospitals will take the12am-4am and 12pm-4pm shifts. "C" group hospitals take the 4am-8am and 4pm-8pm shifts. "A" group hospitals take the 8am-12pm and 8pm-12am shifts.
"C" shift week -	"C" hospitals will take the12am-4am and 12pm-4pm shifts. "A" group hospitals take the 4am-8am and 4pm-8pm shifts. "B" group hospitals take the 8am-12pm and 8pm-12am shifts.

During Override Condition, the day will be divided into 4 hour "override shifts" starting at 12am, 4am, 8am, 12pm, 4pm, and 8pm. If all but one of the hospitals in a region are diverting squads in the same of any of the five categories (Critical Restriction - Medical, Critical Restriction - Trauma, Full Restriction, Treat and Release Only or Full Restriction Except for Trauma), CECOMS will declare an Override condition. Immediately, depending on the time of day and the Shift Week, the appropriate group of hospitals within the relevant region will be on diversion override. This means that they will not be able to divert the group of patients in question until the end of that diversion shift. At the end of an "A" hospital's override shift the "B" group of hospitals will then take over and will not be able to divert the group of patients in question until the end of their override shift.

No hospital will be required to remain open on an override condition for more then 4 continuous hours. Also, any- time override terminates and then is activated again within the same override shift, that group of hospitals previously open due to override will be required to reopen until the end of their preset override shift. Should the override still be in effect at the end of the preset 4-hour shift the hospital grouping shall rotate. For example:

• If it is an "A" shift week and override is activated at 12:30 a.m. then the "A" hospitals will open from 12:30 a.m. to 4:00 a.m. However, if override terminates at 2:00 a.m. and then is activated again at 2:30 a.m. the "A" hospitals will be required to open again from 2:30 a.m. - 4:00 a.m. If override continues beyond 4:00 a.m. the "B" hospitals will be responsible for the next 4-hour override shift an so on.

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WEST REGION

A. St. John West Shore Hospital, Parma Community General Hospital
B. Southwest General Health Center, Lakewood Hospital
C. Fairview Hospital

In the West region, during Override three subgroups will rotate with each other every 4 hours. Those 3 groups are "A" hospitals and "B" hospitals and a "C" hospital.

In this organization, the most central hospital will be on override alone in order to preserve the principle of minimizing squad transport time.

CENTRAL REGION

A. St. Vincent Charity Hospital, University
B. Lutheran Hospital, Cleveland Clinic
C. Huron, MetroHealth Medical Center

These are the "A", "B", & "C" hospital groupings in the Central Region. However, for the purpose of activation, the central-west and central-east regions will remain separate. For example, if only one hospital (out of four) is open in either the central-east or central-west region then the override policy is activated for the entire central region.

FOR ACTIVATION

CENTRAL EAST Huron University Cleveland Clinic

CENTRAL WEST St. Vincent Charity Lutheran MetroHealth Medical Center

EAST REGION

A. UHHS Bedford Medical Center, UHHS Richmond General Hospital
B. Euclid Hospital, South Pointe Hospital
C. Marymount Hospital, Hillcrest Hospital

Please refer to the map and calendar.

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ADDITIONAL ASSUMPTIONS

1. Patients "in extremis" always go to the closest appropriate facility.
2. The order of the rotation is always the same, unless hospitals negotiate a different order, which is agreed upon by all hospitals in the region and provided to CECOMS prior to the Override.
3. The time the Override starts is always the time when all but one hospital in the region is closed to one of the five categories. The time the Override ends is always the time the first two hospitals in the region opens.
4. To avoid multiple regions being on different schedules, the rotation times are fixed at 12am, 4am, 8am, 12pm, 4pm, and 8pm. CECOMS will advise all hospitals in the region when only two hospitals in that region remain open in any category, and when Override begins. CECOMS also notifies each hospital of the termination of the Override condition.
5. Since this system occasionally requires significantly longer transports than what certain squads currently do, the decision about whether a patient is in extremis, requiring delivery to a nearer hospital, is made in consideration both of the patient's condition and the required length of transport. This concept is intended to protect patients whose care might suffer from a significantly longer transport.
6. Once a hospital on Override status communicates with an incoming squad, that hospital must accept that squad, even if that hospital's Override status changes before the ambulance arrives.
7. Some squads on the periphery of the County may elect to deliver patients to hospitals in other counties or other regions. This will relieve the burden upon squads on the periphery of their regions.
8. Some hospitals have special arrangements with certain squads. As long as all squads have an open hospital destination within reasonable distance at all times, the diversion and Override policies shall have no effect upon individual arrangements specific hospitals have with specific squads.
9. Upon rare occasion, hospitals may have no ability to take all or certain types of patients. This could be due to fires, electrical or plumbing problems, local disasters, etc. Under these circumstances, hospitals may negotiate with other hospitals near them in their region to arrange for another hospital to take the load until the problem is resolved. CECOMS must receive verification of any special arrangements between hospitals from both hospitals before those arrangements are operative. Hospitals should make special arrangements, if any, with very close facilities within their region such that those arrangements do not result in significantly longer transports for any pre-hospital provider.
10. All provisions of the CECOMS OPERATIONS PROCEDURE: HOSPITAL CAPABILITY RESTRICTION ADVISORY SERVICE which may apply to this HOSPITAL SQUAD DIVERSION OVERRIDE POLICY remain unchanged and in effect. The same hospital officials designated to interact with CECOMS with respect to hospital diversion are authorized to interact with CECOMS with respect to Override.
11. CECOMS shall conduct a semi-annual drill to remind health providers of the Override Condition system. No actual squad diversion override will occur during the drill. Real activation of the Override system eliminates the need for a drill for 6 months.
12. Hospitals are encouraged to use a formal process to accurately monitor and report bed availability. Accurate information can optimize hospital bed utilization, thereby decreasing the requirement for diversion override.
13. The Medical Standards Committee (MSC) recommends that all hospitals maintain Quality Management Programs to address issues raised by pre-hospital and/or hospital providers about diversions and patient transports. All providers must know that they can access the Quality Management Program that will hear and appropriately review their concerns. They should have reason for confidence that the Quality Management Program will institute corrective action plans whenever those plans are indicated.

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