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PA Bulletin, Doc. No. 02-1143

NOTICES

Hospital Diversion

[32 Pa.B. 3163]

   The Department of Health (Department) has observed an increase in the number of hospitals that go on emergency department divert during the last 2 years. This practice is a serious problem since it can have the effect of reducing access to care. It is particularly problematic when all hospitals in a geographic area go on divert. The Department wants to remind all hospitals that, despite their divert status, they must provide for an appropriate medical screening examination for a individual who comes to the emergency department and who requests examination or treatment for a medical condition. Also, hospitals are subject to State and Federal sanctions for failing to provide screening to all patients present during the divert period.

   This notice provides guidance on the Department's expectations regarding: 1) content of the hospital's diversion policy; and 2) reporting of occurrences of diversion under 28 Pa. Code § 51.3(f) (relating to notification) (Chapter 51).

   1.  Each hospital should have a written diversion policy. This policy should be developed in consultation with the regional emergency medical service (EMS) council or its successor. This policy should describe those things that will trigger consideration of going on divert and what criteria will be used to go on divert. The policy should include and define the levels of divert to be used internally. These levels may be determined by the number of hours the facility is on divert status or some other unit of measurement. The policy should specifically identify a high-ranking physician or administrator who shall personally approve and document each decision to go on divert. The individual approving the diversion may differ depending on the level of diversion invoked.

   The hospital policy should identify who inside and outside the hospital will be notified of a decision to go on divert and contain a description of how the decision will be communicated to them. Notification of divert to outside entities should include the EMS system and public safety answering points (911 centers).

   2.  The decision of a hospital to go on divert (either total or a lower level) when the diversion is for 8 continuous hours or more than 12 hours in a 24-hour period, is a Chapter 51 reportable event to the Department. (Note: notification to a regional EMS council does not substitute for notification to the Department.) The written report of the event should contain the date and time when the hospital went on divert, the date and time when the hospital went off divert, the reasons for divert and what the hospital did to avoid the divert status.

   The Department will review a hospital's divert policy as part of regular survey inspections, complaint survey inspections and incident survey inspections.

   Questions regarding this guidance should be directed to Department of Health, Bureau of Facility Licensure and Certification, Division of Acute and Ambulatory Care, P. O. Box 90, Harrisburg, PA 17108, (717) 783-8980, e-mail at paexcept@health.state.pa.us.

   Persons with a disability who require an alternative format of this notice, or wish to comment on it, should use V/TT: (717) 783-6514 for Speech and/or Hearing Impaired Persons or the Pennsylvania AT&T Relay Service at (800) 654-5984 (TT).

ROBERT S. ZIMMERMAN, Jr.,   
Secretary

[Pa.B. Doc. No. 02-1143. Filed for public inspection June 28, 2002, 9:00 a.m.]


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