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Banning Bypass: Good Policy or Tempting Fate?

Remember this skit from I Love Lucy?

Lucy and Ethel worked on an assembly line and were responsible for wrapping all of the chocolates that came down the conveyor belt. At first, things were easy, but as more and more chocolates came faster and faster, eventually Lucy and Ethel became overwhelmed and the whole process fell apart. The result was a classic comedic moment.

In emergency medicine, things aren’t so funny. The chocolates are our patients. At times, patient flow is manageable. At other times, patient volume becomes so high that we have difficulty providing good medical care. When things get too busy, usually there is a relief valve called “bypass”. Hospitals have to meet certain criteria to go on bypass, but once a hospital declares bypass, no ambulances may bring additional patients, giving the emergency department time to stabilize patients already there and to open up beds to accept new patients.

Massachusetts is pushing the envelope in medical care and, in January, created a statewide policy that hospitals could not go on bypass. According to this article from the Boston Globe, the law seems to be having its intended effect … for now.

By refusing to allow hospitals to go on bypass, the state forces busy hospitals to keep accepting ambulance runs. It is then up to the hospitals to find a way to make room for the additional patients. Kind of like pushing a kid into the deep end of a swimming  pool and telling him that he better figure out a way to stay afloat.

Hospitals are now opening up additional units and are hiring additional staff to get floor patients discharged earlier in the day. However, wait times haven’t changed much – still an average of about 5.5 hours for admitted patients and 2.5 hours for discharged patients since the rule went into effect.

So is forcing hospitals to work at above capacity a good idea or not? Is necessity the mother of invention? Or will we start to see a bunch of hospitals floating to the surface at the deep end of the swimming pool?

I seem to remember a lawsuit that stemmed from emergency department not providing prompt enough care to a celebrity

9 Responses to “Banning Bypass: Good Policy or Tempting Fate?”

  1. Ryan says:

    As a hospitalist working in MA, I’m familiar with these rules, and my role to play in assisting the ED when pt volume become overwhelming.

    The main idea behind preventing EDs from going on bypass is that these busy times aren’t isolated to one hospital. If you’re ED is flooded with patients, so is the ED in all of the other hospitals.

    So, if you go on bypass, your patients (who have local doctors and lots of records in your hospital) get diverted to hospital X across town. Then, hospital X goes on bypass, and since you’ve come off bypass, their patients are sent to you.

    Now both hospitals have had time on bypass and come off, have the same number of patients, but have the wrong patients. This fractures care and doesn’t really accomplish anything in the long run.

    We all need to come up with systems that allow us to deal safely with patients at peak times, not just average times.

  2. Dafydd says:

    In the OR, we at times will put the our hospital on surgical “divert”. (I assume that doesn’t stop non-surgical ambulance runs.) When we do it is because we have no more staff, either all of the surgeons are working or we have all call crews working. If a “door-crasher” comes in in those situations, they are going to die. So, no this is not a good idea.

  3. Doc99 says:

    24/7 Urgicenter/Walk-in Clinic across the street from the Hospital ED would seem a better solution.
    I look forward to the statistics after a year.

  4. Marilyn says:

    24/7 Urgicenter/Walk-in Clinic across the street from the Hospital ED would seem a better solution

    I think a 24-hour Urgent/Immediate Care facility in close proximity to the hospital is a very good idea.

    I’ve had to make to runs to the ER (yes, that’s what MY hospital calls their department ;-)) this past year. Not because of a life-threatening emergency, but because of an urgent need when our Urgent Care was closed (they close at 6:00 PM on Sundays!)

    Couldn’t wait the 14 hours for Immediate Care to open…one was a laceration that might have destroyed a pianist’s ability to play (possible tendon damage), the other a deep-puncture cat bite. We were apologizing all over the place to the lovely emergency personnel; they graciously said that even though it seemed insignificant emergency attention very likely prevented serious infection in the cat bite.

    I vote for better Urgent Care accessibility.

    • Katherine says:

      Exactly. Last time I went to the hospital late at night I just needed some stronger pain killers for a bad ear infection, and where can you get those except at the hospital at 1am?

  5. RSDS says:

    In my large rural county, there is one, and only one, small, hospital. Therefore, going on bypass is something that just can not happen in the first place. A divert of over 100 miles, just is not practicle.

  6. throckmorton says:

    One of the economic realities of hospital medicine is that for most hospitals to remain solvent, they need about an 87% occupancy rate. As reimbursement falls, they need to maintain an even higher rate. As a result, the number of beds available in the hospital is not sufficient to accomidate a rapid flux. The number of beds that a hospital can fill is regulated by law. Also because of econimics, we have hosital staffing based on that occupancy rate, and that staffing is stretched to the gills, so there just isnt enough staff. So what do we do when we are all filled?

    Out our center, we occaisionally have to go on trauma divert. This is usually simple to figure out because we have every OR and ICU bed in use. These diverts do not last long, but do occur.

    As we lose more and more hospitals and as hospitals constrict their number of beds we will see more and more of this. Step one fix the economics.

  7. Randy says:

    Simple economics holds true in healthcare and anything else.

    You can’t on one hand expect more of a product (healthcare/inpatient/ED beds) while at the same time insist on paying less for it. Like throckmorton says, fix the economics and the rest will fall into place.

  8. MysteryMedic says:

    To be clear though, bypass (or divert in my area), is a favor, NOT a requirement. You are only asking the 911 system to ask patient to go to another hospital. Not taking a patient requesting to go to a hospital that the ambulance would normally take a patient to because it’s on bypass is illegal. You cannot say to a patient a hospital is closed. You can bar entrance to the entire ER including walk-ins under rare circumstances but that has to be justified, usually because of an unsafe environment, and then our dispatch would alert us prior to a call if we didn’t know already. You can explain to the patient the hospital is asking them to go to another hospital because of low resources and may not be in their best interest but if they still want to go, then they have that right. As long as people can still walk in then you still have to accept that ambulance. I have had doctors on the command phone with the patient trying to talk them out as well and a few times it works because I know it’s in the best interest for the patient to take them somewhere else, but there were a few that refused and I told the patient they may be on my uncomfortable stretcher for a long time or may being going to a very packed waiting room. The really sick, the MI’s, strokes, severe burns, and trauma activations don’t really matter especially with a decreased LOC. They don’t care and it’s easy to convince a family if they need a specialty center and I have several of each type around. The hard patient is the 80 Y/O F who has been going to the same hospital for 20 years and is in minor/moderate distress with indeterminate chest pain. No one is convincing her and sometimes you have to pick your battles, even if you roll you eyes and ignore me I don’t want to be there anymore then you do but I tried. So please try to find me a stretcher so I can get back out to work. There may be a real emergency I need to get to.

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