How EMTs select a hospital ER for a patient, and when hospitals can turn them away

Emergency medical services (EMS) need be able to decide quickly where to take an emergency or trauma patient.

Most states have laws, rules, and regulations directing EMS on where to go under normal circumstances. That’s why some patients and family members are frustrated when an ambulance crew won’t take them to the hospital of their choice.

For some types of emergencies, EMS will go to the nearest hospital emergency room (ER).

For more complex cases, though, the closest hospital might not be the choice at the top of the EMS list. Those hospital lists are made with the help of national and state organizations that accredit or certify hospitals based on their capabilities and staffing to handle certain types of emergencies.

Stroke care. Hospitals can apply to national healthcare accrediting organizations such as The Joint Commission for stroke center certification. The highest designation a hospital can achieve is comprehensive stroke center, which means they’re staffed and equipped to handle the most complex stroke cases and treatment. In Houston, Texas, for example, Memorial Hermann – Texas Medical Center and Houston Methodist Hospital are comprehensive stroke centers. The next level down is primary stroke center, which are staffed and equipped for more basic stroke patients and care. Some hospital emergency departments have no stroke certification at all, although an emergency medicine experts has commented to me that most hospital ERs, whether urban or rural, offer clot-busting tPA medication for treating ischemic strokes.

Trauma care. Hospitals can seek national and state certification as a trauma center in one of four levels. Level I comprehensive trauma centers are located in hospital ERs that have the highest level of staffing and capabilities. Even in a state as big as Texas, there are fewer than 20 Level I trauma centers. The short lists includes hospitals such as Baylor Scott & White–Temple, Baylor University Medical Center in Dallas, and Memorial Hermann–Texas Medical Center in Houston.


What do EMS do in circumstances that aren’t normal?

Sometimes conditions at a hospital are such that it’s unsafe to accept patients. It could be because the hospital has a patient load that’s at or over capacity. It could be because of bad weather or a natural disaster. It could be because of a utility failure.

This led to emergency planners coming up with a somewhat controversial concept called diversionary status.

Many areas have developed communication systems among hospital emergency departments and EMS to advise when a hospital is on diversion. In Houston, Harris County, Texas, hospital ERs and EMS use a shared system called EMSystem.

Diversion is a process of temporarily routing ambulances and EMS patients away from hospital emergency departments that can’t handle them. The idea is to avoid situations where EMS patients will receive delayed care or suffer potentially bad outcomes.

When a hospital is on diversionary status, EMS should normally take patients to a different hospital emergency room.

We are dealing with this issue now in a Houston area medical malpractice case. A patient fell face first and hit her head. She was unable to move at the scene and required EMS assistance. When emergency medical technicians (EMTs) evaluated her, they wrote in their chart a differential diagnosis that included potential head injury and potential spine injury.

EMS called a nearby suburban Houston hospital that was on diversionary status. The ER nurse told EMS that they were operating under internal disaster, with a flooded operating room, no heat, and saturated patient population in the emergency department and hospital as a whole. Yet, she told the ambulance crew to bring the patient to the hospital anyway.

It’s unclear what the hospital nurse or EMS thought the hospital could do for a patient with a potential head or spine injury under these circumstances. Our ER physician and nursing experts think the nurse should’ve stuck with the diversionary status and had EMS take the patient to another hospital. Instead, the hospital activated a financially lucrative trauma activation and brought the patient in.

Unfortunately for the patient, her spinal cord injury went undiagnosed in the packed emergency department and she was sent home, even though the ER nurse’s last documentation reflected “MD aware” of the patient’s continued weakness at the time of discharge. The patient couldn’t move her extremities yet was sent home. Her spinal cord injury was untreated and she was left with permanent deficits and injuries.

If you’ve been seriously injured because of poor emergency room care in Texas, contact a top-rated, experienced Texas medical malpractice attorney for a free consultation about your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.