Medcom Bypass Diversion Diversion Request Communication Form Active Participation Guidelines
Trauma Service Area V
Diversion Request Communication Form
Diversion Request: (Please Check Appropriate Box Below)
Ø Diversion is simply a request by the facility.
Ø Patients may request transport to any facility despite diversion status.
Ø All Requests for Diversion are for Code 1 Status Patients Only.
Ø Diversion requests DO NOT apply to those patients with extremely life threatening conditions (e.g., cardiac or respiratory compromise, Cardiac Arrest, lack of airway control or other problems that must be immediately addressed by a physician).
r Physical Plant Failure/Structural Compromise: The Physical Plant or structure has been damaged or compromised in such a manner that it is no longer possible to maintain services.
r Disaster Activation Response: The facility is participating in the activation of a regional, local or internal (including hostage or gunman situation) disaster plan and has been overwhelmed, such that the equipment or supplies necessary to care for additional patients are unavailable.
Provisional Requests:
r Inoperable CT Scanner: CT Scanner is unavailable due to preventive maintenance or failure. (Any patients requiring immediate intervention for stabilization will still be transported to the nearest facility despite status of CT Scanner)
r Multiple Critical Patients in the ED or Numerous ED Holds: Conditions exist that the Emergency Department is inundated by inpatient or outpatient census and requires short period of diversion. (Any patients requiring immediate intervention for stabilization will still be transported to the nearest facility despite status of ED) Number of inpatients currently being held in the Emergency Room_________.
r No Trauma Surgeon Available: Facility has no Trauma Surgeon coverage. (Any patients requiring immediate intervention for stabilization will still be transported to the nearest facility despite surgeon availability)
r No Orthopedic Surgeon Available: Facility has no Orthopedic Surgeon Coverage. (Any patients requiring immediate intervention for stabilization will still be transported to the nearest facility despite surgeon availability)
r No Neurosurgeon Available: Facility has no Neurosurgeon Coverage. (Any patients requiring immediate intervention for stabilization will still be transported to the nearest facility despite surgeon availability)
Detailed Requests:
r No in-house bed availability ( ICU, Pediatrics, Telemetry, Med/Surg etc..): The hospital does not have beds available in specific units for patient admission. This does not preclude the emergency department from accepting any patient requiring services since the facility may stabilize and then transfer if necessary.
rOther: _________________________________________________________________________________________.
Confirmation Information:
Name of individual completing the form: (Please Print) _____________________________________________________
Date
Signature of individual completing the form: _____________________________________________________
Date
Job Title of individual Completing the form: ___________________________
Administrative Approval: rY rN Administrator’s Name:_________________________________________
Form Completed and Faxed @_____:_____ Diversion Started @_____:_____ Diversion Cancelled @______:_______
Period of Diversion request for __________Hours Due to call again@ _____:_____