2.6 Protocol for Monitoring Diversion from Trauma Center

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Description of Indicator

Relationship to Quality  Medical care should be equitable and efficient 
Type of Indicator Prehospital structure, System level
Proposed Data Source Survey
Definition Trauma systems with a protocol for monitoring the frequency and reasons for EMS patient transports diverted away from a trauma center (patient declined by trauma center)
Numerator Trauma systems with a protocol for monitoring the frequency and reason for EMS transports of injured patients age 18 years and older diverted away from a trauma center
Denominator Not applicable
Benchmark Not applicable
Risk Adjustment Not applicable


This indicator is intended to identify trauma systems with protocols for monitoring the frequency and etiology of trauma centers diverting EMS patient transports to other facilities.

Panel Review
Panelists emphasized that this is a key indicator because the best trauma systems have a no diversion policy for Level 1 trauma centers. Panelists indicated that protocols need to include a mechanism for capturing the reason for diversion. It was also noted that an integrated trauma system would likely be needed in order to capture the required data for this indicator.
Panelists expressed that the potential value of this indicator may vary according to the ownership status of hospitals (private for profit, private not for profit, government). It was also suggested that it might be most valuable to focus on severely injured patients for this indicator. Panelists separately indicated that outcomes of diverted patients should be evaluated.

Trauma Center Review
Trauma centers strongly emphasized that trauma center diversion should not occur and suggested that centers should have a no divert policy for trauma, cardiac arrest or other unstable patients. While the importance of this indicator was evident, trauma centers had concerns regarding documentation. They noted that it would be important to monitor reasons for diversion but acknowledged that current documentation practices would need to be altered in order to obtain this data. It was suggested that EMS may be the best source of data for monitoring reasons for diversion.

Review of Literature & Evidence
Face Validity: In one study, 98% of Delphi panel participants ranked monitoring instances and causes of trauma center diversion as very important13.
Construct Validity: No studies identified.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: Protocol for Monitoring Diversion from Trauma Center is used as an indicator by a small number of trauma centers: USA 15% (30/200), Canada 3% (1/35), Australasia 0% (0/12).

Rosengart et al. developed the indicator using a Delphi panel of trauma experts13.


13. Rosengart MR, Nathens AB, Schiff MA. The identification of criteria to evaluate prehospital trauma care using the Delphi technique. J Trauma. 2007;62(3):708-713.