S-SV EMS Ambulance Patient Diversion Form

Instructions

Complete all pertinent sections of the form, and click the 'Submit' button at the bottom of the page to send the information to S-SV EMS staff & any additional email addresses you entered (a copy will automatically be sent to the 'Contact email' address entered below).

The S-SV EMS Duty Officer must also be notified by telephone for any diversion event:
• Primary: (916) 625-1702 (during business hours) or 916-625-1710 (after business hours)
• Backup: 530-245-6550 (SHASCOM Dispatch - ask for the S-SV EMS Duty Officer)

Hospital name *

Contact name *

Contact telephone # *

Contact email *

Would you like to send a copy of the completed form to additional email addresses?

Yes
No

Additional recipient email address #1

Additional recipient email address #2

Notification type: *

Planned diversion (diagnostic equipment maintenance, etc.)
Pre-diversion
Initial diversion
Ongoing diversion

Diversion type *

Pre-diversion notification only
Specialty patient diversion (STEMI, stroke, trauma)
Code 2 ambulance patient diversion only
Diversion of all ambulance patients

Diversion reason *

Note: If you select 'Internal Disaster' or 'Patient surge event', additional required data entry fields will be displayed

Briefly describe the reason for the planned, anticipated, or current diversion: *

Have appropriate hospital clinical and administrative staff been notified/consulted?

Yes
No

Briefly describe any diversion avoidance measures taken:

Current ED Census & Hospital Bed Availability

Staffed ED Beds (#)

Occupied ED Beds (#)

ED Waiting Room Pts (#)

ED Psych Pts (#)

ED Admit Hold Pts (#)

Available Med/Surg Beds

Available ICU Beds

Available Pedi Beds

Available ORs

Current On-Duty ED Staffing

Nursing Staff (#)

Mid-Level Staff (#)

Physician Staff (#)

Form submission date & time *

Date

Time

S-SV EMS Agency

S-SV EMS Ambulance Patient Diversion Form

Instructions

Current ED Census & Hospital Bed Availability

Current On-Duty ED Staffing