Thread: California ERs Increasingly Shutting Doors to Ambulances

I think we know why hospital ERs are overwhelmed in California.

http://www.latimes.com/news/local/la-me ... 2204.story

ERs Increasingly Shutting Doors to Ambulances
Last year, some hospitals diverted paramedics more than half the time, according to medical agency data.
By Arin Gencer
Times Staff Writer

March 9, 2006

Los Angeles County emergency rooms turned away paramedic ambulances 8% more often in 2005 than a year earlier, with some major hospitals closed more than half the time, according to data from the county Emergency Medical Services Agency.

Public hospitals such as County-USC and Harbor/UCLA medical centers closed to ambulances an average of about 20 hours a day while some private hospitals — including Pasadena's Huntington Hospital, Bellflower Medical Center and Lynwood's St. Francis Medical Center — closed for 12 hours or more.

Emergency room directors throughout the county say reasons for the overload include population growth, greater numbers of seriously ill or injured patients, increasing use of emergency departments for routine care, and recent hospital closures throughout the region.

The persistence of the problem has led the county to revise its diversion policy, further limiting the length of time in which hospitals can turn away ambulances. Those guidelines will be implemented in a couple of weeks, said Carol Meyer, director of the county Emergency Medical Services Agency.

Current policy allows hospitals to shut their emergency rooms to incoming ambulances for two-hour periods when hospital officials decide they are overwhelmed. The new policy would allow diversion for one hour at a time and require hospitals to stay open for at least 15 minutes before going back to diversion status, Meyer said.

Sending ambulances to nearby hospitals can create a domino effect, forcing other departments to close in succession as they too become overwhelmed.

Ambulances have to travel farther to find an emergency room, which can take them outside their primary coverage area and increase their turnaround time, said Dr. Marc Eckstein, medical director for the Los Angeles Fire Department.

Paramedics who choose to stay to monitor patients until a doctor is available can't respond to the next emergency, Eckstein said. Paradoxically, when all hospitals in a designated area are closed for diversion, county policy demands that every one open up.

After dramatic increases in diversion hours in 2000 and 2001, the Emergency Medical Services Agency encouraged hospital officials to analyze more closely when and why they closed. The block of time allowed for diversion was halved from eight hours at a time to four in 2001, Meyer said, and from four to two in 2002.

This year's changes were another attempt "to cut down on possible overuse of diversion," Meyer said. The agency plans to create systemwide standards for when a hospital can divert ambulances, Meyer said. "Right now it's sort of at the whim of each hospital."

Some experts in emergency medicine say the latest changes are not enough, suggesting that diversion itself is not much of a solution to what is overwhelming hospitals.

"It's window-dressing," Eckstein said. "I don't see how that's going to help anything." If a hospital diverts because it is truly busy, he said, being forced to stay open for that 15-minute period won't alleviate anything.

Federal law requires that hospitals with emergency rooms screen and stabilize any patient who comes to them. If a hospital goes on diversion, the staff still is obligated to see whoever arrives at their doors.

Because emergency rooms prioritize patients, those who are severely ill are seen right away even if a facility is crowded.

In addition, an ambulance can override a diversion request if a patient is in great distress or at risk of harm.

"It's a little bit of a Band-Aid," Dr. Joel Geiderman of Cedars-Sinai Medical Center said of diversion.

Diversion is a symptom of bigger problems with the county healthcare system, Geiderman said, in which hospital capacity is relatively static despite increased demands for care.

Doctors and nurses say a swamped emergency department reflects strains throughout a hospital. Many facilities are unable to admit patients because of a shortage of nurses.

That was evident Monday at Huntington Hospital.

The emergency room had been on diversion since 8:50 a.m. All was relatively quiet by 5 p.m.; only a trickle of patients rolled through the sliding-glass doors from the ambulance bay. But because no beds were available, the nurse in charge kept the hospital closed to paramedic traffic.

In a small room, a computer screen flashed mostly red: 15 of the 18 area hospitals listed on the county's ReddiNet system were on diversion. The only black letters belonged to County-USC, still open.

Nurse Jennifer Waldron said she sees a screen like that "more than half the time."

On slow days, that much red is not a problem, Waldron said. But when one ambulance after another calls in and emergency rooms are closed, she said, "you start getting a little bit panicky at times."

The pressure has only increased as patients stream in from areas that have lost hospitals. Nine medical centers and emergency departments have closed in the last four years.

When St. Luke Medical Center closed in 2002, Huntington almost immediately saw its usual 160 daily patients rise by about 50, said Connie Matthews, a hospital spokeswoman.

Recognizing the hospital-wide struggle with overcrowding, Meyer said, the Emergency Medical Agency will require medical centers to have a plan to speed up overall patient flow. Examples include having housekeeping staff clean beds faster or calling on physicians to write orders and release patients sooner.

Same problem in Florida.

http://www.theledger.com/apps/pbcs.dll/ ... 50413/1039

Published Saturday, February 25, 2006
EMERGENCY CARE

Polk Hospital ERs Overwhelmed
Winter Haven Hospital asked to divert ambulances 3 or 4 times in past 10 days.

By Robin Williams Adams
The Ledger

LAKELAND -- This wasn't the week to be an emergency department patient in Polk County.

Hospitals are packed after a slow-starting winter season. Patients wait for emergency treatment and, if they need admission, for a bed.

Hardest hit is Winter Haven Hospital, which asked Polk County Emergency Medical Services to divert ambulances from its emergency room three or four times in the past 10 days.

"We almost ran out of beds," said Mary Jo Schreiber, vice president of patient services. "We have been running 45 patients a day more than average."

Edward Tate, a 79-year-old Winter Haven resident, said he's never seen an emergency room as congested as Winter Haven's was Thursday.

Patients were on beds in the halls, as well as in its ER rooms, he said, and the lobby was "standing-room only, jammed into the halls" when he left after a several-hour stay.

"This situation is a real tragedy waiting to happen," he said.

Emergency department crowding is a major problem nationwide, intensifying each winter in Polk and Florida, but that's no comfort to patients who encounter waits and crowds.

The average number of patients in the Winter Haven ER waiting to be moved into a regular room is 18 to 20 this month, Schreiber said.

That's more than double the eight waiting in January.

Winter Haven isn't alone. Hospitals countywide are seeing more demand, although none of the others has asked for ambulance diversion so far this winter.

"We haven't had anything near as bad as we did last year, but we have been busy," EMS Director Raymond Chatlos said.

Lakeland Regional Medical Center issued "code purple" alerts, signaling a saturated ER, several times in the past week.

From Feb. 17 through Tuesday, LRMC had 425 emergency department visits a day, 21 more per day than the same period a year ago, Public Relations Director Cindy Sternlicht said.

On Wednesday, LRMC had 712 admitted patients, some of whom were waiting in the ER, for 681 open or staffed beds. The hospital re-opened two closed units in response.

Bartow Regional Medical Center said its ER visits are up 13 percent, and admissions are up 12 percent.

"I am over 100 percent occupied," Bartow Chief Executive Officer Justin Davis said Friday.

"We're well over 100 patients a day through our ER, which is well in excess of what this facility had done in the past and above what we were projecting." On the busiest day, Monday, Bartow Regional had 140 emergency visits, Davis said.

LRMC emergency department visits totaled 44,850 from October to January, which was 2,150 more than during the same time period a year earlier.

Winter Haven's space crunch probably affected other hospitals.

When patients are diverted, Polk EMS takes them to other hospitals for four-hour blocks of time. A couple of times recently, EMS officials said they had to extend that time for Winter Haven.

"You put a hospital on diversion, it's going to crowd the other hospitals," said Harvey Craven, EMS medical control manager. "It's a systemwide problem."

Lack of staffed beds in Winter Haven's 33-bed emergency department isn't the problem, Schreiber said. It's the number needing admission.

The average daily number is 245 patients, she said. Winter Haven officials expected 268 this winter. But this month, the hospital averaged 280 patients needing admission and frequently had more than 300, she said.

Ambulances waited an hour or two to drop off patients at Winter Haven when there was delay in moving patients, Chatlos said.

Lake Wales Medical Center and Heart of Florida Regional Medical Center officials said their ER visits also are high, but they didn't give specific numbers.

"We're in the same situation as all the other hospitals," said Linda Pilkington, community relations director at Heart of Florida in Haines City.

Busier than before, Lake Wales has had "occasional" ER holding for beds, said Michael Yungmann, its chief executive.

ER patients aren't the only ones whose schedules change when hospitals fill up. Patients waiting for scheduled procedures can feel the impact.

Dallas Bachelder needs blood transfusions monthly. He said he waited several hours in December for a bed at Winter Haven Hospital and went through a similar wait in January.

On Feb. 15, he said, he waited from 7 a.m. until late into the afternoon for someone to call him to let him know a bed was available. He went in that evening and was released the next morning.

Bachelder went with the late appointment because there wasn't any guarantee beds would be more accessible another day.

"I depend on transfusions to survive," he said.

Although he received excellent care, Bachelder said, he wants to know why the hospital can't get more staff to open more rooms.

"The multimillion-dollar expansion isn't going to accomplish anything if there is not enough staff (nurses) to provide service and care," he said.

The hospital added a net of 111 more nurses in the past year and is paying overtime bonuses, Schreiber said, although it also added more programs.

Nursing shortages are part of the problem, but not all of it.

Emergency rooms deal with an aging population, growing numbers of uninsured and, in Polk County, shortages of doctors.

Tate, who went to Winter Haven's ER with unresolved pain from an accident weeks earlier, said he tried unsuccessfully to see a new doctor he enrolled with.

"They told me she was on vacation and, if I had a problem, go to the emergency room," he said.

Hospital officials said they aren't ignoring the growing number of ER patients, but that the numbers increase faster than expansions or changes can occur.

At meetings this past week, Winter Haven Hospital officials discussed opening 24 more regular beds a year for at least the next two, Schreiber said.

Lake Wales increased its ER beds from eight to 14 when its ER opened in 2003, Marketing Director Cindy Whitley said.

Construction is under way at Bartow Regional to add four beds to the existing 12.

LRMC added eight emergency beds in March, bringing its total to 82, more than triple the 25 in 1988. Other expansion is coming.

For LRMC, Winter Haven and others, however, hallway beds are likely to remain a reality in their emergency departments.

"Our other option would be to leave them in the lobby, and I don't think any regulatory agency would support that," Schreiber said.

Robin Williams Adams can be reached at robin.adams@theledger.com or 863-802-7558.

Also Arizona. Let's bring in millions more to make us all have a better life.


http://www.azcentral.com/arizonarepubli ... d0308.html

Mesa hospital faces fines for closing ER

Jodie Snyder
The Arizona Republic
Mar. 8, 2006 12:00 AM

State health investigators have found that Banner Baywood Medical Center violated several state rules when it closed its crowded emergency department for three hours in January.

The Arizona Department of Health Services is considering fining the Mesa hospital for taking the unprecedented step of closing its emergency department. Federal reviewers are examining the case to see if Banner broke any laws.

Banner Health, the state's largest health care system, is contesting the state's report and believes it made the right decision to protect its patients.

The report, released Tuesday, shows what happens when a crowded hospital reaches "Code Purple." Among the findings:

• The hospital was in "gridlock" when it closed, the hospital's chief executive officer said. According to the state, there were 75 patients in the emergency department and waiting areas. Banner says it had 93 patients at the time. Both agree that there were four doctors on staff.

• After deciding to close, hospital officials sent two security guards to the hospital's street entrance to tell people not to come in and to give them maps to other facilities. The guards were there for at least 40 minutes before the Mesa Fire Department showed up to help with triage.

• One patient's care was delayed almost 90 minutes because of the closure. The unidentified patient had been treated at Baywood the day before for a kidney infection and was told to come back if there were problems. The patient returned, complaining of vomiting and difficulty breathing. Mesa Fire took him to another hospital, where he was treated in intensive care for 24 hours.

• In the more than two hours that Mesa Fire staffed barriers at the hospital, 30 to 40 people were turned away. During the 40 minutes that the security guards were there, two or three people were turned away.

State investigators also found confusion over why administrators closed the emergency department.

Hospital officials originally told investigators they believed they should close if they couldn't take any more ambulance patients.

The decision was based on a pilot program, started last summer, that asked East Valley hospitals not to turn away ambulances. The program was created by a coalition of health care providers and is not a state rule.

Two weeks after the initial questions, Baywood's chief nursing officer, Deb Krmpotic, said Mesa Fire did not tell hospital officials that if they turned away ambulances they would have to close the emergency department.

Ultimately, Krmpotic and the hospital chief executive officer, Don Evans, made the decision to close, she said.

Banner officials say they stand by the decision.

"Our decision was based on patient safety. We support it then, and we support it now," said Bill Byron, Banner spokesman.

Byron wondered what state regulators would have said if a patient collapsed unattended in the crowded department.

"We used our best judgment, and patient safety is going to trump a regulation any time," he said.

Byron said the diversion policy was a factor in closing the emergency department. Hospital officials had a made a commitment to the coalition and wanted to honor it, he said. The hospital also was being hit hard by a busy flu season and winter visitors.

The emergency crunch will be helped by Banner Baywood's addition of 123 beds to its current 242 beds by the end of the year.

Other hospitals are being built in the area, too, he said.

Banner also will work to make sure emergency patients are transferred to other hospitals if necessary.

The emergency department re-opened after it transferred at least 10 patients to other facilities.

State health officials are meeting with hospital, ambulance and fire officials this week to talk how the groups can work together to prevent problems, said Michael Murphy, DHS spokesman.

The crowding at Banner Baywood is not uncommon, Byron said.

Todd Taylor, vice president of public affairs for the Arizona College of Emergency Physicians, agreed.

"Baywood's solution on New Year's Day was certainly unusual. But situations with too many patients, not enough hospital space, occur nearly every day now," he said.

"Arizona has excellent emergency care, but people have no idea how dangerous it has become to be ill or injured at the 'wrong' time, when the system is overwhelmed."



Contact the reporter at (602) 444-8667 or jodie.snyder@arizonarepublic.com.

Also Arizona. Let's bring in millions more to make us all have a better life.

nah this couldn't be related to illegal immigraton could it?

The Arizona Department of Health Services is considering fining the Mesa hospital for taking the unprecedented step of closing its emergency department. Federal reviewers are examining the case to see if Banner broke any laws.

So if they get fined, they should just pay for it out of their emergency care funding, so as to require another closure later. Tell ADHS that fining them will only bring about the next closure sooner.



With a situation like this, who would want to build a hospital?


-pa

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