Ambulances in D.C., Md. Often Diverted; Some ERs Too Crowded - washingtonpost.com

Ambulances in D.C., Md. Often Diverted; Some ERs Too Crowded - washingtonpost.com

Imagine what will happen when we flood the health care industry with another 41 million people 20 million being people who don't even belong here or pay into the system at all! It is going to crash and crash HARD!

Hospitals in the District and Maryland must frequently divert ambulances carrying all but the most critically ill and injured patients because of emergency room overcrowding, forcing many less-critical patients to travel farther for care, increasing costs and potentially causing dangerous delays.

Health-care analysts say ambulance diversions in the Washington region illustrate a national problem that has led some states to ban the practice. But detailing the extent of concern is difficult because of the limited information available in many states, including Virginia, about how often those redirections occur and a lack of national standards.

Since 2004, some District and Maryland hospitals have had to divert ambulance traffic with increasing frequency because they lacked the beds, equipment or staff for patients. Some D.C. hospitals diverted ambulances the equivalent of one out of five days in 2008, and some Maryland hospitals' emergency rooms diverted ambulances at least 15 percent of the time last year, according to a Washington Post analysis of data from District and Maryland health authorities.

"That delay could be a matter of life and death," said Bruce Siegel, research professor in the Department of Health Policy at the George Washington University School of Public Health and Health Services. "We should be very worried there are no national rules."

At the very least, the practice increases the cost of health care. When ambulances are diverted from crowded emergency rooms to less crowded ones farther away, the patients' records are often not available, leading to duplicate tests and procedures. And patients' regular doctors might not be able to treat them at hospitals where they usually practice.

The reasons for the crowding often vary by hospital. Some, especially in the District, are overwhelmed by poor patients for whom the ER has become their family doctor's office. Some suburban hospitals have not kept pace with population growth. And in many instances, internal management problems are to blame, such as when hospitals don't move patients out of emergency rooms and discharge them or admit them for care elsewhere in the facility fast enough to prevent a backlog.

Different jurisdictions use different criteria about when to limit ambulance traffic. Maryland has two categories -- yellow alerts for when emergency rooms are too crowded to accommodate additional patients and red alerts for when emergency rooms lack beds for patients who require monitoring, such as those with cardiac problems.

Hospitals and local health authorities have tried to improve but have come up short.

Howard County General Hospital was on yellow alert 8 percent of the time in 2004 and 26 percent last year, The Post analysis found. It is the county's only hospital, so during those alerts, ambulance patients might be sent to Montgomery, Prince George's or Baltimore counties. Depending on where the patient is picked up, travel could take twice as long and tie up emergency medical service crews longer than authorities would like. Hospital officials said that despite the alerts, they rarely send patients to other hospitals but that those who are less critically ill face longer waits because of crowding.

Hospital officials in Howard said part of the problem can be attributed to population growth in the county, especially among elderly residents seeking care. This summer, Howard General will expand its emergency room for the second time in eight years, adding 18 beds. But that probably will not be enough with 5,500 new homes planned in Columbia and significant growth expected around Fort Meade because of military base realignment in the region. The issue has prompted the Howard County Citizens Association to form a task force to examine emergency care in the county.

"We're trying to make [the emergency room] as streamlined and efficient as possible to see the maximum number [of patients] we can see, but space continues to be a limitation," said Walter Atha, head of the hospital's emergency room.

In the District, The Post analysis found that Providence and Washington Hospital Center diverted ambulances from their emergency rooms the most. Providence diverted ambulances more than 25 percent of the time in 2007, and Washington Hospital Center diverted traffic 33 percent of the time. They are the busiest emergency rooms in the District, which experts said underscores the importance of their doors being kept open to ambulance traffic. Both hospitals improved last year because of internal management changes but are diverting ambulance patients at least one-fifth of the time.

Worried by the statistics, D.C. Fire and Emergency Medical Services placed someone at the city's Unified Communications Center in June to be a liaison between hospital emergency rooms and EMS units. If one hospital becomes too crowded, EMS has the authority to redirect ambulances to another. Previously, an ambulance might arrive at a hospital, then be forced to wait for hours behind others that had gotten there ahead of it. Because of the new strategy, the amount of time District hospitals were on diversion fell for the first time last year.

James J. Augustine, medical director for D.C. Fire and EMS, said that officials meet regularly with hospital executives and have made important progress. But, he added, "our goal in working with the hospitals is, let's get to zero."

Maryland's hospitals have also implemented strategies to better manage emergency room traffic. A statewide database offers real-time information about which hospitals are limiting ambulance traffic. Also, EMS workers can reroute themselves if they know that the closest hospital is overcrowded.

Officials at Prince George's Hospital Center, which had one of the highest percentages of yellow alerts in the D.C. region, have been able to reduce them by two-thirds because of new measures that streamline patient flow in the emergency room. Even with the drop, however, the hospital averages the equivalent of four days a month on yellow alert, officials said. Mark Arsenault, associate vice president for emergency and disaster services at Dimensions Health Care, which owns the hospital, said that better management has helped but that support from policymakers is needed to help tackle other causes of crowding, including the high number of people who lack health coverage and the shortage of doctors and nurses.

The delays have led to inconveniences and increased costs for some patients. That's what happened to Stuart Kohn's father-in-law. In 2004, Kohn said, his father-in-law was supposed to go to the emergency room at Doctors Community Hospital in Lanham for heart and kidney problems but was diverted to Washington Adventist in Takoma Park, almost twice as far from his College Park home. It happened three more times -- two trips to Washington Adventist and one to Laurel Regional Hospital -- before he died last year.

Kohn said his father-in-law received fine care at both but would have been better off being treated by the doctors most familiar with his case, but they did not have privileges at the other two hospitals. "His own doctors couldn't even come and see him," Kohn said.

Health authorities acknowledge the inconveniences but also say the diversions have not led to any deaths in the Washington region because of delayed care.

That has not been the case elsewhere. Guy Clifton, a University of Texas Medical School professor and former emergency room doctor, said he has identified at least eight deaths in the Houston area between 2001 and 2005.

"The public doesn't know what the risk is," he said. "It really is a systemic failure, and nobody is keeping the books on this in the country. Get sick on a bad day, and you're dead."