Local News

Saturday, Nov 26 2011 09:00 PM

No ER closure could improve patient choice

BY KELLIE SCHMITT Californian staff writer kschmitt@bakersfield.com

Susan Handy knew something was very wrong when her husband Arthur's blood pressure dropped, his face turned gray, and he started sweating.

At an urgent care center, the doctor told her that Arthur was facing a heart attack and needed to go by ambulance to the emergency room.

Handy requested San Joaquin Community Hospital since her insurance only covered emergency room visits at specific locations.

But, at that moment, Bakersfield's emergency rooms were overwhelmed. One had decided to close to ambulance traffic, then another, and eventually the county Emergency Medical Services had put them on rotation -- and San Joaquin was not next.

When the ambulance came for Arthur Handy, he had to go to Bakersfield Heart Hospital, a facility not covered by their insurance.

"We didn't have a choice," Handy said. The paramedics said, 'Lady, you're going to Heart Hospital, or we're not taking you.'"

Since driving her husband didn't seem safe, Handy agreed. While they were pleased with the care, the Handys are now facing a $5,168.78 bill for going to a non-provider.

"Clearly, the consumer didn't have a voice," she said. "It was the luck of the draw."

Now, local medical leaders are considering ending the policy that allows hospitals to close to ambulance traffic when they're too busy.

Opponents say the proposal could burden already overcrowded emergency rooms that don't have space for more patients. But, advocates say the change would force hospital staff to be more efficient throughout the facility, ensuring that patients like Arthur Handy have a choice.

"Closure creates so many negatives from a patient care standpoint," said Ross Elliott, the county's director of emergency medical services. "It seems the right thing to do is to do away with closure."

A different approach

Earlier this month, The Californian reported that Kern Medical Center, the county's only trauma center, was closing its doors to ambulance trauma traffic seven times more often than last year.

But KMC isn't the only local hospital more frequently shuttering its doors to ambulances. From January until the end of October, Bakersfield hospitals went on so-called "closure" a total of 127,682 minutes, which is equal to about 89 days. Last year, they closed for the equivalent of 32 days, and, in 2009, for about 48 days.

Those growing figures, combined with stories such as the Handys', spurred the idea for a different approach.

In November, the county's Emergency Medical Care Advisory Board, which has representatives from emergency services and the public, approved the no-closure idea in concept. Still, there are many logistics to figure out and implementation would require a Board of Supervisors' vote.

Hall Ambulance Service is in favor of the move, in part because of patient concerns, said John Surface, the ambulance division manager.

Surface said he fields a lot of calls from customers upset because they weren't able to go to their hospital of choice, and had to deal with the insurance payment repercussions. Trouble also arises when patients realize the hospital is closed to ambulances, but not to walk-in patients.

A couple of months ago, paramedics picked up a patient with a collapsed lung. The hospital he requested was on closure at that time.

"He said, 'Pull over, I'm going to have my daughter take me,'" Surface said. "I am going to walk in the front door."

Hospitals' take

For years, Bruce Peters, Bakersfield Memorial Hospital's chief operating officer, was against the idea of removing the closure option. He felt the step was necessary for increasingly busy emergency rooms overflowing with patients.

More recently though, he's changed his mind: "I think the system has become way too complicated, and, in some cases, abused for far too long."

While the decision to go on closure is often legitimate, sometimes staff just feels they need a break.

"Doctors and nurses in the emergency department will just say, 'We just felt it was time,'" Peters said. "There's no real policy trigger, no procedure that puts people on closure."

Once one hospital closes to ambulances, there's more pressure on the other hospitals, some of which may also request closure. Three requests for closure triggers a rotation, which means ambulance patients must go to the next hospital in line.

"That's how patients end up going to hospitals where they don't want to go," he said. "Patients get upset. They have preferences for hospitals just like department stores."

Eliminating closure would undoubtedly have effects, Peters said. If hospitals are forced to see more patients when they're overwhelmed, people with less severe problems -- such as sore throats or ear aches -- may have to wait even longer.

The change would also put more pressure on hospitals to respond to overcrowding with internal strategies, Peters said. Often, the emergency room gets backed up because there aren't enough beds or staffing available in other parts of the hospitals.

The move will force leaders to take a good look at how patients can be moved through the hospital more efficiently, added Debbie Hankins, the chief nursing officer at San Joaquin Community Hospital. That could include everything from the system of labs to how a patient gets discharged.

"It's kind of like disaster planning," she said. "You have to try things out. We'll create scenarios."

But Paul Hensler, the CEO of Kern Medical Center, said he could foresee problems if a busy hospital can't close to ambulance traffic. Patients could start backing up, and it could be difficult to unload ambulances if there wasn't enough staff to help.

He also questioned what would happen if the patient to nurse ratio fell below the state-mandated number.

"I'm looking at what's best clinically," he said. "If I'm in an accident I want to be brought to KMC. But, if we're full and Memorial and San Joaquin or Mercy can immediately treat me, I'd want to be treated immediately and then transferred."

Having a central authority control a jammed system may be preferable to simply eliminating hospital's ability to close to ambulance, he said.

"The hospitals aren't closing because they want to avoid ambulances," he said. "The problems are real and complicated."

No-closure communities

A no-closure policy has already been implemented in numerous counties across the state. In 2003, the emergency medical service that oversees Fresno, Kings, Madera and Tulare counties discontinued the closure option.

Before doing so, that region was struggling with overcrowding and frequent hospital emergency room diversions, said Dan Lynch, the EMS director. When one hospital closed its doors, it didn't take long for another to follow.

"Ambulances would be circling the city, searching for a place to land," he said. "People with certain health plans were ending up at the wrong hospitals."

Now, hospitals have to deal with overcrowding without a closure option -- and it's worked, he said. Each hospital implemented changes differently by adding staff, getting permission for hallway beds, or seeing more patients in the waiting room.

The change forced hospitals to be more efficient throughout their facilities, not just in the emergency room.

"They become creative like they probably should have been in the first place," he said. "I think they used diversion as an excuse not to make changes in their own facility. Now, they're much more efficient because they know they're not going to be able to divert patients."

During especially busy times -- such as flu season -- ambulances might have to wait for an hour while the hospital finds a bed for a patient.

"We understand that, it's just going to happen," Lynch said. "But we haven't seen patient care impacted detrimentally."

Likewise, the 2008 decision to stop closure in San Bernardino, Inyo and Mono counties has resulted in hospitals better managing overwhelming situations, said Dr. Reza Vaezazizi, the medical director of the inland counties' EMS.

That region still allows hospitals to close emergency departments to ambulance traffic when there are internal disasters such as flooding or electrical problems. And, trauma centers can still close if they run out of resources. But simply being too busy is no longer a valid reason.

The counties have seen high "wall" times, meaning patients wait on their ambulance gurneys before rooms are ready. Overall, though, the move has been considered a success.

"It's a difficult concept because it's the way things have been for a long time," he said. "Hospitals felt this was their safety net. We had to convince them this was a false sense of security safety net."

As for Arthur Handy, the patient taken to the hospital outside his insurance coverage, he's recovered and doing well. But the couple is still fighting to get their bill covered.

Susan Handy says she hopes Kern County will change its policy for the sake of people like them.

"I would like to see things changed," she said. "It's not just my family. I'm talking about everyone."

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