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NIE program Homework Helpline CONTACT US Letters to the Editor How to reach us Newsroom directory Advertising In critical condition Diverted ambulances reflect 'looming crisis' for Austin hospitals. By Ann Roser American-Statesman Staff Sunday, January 20, 2002 Maud Branton shifted her weight on the emergency room stretcher and contemplated her wait. After seven hours in the emergency room at St. 's Medical Center in Austin, she was still waiting. Not to see a doctor. One examined her promptly, under a system at St. 's in which patients see a doctor first, then go through ER registration at the bedside. Branton needed to be admitted to the hospital and was waiting for a bed with a heart monitor. None was available. " We've been right in here ever since, " Branton said earlier this month, fidgeting again on the uncomfortable stretcher. Branton, 93, was rushed by ambulance from her McDade home in northeastern Bastrop County to St. 's shortly after noon, partly because her family thought she would get faster service than she got a week earlier at Austin's crowded Brackenridge Hospital. Now, she prepared to spend the night in the ER, a common practice at many hospitals as beds have become increasingly scarce. An aide left to find her a more comfortable bed. " We've been real pleased with the attention and the services, " said Branton's son, Louis, who took off work to be at his mother's side with his sister, Rita Honey. " But this is a lot harder than working -- waiting, waiting and waiting. " Almost nine hours after she arrived in the emergency room that Monday, Branton was admitted to a room. But two other patients spent the night in the ER: a baby waiting for a bed at Children's Hospital and another heart patient, said Mark Dorward, director of St. 's emergency department. St. 's was so busy that it came close to turning away ambulances that night, Dorward said. Jammed emergency rooms and diverted ambulances are becoming more common in County and around the country as hospitals grapple with record numbers of ER patients, rising hospital admissions, a flood of uninsured patients, not enough beds and too few nurses. Patients are taking longer rides in ambulances and waiting longer in emergency rooms. Authorities in at least two states, California and Massachusetts, are investigating patient deaths during ambulance diversions. In Texas, the diversions are now a problem statewide and are being examined by a governor's task force, hospitals and others. Dr. Pat Crocker, chief of emergency medicine at Brackenridge and Children's hospitals in Austin, said the diversions spotlight " a looming crisis " that " affects the medical care that will be available to all of us in the future. " He and others expect the problem to get worse. " We will have more hospitals diverting for longer periods of time before we start to see any improvement, " predicted Dr. Ed Racht, medical director of Austin- County Emergency Medical Services. Patients also will wait longer and experience other inconveniences. At Brackenridge, for example, increased patient loads cause a daily jugging act of moving patients and sometimes canceling elective surgeries. " It's kind of a constant game, " hospital administrator McClernon said. The ambulance diversions are the most visible sign of a health system under stress. A serious growing pain Although such cities as Houston, Boston and Los Angeles have been diverting ambulances frequently in recent years, Austin was coping fine until last April. For no apparent reason, Brackenridge was overrun and closed its emergency department for two days to all but children and the most critically injured patients. By year's end, County's eight general hospitals had diverted ambulances to other hospitals a record 2,546 hours. This year is already off to a bad start. Last week, the 110-bed Children's Hospital was so inundated with patients with respiratory ailments that 14 children had to sleep in the ER area. Other County hospitals also reported long waits in their emergency departments. Several closed to ambulances. And flu season, typically the worst time for hospitals, hasn't even peaked yet. Hospital officials are worried. They say hospitals used to fill up seasonally, but that has changed. Many stay full year-round, despite predictions in the 1990s that demand would decline because managed-care companies would provide preventive services, reducing the need for hospitalization. Hospitals put off construction projects as their budgets were squeezed by lowered reimbursements from government and private insurers. Some closed beds. Many still do not operate all of the beds for which they are licensed, partly because of a worsening shortage of nurses and other hospital staff. In County, where the acute-care hospitals and Children's are licensed for a total of 1,769 beds, only 1,553 beds are open. County, however, is in better shape than many areas, possibly one reason the ER closures took longer to erupt here. The county has gained three hospitals since 1995 -- Seton Southwest, the Heart Hospital and North Austin Medical Center. But it is clear now that even with the additions, the health-care system has not kept pace with growth. The population in the 11-county region that uses the trauma center at Brackenridge Hospital grew 42 percent in the past decade. The number of hospital beds in County increased 21 percent. There are fewer than 500 inpatient beds in the other 10 counties -- Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, San Saba and on -- in the region. Up to 30 percent of the patients who use Austin hospitals come from counties other than . Children's Hospital serves 46 counties. Several Austin groups have suggested that the 11 counties be taxed to support Brackenridge, but that notion faces many political hurdles. Austin health officials say they are proud that local hospitals have managed to tread water without sinking into a crisis. But they acknowledge that the diversions are a warning. And they warn that patient care will suffer if solutions aren't found. " At some point, " Crocker said last week, " the system has to break. " `He would have lived' " If Houston is any judge, it gets worse and worse and worse, " said Dr. Guy Clifton, chief of neurosurgery at Memorial Hermann Hospital in Houston and chairman of the neurosurgery department at the University of Texas Medical School at Houston. " You have people not getting care, and they die. " Clifton said he knew of two cases in which patients died during diversions in Houston. In a third case, a 21-year-old man died at Brackenridge a day after he had to be flown here from Katy when no trauma or intensive-care beds were available in Houston. Clifton is co-chairman of Save Our ERs, a new coalition of doctors, hospital administrators and business leaders trying to aid trauma centers and ERs in Houston. One of the only ways hospitals can control patient loads is by refusing ambulances. And in County, they can refuse all ambulances or just those carrying certain types of patients. Brackenridge never rejects critically injured patients, or children, Crocker said, but heart or stroke patients have been refused. The EMS medic can overrule the hospital's temporary closure if he or she believes a patient's life is at stake. Hospital and emergency medical officials in , on and Hays counties said they were unaware of any local deaths during diversions. But one Hays County woman believes her brother would be alive today if Brackenridge had not been turning away ambulances. " I know he would have lived, " said Delfina Cardenas. Her brother, Robles, died at St. 's Medical Center on June 18 after passing out at home, hitting his head and vomiting. He regained consciousness in severe pain. His niece who was at home with him asked the San Marcos/Hays County ambulance crew to take him to Brackenridge. Robles had no insurance, and Brackenridge is a publicly owned hospital that serves many of the region's poor and uninsured. It is also the only trauma center between Temple and San where the most severely injured patients have access to the physicians, equipment and expertise that make a life-and-death difference. " We were almost at Brack when they were calling in the patient report, " said Tom Partin, director of San Marcos/Hays County Emergency Medical Services. Partin was not on the run but was familiar with the case. " Brack told us they weren't taking patients, " he said. " We weren't aware they were on diversion. " The ambulance turned around in Brackenridge's driveway without trying to enter, Partin said. The crew asked the niece, , who was following in her car, where she wanted to go next. She said St. 's. To get there, the ambulance got back on Interstate 35, although it could have driven north on Red River about 19 blocks, said. She estimated the detour took 20 minutes; Partin thought it was shorter. County Medical Examiner o Bayardo said Robles, 64, died of an abdominal hemorrhage four hours later. Neither Bayardo nor the doctor who treated Robles believe the extra time in the ambulance cost the patient his life. But Robles' death could serve as a cautionary tale of what can go wrong when emergency departments close. ERs over doctors' offices In 10 years, emergency room visits in County have more than doubled, from 154,808 in 1991 to 344,802 in 2001. Brackenridge, which has the third busiest trauma center in the state, saw a record 111,000 ER and trauma patients last year, Crocker said. That's 304 patients a day, waiting for one of the 20 adult ER beds, 10 trauma beds or 12 emergency beds at adjoining Children's Hospital. Brackenridge diverts ambulance patients more often than any other County hospital, twice as much as No. 2 Seton Medical Center. on County hospitals occasionally close, too, because of increased patient loads. Round Rock Medical Center has seen a huge 20 percent jump in ER visits in just one year's time: from 38,767 in 2000 to 46,346 in 2001. Use of the emergency department -- a great equalizer where the rich and poor intersect -- has been soaring as managed-care plans loosened restrictions on emergency care. Aging baby boomers use the ER more, as do the uninsured, often for nonurgent care. Even those with insurance use the ER more for primary care. Doctors coping with managed care sometimes see 60 patients a day, leaving no flexibility to squeeze in another earache or sinus infection. " The typical scenario, is: `I called my private doctor and I can't get in,' " said Dorward, the emergency department director at St. 's. " That's what I hear from patients on a daily basis. " Those without insurance have even fewer options. People's Community Clinic, the largest clinic for the uninsured in County, sees about 3,200 patients a month. It has been turning away up to 2,200 patients monthly. Costlier ERs can't do that. The Emergency Medical Treatment and Active Labor Act requires them to see anyone who walks in. More than a third of Brackenridge's patients, many of them working poor, are uninsured. " We need to figure out a better way to care for nonemergency patients, " Racht, the EMS medical director, said. Treating the uninsured has " always been a problem, but the problem is reaching critical proportions now, " said Roseanna Szilak, executive director at People's. Texas has the nation's second highest rate of uninsured people -- 21.4 percent, or 4.5 million people -- state data show. Only New Mexico had a higher rate -- 23.3 percent. A survey of 10 of Texas' Level 1 and 2 trauma centers, including Level 2 Brackenridge, painted a financial crisis and estimated their cost of uncompensated care at more than $200 million last year. Many patients also walk into the ER and need to be admitted because they get no preventive care. Trauma centers and ERs are money-losers. Hundreds of financially strapped emergency rooms around the country shut down in the 1990s. " This is, I believe, one of the unseen crises beneath the surface -- the lack of access to basic primary care, " Szilak said. " We see the endpoint of that crisis in the emergency room. " Trauma hospitals are especially vulnerable to keeping up with demand. They cost more to run because of the sophisticated equipment and staff they need. But financing is a growing challenge, and some trauma centers have closed or are on the brink. The Texas Legislature last year rejected a bill that would have raised $85 million for trauma centers by imposing a $5 fee on vehicle registrations. " It seems that the only lasting solution is to significantly expand tax-based funding of the health-care system, and nobody likes more taxes, " Crocker said. " Unfortunately, however, in order to insure the emergency and trauma care system is there when you need it for your car accident, the problem must be solved for everybody. " Not enough beds As Crocker and others see it, County needs more inpatient beds, both in the intensive care unit and in intermediate care. The trauma center at Brackenridge also needs more space, he said. The only expansion under way at Brackenridge now is a $7.5 million project for 14 beds, including four in the ICU, to better serve people with brain and spinal injuries. Brackenridge and Children's are part of the Seton Healthcare Network, which operates three other County hospitals. St. 's HealthCare Partnership owns three hospitals, and the Heart Hospital of Austin is independent of the two large systems. Seton Medical Center has launched a $50 million project that will create 14 new ER beds and reopen 15 to 25 beds mothballed in the main hospital. Seton Northwest has mounted a $13.5 million project that includes a substantial expansion of the ER, surgery and maternity. St. 's Medical Center is undergoing a $65 million expansion and remodeling with a focus on the ER, operating room, outpatient services and the women's health center. Another $21 million is being spent at the partnership's North Austin Medical Center to expand maternity services, enlarge the nursery and add 32 beds. Jon , president and CEO of St. 's partnership, said he is hopeful the ER situation will improve as more beds open over the next couple of years. " We believe this will serve our needs for the forseeable future, " he said. But if hospital use continues to rise, " it's going to get tight again and we're going to have accelerate our expansion again. " Froehlich, a senior vice president for the Seton Healthcare Network, doesn't believe the expansions now under way will solve the diversion problem. " None of us are building the critical care and other beds we need, " he said. Expanding ERs could actually make the problem worse, according to a study by the Health Care Advisory Board, an organization of hospitals and health-care facilities. That's because ambulance diversions are rooted in a lack of inpatient beds, the board said. The nation is " still in the foothills of what will be a long upward march in demand for hospital services, " the advisory board predicted. It estimated that as the population ages and demand rises, hospital volume will grow 30 percent to 50 percent in the next 10 years. To remain profitable, hospitals will put more emphasis on moneymaking surgery patients and less on the ERs and medically ill patients, the board said. Regardless of how hospitals meet the demand, one thing is clear. They can't do it without nurses. A nationwide nursing shortage that blossomed in the late-1990s is now in full flower. Experts say it poses one of the biggest threats to the future of health care and quality of care patients receive. Some local hospital officials warned that until the nursing shortage is solved, the diversions will continue. As Crocker said: " It doesn't help to build more beds if we don't have nurses to staff them. " You may contact Ann Roser at maroser@... or 445-3619. When and how County hospitals divert ambulances County's policy for diverting ambulances, in effect since Nov. 12, works like this: * Overloaded hospitals alert Austin- County Emergency Medical Services, via a Web site, that they are temporarily closing to ambulances. * Hospitals can turn away all ambulances or reject only those carrying certain types of patient: the critically ill, maternity patients, premature babies or patients with brain injuries. * If EMS determines an ambulance patient is too critical and must be seen immediately, the hospital must accept the patient. * Two hospitals that are nearest each other and owned by the same company cannot reject ambulances simultaneously. For example, Seton Medical Center and Seton Northwest can't go on diversion at the same time. * St. 's Medical Center must always accept sexual assault victims and hyperbaric patients -- mainly those with burns or scuba diving injuries. * Patients, physicians and family members can no longer insist that a patient be seen at a hospital refusing ambulances. * EMS can order all hospitals to open when dealing with mass casualties or if EMS determines that the diversions are preventing it from doing its job. * The policy does not affect patients who come to the hospital on their own. Under federal law, hospitals must take all walk-ins. * Hospitals, including the trauma center at Brackenridge, may refuse ambulances because of an " internal disaster, " such as a power failure, fire or other loss of critical services. -------------------------------------------------------- Back to top AP HEADLINES • San Diego Base Mourns Dead Marines • U.S. to Pay Drug Smuggler $400G • San Diego Base Mourns Marines • Flight Arrives in Orlando After Threat • 9 Churches Join in Unity Pledge • Names of Marines in Air Crash • First Lady Gives Gown to sonian • Scalia Comes Up Duckless on Hunt • Rumsfeld Backs Treatment of Prisoners • Report: Audit Found Specimens Missing • Nations Offer to Rebuild Afghanistan • Israel Tanks Take Over West Bank Town • Marines Die in Afghan Copter Crash • Taiwan President Picks New Premier • U.S. Planes Arrive in Philippines AP National news AP World news CLASSIFIEDS Employment Center Transportation Real Estate Sales Real Estate Rentals Merchandise Pets & Livestock Services Business/ Education Public Notices Obituaries Weddings Place an Ad Click here to subscribe! 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