From 34 Beds to 12 in 2 Years : Options Fading Fast for L.A. County Burn Victims
A 3-year-old boy was taken to a downtown Los Angeles hospital several weeks ago after a street vendor’s cart tipped over, drenching him with boiling water. The burns on his chest, genitals and hands were so severe he needed to be transferred immediately to a burn center for skin grafts and other special care.
But there were no beds available in any of Los Angeles County’s three burn centers. Or in Orange County. Or at the UC San Diego burn unit in Hillcrest, the only burn unit in San Diego County.
Seven hours after the accident, a burn center in Fresno finally agreed to take him, said Dr. Cheryl Lee, an emergency physician at White Memorial Medical Center who arranged the transfer. A helicopter finally whisked the boy away, leaving his parents behind because there was no room for them on board.
Los Angeles County’s three burn centers have a total of 12 intensive-care beds that are currently staffed, down from 34 two years ago, according to a tally by officials at the Hospital Council of Southern California.
Increasingly, all these beds are occupied, forcing local burn victims to be flown to other counties or even out of the state for care.
“We’ve gotten a lot of calls from major institutions in Los Angeles to transfer very major burn cases,” said Dr. Steve Zumiga at Valley Medical Center’s burn unit in Fresno. “I find it unbelievable that the hospitals there can’t handle them.”
Dr. William D. Davies, founder of the burn center at Torrance Memorial Medical Center, said, “It’s a daily occurrence that people here in Los Angeles have trouble getting placed in a burn center in this county.”
Burn centers throughout the country are in financial trouble, mainly because the patients they treat tend to be poor and often lack health insurance. At the same time, medical advances have enabled doctors to save patients that only 10 years ago would have had no chance of survival--but such highly specialized treatment is costly.
The problem is especially acute in Los Angeles County, where the number of uninsured residents--many newly arrived immigrants--is growing fast and public funding for mental health, trauma care and other health services has been slashed.
Torrance Totters
In what threatens to make a bad situation even worse, officials at Torrance Memorial, a nonprofit community hospital, are considering closing their burn unit because of financial losses from treating burn victims who do not have health insurance or who have inadequate coverage. These patients, hospital officials said, have put the five-bed burn unit in the red, costing the hospital about $200,000 during the first five months of this year.
Two years ago, another private hospital, Brotman Medical Center, closed its Michael Jackson Burn Center in Culver City because of financial problems. And this year, County-USC Medical Center, which is Los Angeles County’s only public resource for indigent burn patients, drastically reduced service. Three of its seven intensive-care burn beds were eliminated, due largely to the unavailability of nurses.
Increasingly, patients burned in car accidents, household injuries, assaults, or on the job cannot get a bed in a local burn center.
One family involved in a fiery traffic accident was split up when the husband was sent to County-USC for care, the wife was sent to Las Vegas and their 4-year old child was sent to San Bernardino County.
“Isn’t that an awful way to have to deal with the biggest tragedy in a family’s life?” said Audrey Bahr, chief of the contract program office of the Los Angeles County Department of Health Services. “How would you like to be a grandmother trying to figure out who to visit?”
During the first six months of this year, county health officials said there was no room at local burn centers for 13% of the patients seeking care there. They had to be treated either at non-burn centers or at hospitals outside Los Angeles County.
Hospitals routinely treat burns, but only specially equipped burn centers are capable of performing the delicate skin grafts and plastic surgery required in the most severe cases. In Los Angeles County, it can take as long as 10 hours and require phone calls to more than six hospitals before a patient is placed, according to county health emergency care official Darlene Isbell.
Because so many of the patients needing to be transferred out of Los Angeles have little or no medical insurance coverage, the UC Irvine Medical Center burn unit will not take them, said Bahr. “We have trouble getting San Diego to take them, too.”
“We have received an increasing number of calls from Los Angeles,” said Dr. John Hansbrough, medical director of the UCSD burn unit. “But we have never had to turn away a funded patient” when an out-of-county hospital has requested a transfer.
UCSD’s unit, which includes six intensive-care unit beds and eight special care beds, has been able to meet the demand generated by San Diego County, according to hospital spokeswoman Sheri Smith.
The worst burn cases end up in the ICU beds. Less-severe burn cases and patients who are recovering are treated in the special care beds, Smith said. The burn unit on occasion has been used to handle other types of seriously injured patients, especially when the UCSD hospital is swamped by trauma patients, Smith said.
Davies recalled a recent accident in which two children were burned over half their bodies when a pickup truck and car collided.
“One kid had insurance,” Davies said, and he was accepted at the Southern California Burn Center, a private facility at Sherman Oaks Community Hospital, the county’s third operating burn center with three beds. “The other kid had none, and nobody (at any Los Angeles burn center) was able to take care of him.” Eventually, a bed was found for him at San Bernardino County Medical Center’s burn unit, Davies said.
Bahr said that over the July 4 weekend, four burn patients were transferred out of Los Angeles County, including a 5-month-old infant burned in a crib fire and a 29-year-old man who tried to swallow a firecracker while high on drugs.
Airlifting burn victims is not medically unsound in most circumstances, doctors say. For example, the Army for years has transported burned servicemen to specialized centers thousands of miles away. And in many rural areas of the country and small cities, patients are commonly helicoptered to regional burn centers.
But it is preferable to avoid helicopter trips. They’re not only expensive, but separate patients from their families and friends whose support is usually vital to their recovery.
“Personally, I grieve the most for the indigent child,” who gets shuttled around without his parents, said Davies at Torrance Memorial. He pointed out that a 5-year-old girl from Los Angeles, now under his care, was sent to San Francisco for initial burn treatment because there were no beds available in the Southland.
“It is a crime that a county like Los Angeles” has so few intensive-care burn beds that patients have to be sent as far away as Dallas for treatment, said David Langness, vice president of the Hospital Council of Southern California.
Unlike Los Angeles, other major metropolitan areas usually have enough beds to accommodate their burn victims.
“New York City seems to be pretty well served by the available burn beds,” said Dr. Cleon W. Goodwin, director of the burn center at New York Hospital-Cornell University Medical Center in Manhattan. Rather than flying patients out of town for care, he said patients are often flown into New York for treatment at one of the three burn centers.
In Miami, the city’s single burn center at Jackson Memorial Hospital is big enough to accommodate the vast majority of Dade County’s burn victims, said Dr. Charles G. Ward, director of the hospital’s burn center and immediate past president of the American Burn Assn.
Problem Is Money
Despite financial strains, the nationwide network of about 120 burn centers that sprung up during the late 1960s and early ‘70s is not collapsing, according to Ward.
“Everyone has the same problem--funding,” he said. “But we haven’t seen any collapse yet.”
“Most burn centers . . . are aware that you aren’t going to balance the books by taking care of burn patients. . . . They continue the care as part of their obligation to serve the community,” Goodwin said.
Many of the country’s biggest burn centers, especially in large urban areas, are located in teaching institutions or public hospitals where patient care is subsidized. In Miami and New York City, for example, all the critical burn care is provided by such institutions.
But in Los Angeles, the burn center at County-USC has lost beds as the number of patients seeking care there has grown.
“We’re moving backwards,” said Dr. Bruce Zawocki, director of the County-USC burn center, which is plagued by a shortage of critical-care nurses. “My fear is that we’re turning back the clock about 15 years.”
Health officials estimate a 75% yearly turnover of nurses at County-USC. Without nurses, the unit’s critical-care beds cannot be filled.
Generally, County-USC concentrates on providing care for the county’s poorest burn victims, allowing the county’s two privately operated burn centers to care for those who have insurance.
But when County-USC is full, the private hospitals are called upon to accept indigents, as well as privately insured patients.
“We shudder when we get a call,” said Ray Alan Rahn, senior vice president at Torrance Memorial. “Every time we get a call, it could be a half-million-dollar exposure for us. It’s really frightening.”
Profit Wiped Out
Nine of the 31 patients treated at Torrance Memorial’s burn center during the first five months of 1989, he said, were sent there because County-USC was full. The cost of caring for them--about $200,000--wiped out the burn center’s overall profit, provoking serious consideration of closing the unit down, he said.
In previous years, Rahn said, the burn center has by and large broken even. But this year, he said, the center has been hit by increasing numbers of patients with little or no insurance coverage.
He provided a list of 10 instances during 1988 in which the hospital wrote off between $18,000 and $200,000 in medical charges incurred by patients with no medical insurance or limited coverage through Medi-Cal or Medicare.
Most of them lived in parts of the county outside of the hospital’s general service area, Rahn pointed out.
$134,000 Bill
One woman lived as far away as Tacoma, Wash. She was driving on a freeway near Bakersfield when she was hit by a truck, severely burned, and helicoptered to Torrance Memorial. Before she died, Rahn said, she spent 22 days in the hospital and ran up a bill of $134,000. She had no health insurance.
Patients insured through Medi-Cal and Medicare also leave behind staggering unpaid bills, Rahn said. Torrance Memorial is reimbursed about $900 a day for Medi-Cal patients.
“That formula is a disaster for us,” Rahn said, because the hospital charges $4,300 a day for care.
Hospital officials are now lobbying state health officials for an increase, which Rahn described as critical to the burn center’s survival.
BURN CENTERS Rising medical costs and an increase in uninsured patients have led to cutbacks in care at special burn centers. Los Angeles County officials say the number of staffed intensive care unit beds in the county’s three burn centers has dropped to 12, from 34 two years ago. There are 12 other burn centers in the state, as well as one in Las Vegas. Three staffed, intensive-care-unit beds for burn patients are located in Los Angeles County. L.A. COUNTY CENTERS 1. Sherman Oaks Community Hospital: 3 beds 2. County-USC Medical Center: 4 beds 3. Torrance Memoria Medical Center: 5 beds
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