21 Local Emergency Rooms Bar Neurosurgical Patients

Twenty-one hospitals in Los Angeles County, plagued by a shortage of neurosurgeons, are systematically shutting their doors to ambulances carrying patients with head injuries and other neurosurgical emergencies, county health officials have disclosed.

The closures in turn have overloaded emergency rooms at other hospitals, where some administrators are so incensed that they, too, are threatening to close. This is creating a “classic domino effect,” said county health services official Virginia Price Hastings.

The neurosurgery conflict is the latest problem to afflict the county’s embattled emergency services network, which over the last five years has seen the virtual disintegration of its trauma hospital system and fended off the threat of major emergency room closures.

Calling the situation “especially acute,” Robert Gates, county health services director, has proposed adopting new policies that would force all emergency rooms to share the burden of treating neurosurgical patients--more than 6,200 patients in 1990.

All emergency rooms are required by law to have a list of specialists who are on call. These specialists--obstetricians, orthopedists and neurosurgeons--are crucial because only they can admit patients to the hospital and provide highly specialized patient care.

But because many neurosurgeons are increasingly unwilling to make themselves available to treat emergency cases, some hospitals say they have no choice but to divert ambulances from their emergency rooms.

Hospital administrators say the specialists are reluctant because the hours are irregular, malpractice insurance premiums are high and the financial rewards are much greater in private practice.

Moreover, those doctors who do participate often require hospitals to pay them a retainer fee, to compensate them above and beyond the fees they charge patients. A survey by the Hospital Council of Southern California in 1990 found that 47% of the hospitals that were canvassed were compensating specialists to be on call.

While the problem is countywide, Gates informed county supervisors in a memo last week of an “immediate problem” involving emergency neurosurgical care for patients in the Glendale area.

Gates said that for more than a year, two major hospitals--Glendale Adventist Medical Center and Glendale Memorial Hospital and Health Center--have been diverting ambulances carrying patients with neurosurgical emergencies to a third facility, Verdugo Hills Hospital. And to make matters worse, Hastings said that during the last few months, St. Joseph Medical Center in nearby Burbank has cut back its emergency neurosurgery care.

As a result, Gates said that Verdugo Hills has become so overloaded that “it, too, will lose its neurosurgical call panel unless diversions from the other hospitals cease.”

Verdugo Hills Hospital President Ronald Davey declared several months ago in an angry letter to county health officials: “We want relief. . . . The practice of dumping on Verdugo Hills Hospital cannot and will not continue.”

Administrators at the two Glendale hospitals, which have a total of 784 beds, denied they have “dumped” any patients on Verdugo Hills, but acknowledged they typically divert ambulances carrying patients with neurosurgical emergencies.

About six neurosurgeons have staff privileges at both hospitals, where they admit their private patients and perform tests and surgery. But all six neurosurgeons have declined for “different reasons” to make themselves available to treat patients in emergencies, said William Parente, president of Glendale Memorial.

Hastings, chief of the health department’s paramedic and trauma hospital system, said that county policies permit hospitals to temporarily close their emergency rooms because of overcrowding, but she said the rules have been abused by hospitals that are systematically closing their doors day after day.

The hospitals are obliged to report their closures to the county’s centralized dispatching service for ambulances. In a recent review of dispatcher records from August, 1990, through May, 1991, Hastings found that 21 of the county’s 89 emergency rooms have been systematically closed to neurosurgery cases. “They are closed 80% of the time or more,” she said, because they have no neurosurgeon or neurologist on call.

With so many emergency rooms closed to neurosurgery patients, Hastings said that paramedics are often forced to drive to more distant hospitals seeking care for the patients. “And anytime you have to take a patient a longer distance, there’s a potential” of endangering the patient, she said. Moreover, taking the paramedics so far afield also runs the risk that they will be late in responding to their next emergency call.

In order to more evenly distribute the patient load, Hastings said she has proposed changing county guidelines to eliminate a hospital’s option to divert ambulances with emergency neurosurgical patients.

“We have learned the hard way” from experience with the county’s hospital trauma system “that we can’t overload a hospital,” Hastings said. “We need to institute policies that will control (the) volume” of patients so that individual hospitals don’t collapse and put even bigger burdens on the others.

Those hospitals that are now systematically diverting neurosurgical emergencies from their doors would be forced under the new proposal, Hastings said, “to sit down with their doctors and resolve the problem, and not just tell the paramedics to truck on down the street” to the next hospital.

The problem in Glendale is the worst, Hastings said, because of Verdugo Hills’ explicit threat to cut back its neurosurgical coverage. But Gates said many other hospitals countywide are facing the same dilemma. He said they are making “identical” complaints--”that their neurosurgeons cannot and will not continue to provide care to patients being diverted to their hospitals from outside their geographic areas.”

Gates told the county supervisors in a memorandum last week that unless the Glendale hospitals can come up with a better solution to the problem, he will immediately implement Hastings’ proposal, which would affect all emergency rooms countywide.

David Langness, spokesman for the Hospital Council, said that five Glendale area hospitals met last week and agreed to suggest to county health officials that they form a single panel of neurosurgeons who would rotate among the various institutions to treat patients in emergencies.

“The patients would be routed to whichever hospital was designated that night to provide emergency neurosurgical care,” said Langness.

Reacting to the proposal, Hastings said it “sounds like there are a lot of operational questions to be resolved.”

Dr. John Kusske, an official with the state Neurosurgical Society, estimated there are 120 neurosurgeons in all of Los Angeles County eligible to be “on call” in hospital emergency rooms. The problem, Kusske said, is that there is an overwhelming workload for too few neurosurgeons.

The Neurosurgeon Shortage

All hospital emergency rooms must have a list of specialists such as neurosurgeons, obstetricians and orthopedists who are “on call” for emergencies. But increasingly, neurosurgeons have refused to participate, prompting 21 hospitals in Los Angeles County to permanently shut their doors to ambulances carrying patients with head injuries and other neurosurgical emergencies.

Neurosurgery: Difficulty by Area

Hospitals in different parts of Los Angeles County have varying degrees of difficulty in getting neurosurgeons to care for patients in emergencies. Figures below reflect the percentage of hospitals, by region, that are experiencing difficulty. Coast: 43% Harbor: 57% Los Angeles: 50% Northwestern: 61% San Gabriel: 45%

Specialty Problems

Hospitals in Los Angeles County have varying degrees of difficulty in getting specialists to care for patients in emergencies. Figures below reflect the percentage of hospitals which have trouble getting specialists to be on call in the emergency room. Others: 35% Pediatrics: 3% General Surgery: 5% Orthopedics: 10% Psychiatry: 12% OB/GYN: 17% Neurosurgery: 47% Source: Survey of hospitals conducted in November, 1990 by Hospital Council of Southern California.

Sending Patients Away

Here are the 21 local hospitals* that county health officials say are systematically redirecting ambulances carrying patients with head and other neurosurgical injuries: Alhambra Community Hospital Brotman Medical Center, Culver City Coast Plaza Medical Center, Norwalk Daniel Freeman Marina Hospital, Marina del Rey East Los Angeles Doctors Hospital Glendale Adventist Medical Center Glendale Memorial Hospital and Health Center Greater El Monte Community Hospital Hospital of the Good Samaritan, Los Angeles Kaiser Foundation Hospital, West Los Angeles Medical Center of North Hollywood AMI Monterey Park Hospital Palmdale Hospital Medical Center Queen of Angels-Hollywood Presbyterian Medical Center AMI San Dimas Community Hospital Santa Marta Hospital, Los Angeles St. Francis Medical Center, Lynwood St. Joseph Medical Center, Burbank Thompson Memorial Medical Center, Burbank Valley Hospital Medical Center, Van Nuys White Memorial Medical Center, Los Angeles * The hospitals redirect neurosurgery patients at least 80% of the time because of a lack of neurosurgeons or neurologists.

SOURCE: Los Angeles County Department of Health Services