Officials Seek Cure for Ambulance Diversion

Oxnard paramedic Lynn Borman rolls out every day to help the victims of gunshots, auto accidents and chronic disease. And what she hears too often are patients’ angry questions about why her ambulance is taking them to the wrong hospital.

“When we tell a patient, ‘Sorry, sir. We can’t take you to your hospital because it’s closed,’ it sounds so weird,” she said. “I think it adds to patients’ anxieties.”

But it’s a common situation for patients in Ventura County, where several hospitals frequently divert ambulances to other communities because their critical care beds are full.

Last month alone, the county’s general hospitals declared themselves closed to intensive care patients for at least part of 141 eight-hour shifts. This is up from 93 in the same month a year before, which was itself high because of the flu epidemic.

Experts are not sure why the December diversions spiked so high--why so many patients were so ill with such a wide variety of ailments.

“We just don’t have that answer,” said Barbara Brodfuehrer, county Emergency Medical Services coordinator.

The problem was most pronounced in Camarillo, where St. John’s Pleasant Valley Hospital called diversions 55 times, meaning that critically ill patients were routed to other communities more than half the time.

In Ventura, Community Memorial Hospital diverted ambulances for at least part of 36 eight-hour periods last month. In Oxnard, St. John’s Regional Medical Center called 25 diversions.

In the east county, Simi Valley Hospital had 17 diversions and Los Robles Regional Medical Center had five. The actual number of patients affected by the diversions for November and December has not been tallied, but the average for the first 10 months of 1998 was 54. In all, 540 patients were taken to alternate hospitals during that period, with the highest being 117 in January, at the peak of the flu epidemic.

“It’s something I live in fear of as a patient,” said Jennifer Rech, clinical manager of critical care at Los Robles hospital. “If my husband were to have a heart attack and he had to be routed to a completely different hospital, it would be frightening. And it’s unacceptable, because the transport time is too long.”

Although paramedics say it takes an additional 10 to 15 minutes to reroute a patient in Ventura County, local officials say they know of no loss of life from ambulance diversions. Patients in true crisis situations as a rule are taken to the closest hospital equipped to care for them.

Yet, the issue is a hot topic at meetings of those who oversee the county’s hospitals and its emergency medical system.

“It comes up frequently, and we’re working on it,” said Simi Valley Administrator Alan Rice, who chairs a committee of hospital executives. “The issue is local residents getting services locally. Patients want to go to the closest emergency room, and that’s understandable. We want that too.”

Hospitals Drafting Crisis Plans

Beyond that issue, however, is the question of how--given the current high level of ambulance diversions--local hospitals could deal with another flu epidemic like the one that filled them all to overflowing a year ago.

In recent months, hospitals have drafted plans for such crises, but nobody’s happy about the prospect.

“With these diversion numbers,” Rice said, “if we had another flu epidemic, it would be quite an event, wouldn’t it?”

Hospital administrators study the trends toward ambulance diversions, seeking a long-term fix. Most agree that the demand for beds for critically ill patients is on the rise, partly because the number of county residents is increasing and aging and partly because HMO guidelines keep patients out of hospitals until they are very ill.

Patients show up at emergency rooms much sicker than a few years ago. In 1991, about 11,600 critically ill patients were admitted through emergency rooms to local hospitals, but that number climbed to 18,538 by 1996, state records show.

So why not boost supply to meet demand by providing more critical-care beds and the doctors and nurses to staff them?

One possible reason, which administrators are loath to cite, is that hospitals can suffer financially by taking care of too many very sick people--especially the 26% of the population with no insurance. Even those with standard health maintenance organization coverage can be money losers.

“The more we do, the more it costs us,” said one hospital official who asked not to be identified. “Under the old fee-for-service system we got paid for everything we did for a patient. Now we get paid a set fee no matter what we do.”

‘Step-Down Beds’ Help Ease Crunch

Several county hospitals are making changes so they can care for more critically ill patients at any one time.

Blessed with high occupancy and an affluent community, Los Robles has been the most aggressive, planning construction of a new 10-bed intensive care unit by next year and adding 17 new “step-down beds” where care is a notch below that in critical care units.

Other hospitals are also responding, but more cautiously.

That is because the demand for costly, closely monitored beds is inconsistent--usually up in the winter and down most of the rest of the year. But hospital costs to maintain those beds, which require hard-to-find, on-staff critical care nurses, stay high all year long.

Administrators say they are doing all they can, but in this age of health care retrenchment, insurance reimbursements are extremely low.

For example, the St. John’s hospitals in Oxnard and Camarillo--both part of the large Catholic Healthcare West chain--have no expansion plans. Yet, the two hospitals accounted for 441 diversions in 1998, more than the other six local hospitals combined.

“It’s not like we’re trying to turn patients away; it’s an issue of cost,” said Dr. Allen Hooper, director of the emergency department at both hospitals. “We keep getting our reimbursement cut down, so we can’t afford to build a new intensive care unit. Unlike the military, we’re not funded to be prepared for disasters. We’re obligated to be prudent business people with the bare-bones minimum.”

“Nobody’s happy about these diversions,” Hooper said. “It upsets us. And patients are upset. They don’t have their own doctors. It’s like strangers are taking care of them.”

Based in Oxnard, a blue-collar town with a high incidence of violent crime, St. John’s Regional diverted more seriously ill or injured patients than any other local hospital in 1998--turning patients away an average of 19 eight-hour shifts a month.

St. John’s has 20 critical care beds, which rivals Community Memorial and Los Robles for the most in the county.

“But we see the most trauma in the county--stabbings, shootings, drownings and vehicle crashes,” said Stephanie Huhn, the hospital’s liaison with ambulance drivers. “And our E.R. patients tend to be sicker. We’re a poorer area, so many don’t have access to a lot of medical care. They have a lot of chronic underlying diseases, so their diseases get worse before they come to us.”

In response to the diversion problem, St. John’s has set up seven step-down beds and increased the number of beds with heart monitors to 64, nearly doubling the previous total, Huhn said.

“We try to avoid going on diversion, so we make sure we’re well into overflow before we start diverting,” she said.

St. John’s also now uses a high-tech patient evaluation system to determine when patients are able to be moved from intensive care wards, requiring one nurse for every two patients, into the step-down units, where the patient-nurse ratio is 3-to-1. Standard wards are often staffed 4-to-1.

“Rather than having a physician saying, ‘It’s my patient, and we want her there for five days,’ we can now input a bunch of information and determine the best place for the patient,” Huhn said.

At Pleasant Valley, St. John’s sister hospital in Camarillo, diversions also ran high last year. It averaged 15 a month, not counting the extraordinary total of 55 in December.

Economic Feasibility Is Determining Factor

Part of the problem is that Pleasant Valley takes a lot of east Oxnard patients diverted from the busy St. John’s Regional. Also, it is small, staffing only 54 acute care beds and just eight for intensive care. The hospital is licensed for 81 beds and could add more for critical or intermediate care if the economics made sense.

“The solution is more beds, but we have not really pursued that here, because we have not had this problem that often,” Administrator Bill Clearwater said. “We don’t have the business for more beds. It’s not economically feasible.”

Although Pleasant Valley’s intensive care beds were virtually full all of December, that wasn’t true the rest of the year. On average, three of the hospital’s eight critical care beds were empty during 1998, Clearwater said.

Another factor contributing to Pleasant Valley’s diversions, 217 in 1998, was a severe shortage of critical care nurses, allowing the hospital to use only six of its eight intensive care beds, Clearwater said. It is now fully staffed and uses all eight beds.

“We’ve worked very hard to limit our diversions, to add staff so we’re not closing beds,” he said.

A shortage of nurses also contributed to problems at Community Memorial, said Executive Director Michael Bakst. His hospital averaged nine diversions a month last year, but had 13, 33 and 36 the last three months of 1998.

That was partly because there were so many sick people--large numbers of patients with heart, orthopedic, stomach and breathing problems. On some days last month, Community Memorial broke records with 215 adult beds out of 220 filled.

“We are succumbing to the nursing shortage, just like other hospitals,” Bakst said.

He could call in nurses for many extra shifts, but won’t, he said. “You trash your staff,” he said. “They reach a saturation point where it’s not fair to them. We don’t want them demoralized and overly tired.”

Brodfuehrer, emergency services chief, said that short-staffing is not a valid criterion under county policy for hospitals to send patients to other medical centers.

“Staffing is not an acceptable reason to declare a diversion,” she said. “But we don’t have a consequence [for not following policy].”

County policy says that hospitals can divert patients when emergency or critical care units are full, when they cannot provide brain scans or when a hospital’s physical plant breaks down.

Some Hospitals at Saturation Point

A year ago, diversions at Simi Valley Hospital were the highest in the county. But over the last 12 months, the hospital has increased its number of intensive care beds from seven to 11 and added 14 intermediate care beds.

Rice said that has generally satisfied demand, because Simi Valley--unlike Los Robles, St. John’s and Community Memorial--does no heart surgeries, which usually keep several intensive care beds filled at a time.

“We expanded our ICU to deal with these higher numbers,” Rice said, “but I think our hospitals are at a saturation point. The growth of these communities has outstripped several institutions’ capacity for intensive care.”

In Thousand Oaks, Los Robles administrators have embarked on an ambitious expansion plan that has led to fewer diversions.

Los Robles had 20 diversions in December 1997, but only five last month because of the use of step-down beds, spokeswoman Kris Carraway-Bowman said.

Los Robles will be in even better shape in another 18 months, since the hospital is spending $6.5 million to triple the size of its crowded emergency room and expects to break ground soon on a $4-million expansion of its intensive care unit.

Los Robles is lucky, said Carraway-Bowman, because it’s making a 12% profit, while most California hospitals are losing money.

“Our patients are the older population,” she said. “So we can concentrate on cardiac and cancer care and invest in these new facilities for intensive care. When they eventually get to us, they’re so sick they stay in intensive three of four days instead of one or two,” she said.

Patients Transferred When They Are Stable

Despite the general increase in ambulance diversions, three local hospitals rarely divert patients to other communities. Small community hospitals in Ojai and Santa Paula had only 14 and 1, respectively, last year.

Bill Greene, administrator at Santa Paula, said that at hospitals like his the problem is not too many critically ill patients, but too few.

Plenty of emergency patients arrive, but many are transferred out to Ventura hospitals once they are stable, because Santa Paula does no heart or brain surgery.

“We’ve just never had a need to divert,” Greene said. “In fact, we’ve put general patients in ICU beds to be able to justify the staffing. It’s hard to keep ICU nurses.”

In Ventura, the county hospital--Ventura County Medical Center--also diverted patients just once last year.

Administrator Samuel Edwards said he avoids diversions by equipping intensive care beds “all over the hospital” to supplement the 18 he already maintains. He calls in extra intensive care staffers temporarily until a critical care bed opens up.

“I feel I’m holding the public trust here,” Edwards said. “This is the safety net, and I try very, very hard to keep us open.

“I have an aversion to diversions,” he said. “I feel that people deserve to be taken care of in their moment of need.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Ambulance Diversions by Hospital, 1998

The numbers for 1998 reflect the times a hospital declared itself closed to certain types of emergency patients--usually those who were critically ill. Each diversion to other hospitals covers an eight-hour shift.

Hospital: Community Memorial

Jan.: 2

Feb.: 0

March: 3

April: 4

May: 5

June: 1

July: 3

Aug.: 10

Sept.: 3

Oct.: 13

Nov.: 33

Dec.: 36

Total: 113

Avg.: 9.4

*

Hospital: Los Robles

Jan.: 14

Feb.: 18

March: 11

April: 21

May: 16

June: 9

July: 12

Aug.: 9

Sept.: 8

Oct.: 13

Nov. 14

Dec.: 5

Total: 150

Avg.: 12.5

*

Hospital: Ojai Valley

Jan.: 0

Feb.: 0

March: 0

April: 0

May: 4

June: 2

July: 0

Aug.: 1

Sept.: 0

Oct.: 3

Nov. 1

Dec.: 3

Total: 14

Avg.: 1.2

*

Hospital: St. John’s Pleasant Valley

Jan.: 12

Feb.: 10

March: 18

April: 26

May: 19

June: 15

July: 13

Aug.: 16

Sept.: 6

Oct.: 14

Nov. 13

Dec.: 55

Total: 217

Avg.: 18.1

*

Hospital: St. John’s Regional

Jan.: 13

Feb.: 8

March: 16

April: 24

May: 32

June: 20

July: 24

Aug.: 19

Sept.: 9

Oct.: 21

Nov. 13

Dec.: 25

Total: 224

Avg.: 18.7

*

Hospital: Santa Paula

Jan.: 0

Feb.: 0

March: 0

April: 1

May: 0

June: 0

July: 0

Aug.: 0

Sept.: 0

Oct.: 0

Nov. 0

Dec.: 0

Total: 1

Avg.: 0.1

*

Hospital: Simi Valley

Jan.: 13

Feb.: 18

March: 6

April: 4

May: 13

June: 11

July: 16

Aug.: 23

Sept.: 9

Oct.: 6

Nov. 2

Dec.: 17

Total: 138

Avg.: 11.5

*

Hospital: Ventura Co. Medical Center

Jan.: 0

Feb.: 0

March: 0

April: 0

May: 0

June: 1

July: 0

Aug.: 0

Sept.: 0

Oct.: 0

Nov. 0

Dec.: 0

Total: 1

Avg.: 0.5

*

Hospital: Countywide

Jan.: 54

Feb.: 54

March: 54

April: 80

May: 9

June: 59

July: 68

Aug.: 78

Sept.: 35

Oct.: 70

Nov. 76

Dec.: 141

Total: 858

Avg.: 71.5

*

Source: Ventura County Emergency Medical Services