Busy Rhode Island hospitals told not to divert ambulances
Overwhelmed by sick people, Rhode Island's hospitals have been increasingly telling ambulances to take their patients elsewhere prompting the state health director to temporarily ban the practice.
Providence Journal, Jan. 9, 2004
http://www.projo.com/news/content/pr...p9.18d239.html
Busy hospitals told not to divert ambulances
Emergency rooms -- no matter how crowded -- must accept all patients even if, one hospital official said, they might have to be treated in the hallways or the cafeteria.
01:00 AM EST on Friday, January 9, 2004
BY FELICE J. FREYER
Journal Medical Writer
Overwhelmed by sick people, Rhode Island's hospitals in recent days have been increasingly telling ambulances to take their patients elsewhere -- and that has prompted the state health director to temporarily ban the practice.
Health Director Patricia A. Nolan issued her unprecedented edict on Wednesday, shortly after learning that, for the second time in two weeks, 6 of the 10 hospital emergency rooms in Rhode Island were advising ambulances that they were too full to take any more patients.
That left ambulances with only four hospitals to choose from, often requiring long journeys that brought ambulances far from the towns they serve.
Nolan ordered all hospital emergency rooms to accommodate all ambulances "until further notice" so the burden of extra patients could be spread among the hospitals. She has scheduled a meeting Tuesday with hospital executives to map out a plan. "We need to organize this so that we protect patients," she said.
Hospital officials around the state said yesterday that a spate of respiratory illnesses has resulted in many more severely ill patients than in a typical winter -- and a typical winter already strains the hospitals to their limits.
And they said that this year's crisis exposes deep flaws in the health-care system -- especially a lack of financial resources and a shortage of nurses that make it difficult to respond to sudden surges in demand for care.
"This is a very early and severe cold and flu season," said Dr. Andrew Sucov, medical director of the Rhode Island Hospital emergency department. "The hospitals are overflowing. The emergency departments are overflowing. . . . It's certainly much worse than last year, worse than most years."
When every hospital bed is filled, sick patients who need to be admitted back up in the emergency room, occupying treatment bays needed for incoming emergency patients. In such a situation, a hospital will sometimes go "on diversion," advising ambulance companies and rescue squads that they are too full to take more patients and that they should take patients to another hospital.
"I have to say I haven't seen this in all my years in hospital administration," said Louis R. Giancola, president of South County Hospital. "All of the hospitals have experienced a tremendous increase in sick patients, much more than we normally do in January, to the point where virtually every hospital has been on diversion much more than we have experienced in the past."
Giancola said the situation was so bad that he personally got involved with care, holding a patient in the emergency department who was being cleaned by the vice president of patient care services.
On South County's worst day, 16 of the emergency department's 19 treatment bays were occupied by patients who had been admitted but had no place to go, Giancola said.
Emergency-department diversion has been commonplace in the Providence area for many years, and the five hospitals there have an agreement under which, if two metropolitan hospitals are on diversion and a third wants to divert, then all the hospitals have to open their emergency rooms.
No such agreement exists among the five outlying hospitals. Until this winter, diversion was uncommon at South County Hospital and unheard of at Westerly Hospital. But during the past two weeks, there have been occasions when Kent Hospital in Warwick, South County Hospital and Westerly Hospital were all on diversion simultaneously.
"Essentially we end up shopping for a hospital," said Patrick McMahon, commander of the Charlestown Ambulance-Rescue Service. "We have never seen it this bad."
"We had to bring a patient yesterday to Rhode Island Hospital," said Ronald J. MacDonald III, commander of the Westerly Ambulance Corps.
"If all our ambulances are out of town, we have to depend on Charlestown next door. They're going to have to come in, and that might leave their town unprotected. It's a ripple effect."
The Health Department became involved with the emergency-department diversions as a direct result of bioterrorism preparedness efforts. With federal bioterrorism money, two years ago the Health Department bought a wireless communication system that allows all hospitals to confer at once. They contact each other three times a day to discuss emergency-room capacity.
Since the federal government declared a "code orange," indicating a high danger of terrorist activity, the Health Department has been participating in two of those three conversations, keeping count of the number of emergency departments that are on diversion. Along with complaints from ambulance companies, the information about the number of diversions prompted Nolan's ban.
"While this is an unusual step for us to take, I don't want people to think it's something horrendous," Nolan said. "We need to figure out a better structure."
There are no reports of anyone getting hurt or missing out on needed care because of the diversions. Ambulances can still bring patients deemed "critical" to the nearest hospital.
Nolan's ban on diversion allows hospitals facing an internal disaster, such as a fire in the emergency room, to divert ambulances.
South County Hospital's Giancola said he was "very concerned" about Nolan's edict. "We're going to have to make do," he said. "We're going to have to try to take care of them as well as we can."
At Kent Hospital, spokesman Brian Wallin said that Kent would deal with the diversion ban "on a day-to-day basis" and hope that the fact all hospitals are required to keep emergency rooms open will balance out the demand.
Sucov said that Rhode Island Hospital had opened three extra units within the past couple of weeks and since then has had to go on diversion only once or twice. He did not expect the diversion ban to have a big effect at Rhode Island Hospital.
"If we get beyond our ability to open more units, I don't know what I'm going to do," Sucov said, mentioning that if things got bad enough he could put patients in the hallways, the operating rooms or the cafeteria.
"In most cases," said Cathy E. Duquette, vice president of the Hospital Association of Rhode Island, "there's just no physical space left to put anybody."
Edward J. Quinlan, the association's president, said it has become increasingly hard to predict how many patients will come to the hospital. "Hospitals used to be able to look year to year and be able to predict your capacity. . . That's no longer possible."
Remarked Sucov, of Rhode Island Hospital: "If we had a situation where we had plenty of nurses and the hospitals were in good financial shape, we might not even be aware there was a problem today."
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