Code Red

[nightingale, RN]

Interesting Article:

http://www.denverpost.com/framework/0%2C1918%2C36%257E11%257E591633%2C00.html#

Denver Post

CODE RED

A paramedic's frantic ride, with a life in the balance, jolted Denver's medical establishment and helped change a dangerously crowded emergency system

By Marsha Austin

Denver Post Staff Writer

Sunday, May 05, 2002 - The 44-year-old gunshot victim clung to life in the back of the ambulance as paramedic Bryan DeWolfe applied pressure to a gaping head wound.

DeWolfe, with fast, capable hands, had already inserted a breathing tube and started an IV. The guy was in bad shape. The clock over DeWolfe's left shoulder loomed large, a merciless reminder of what the medic already knew. Not much time.

"Scoop 'em up and drive like hell." DeWolfe and ambulance driver Mike Opp had followed the unwritten protocol on all gunshots to the head.

Now, as the ambulance hurtled south on Kipling through the warm night toward Interstate 70, DeWolfe dialed the emergency room on the cellphone in his blood-soaked hand. It was 10:50 p.m. on May 5, 2000. Cinco de Mayo. The chance of getting into a nearby top-level trauma hospital wasn't good - and DeWolfe knew it.

The spring of 2000 was a tough time for paramedics. The metro area's population had grown by INSIDE:

Details of a Post investigation into Denver-area emergency-room "diverts.' 12A-13A 500,000 in the past decade, overwhelming an already strained hospital system.

The problem had begun backing up onto the streets, where ambulance crews found their patients being barred from overcrowded emergency rooms and sent to other medical centers. Hospitals call that a "divert."

ANALYSIS

For these stories, The Denver Post analyzed eight years of ambulance-divert data obtained through state open-records laws from Denver Health Medical Center, which maintains the Emergency Medical Services Information System for public and private metro-area hospitals.

For each diversion incident, the database included:

* Hospital

* Date

* Time on diversion

* Time off diversion

* Diversion type

The Post focused its analysis on emergency-room diverts, but also looked at diverts involving intensive-care units, cardiac-care units, psychiatric wards and operating rooms.

To analyze which hospitals were turning away patients at the same time, The Post broke the emergency-room diversion times into one-minute increments.

There were some discrepancies in the database. In some cases, a hospital was listed as going off diversion at two different times. The Post used the first "off" entry.

Click here for an interactive display of when the 13 metro-area hospitals are on "divert" status and their locations. Macromedia Flash is required.

Contributing to the analysis were computer-assisted-reporting editor Jeffrey A. Roberts, staff writer David Migoya, systems manager Keith Morse and assistant managing editor/technology Erik Strom.

Click here for The Post's large summary graphic, "Aug. 20, 2001: A day of diverts."

.

Medical officials said they had to avoid dangerous overcrowding in emergency rooms, intensive-care units and operating rooms. Belt-tightening by managed-care executives and other financial pressures on hospitals had left them with fewer beds and smaller staffs than they had in 1988, when the area's last hospital was built in Littleton.

In the next year and a half, it would get worse.

"I remember calling four or five hospitals before we'd find one," Lt. Scott Rodriguez, Aurora's Rural Metro Ambulance paramedic shift supervisor, said about the summer of 2001.

Between 1994 and 2001, the number of hours that hospital emergency rooms diverted cases skyrocketed from 600 to 8,883 through last October, according to a Denver Post analysis of computer records.

There were 41 days between Jan. 1 and Oct. 31, 2001, when more than half the 13 emergency rooms in the Denver area locked out patients at the same time, the most recent records show. On June 11, July 14 and Aug. 23, as many as 10 hospitals diverted simultaneously.

At times, all the hospitals in one area shut their emergency rooms to ambulance traffic, forcing patients to be transported many miles across the city or unloaded into a taxed emergency room. For example, on Aug. 20, 2001, when nine hospitals were turning away emergency patients, hospitals in the south - Littleton Adventist, Porter, Swedish - diverted for the same 41/2 hours.

Emergency-room overload isn't unique to Denver. It's a national issue, a symptom, some medical leaders say, of a broken health-care system. The West is particularly afflicted, according to an American Hospital Association study released in April that shows urban hospitals in the Rocky Mountain states face the second highest level of diverts nationally behind the West Coast.

"You might be able to get a patient to the hospital in 10 minutes," said Dr. Gene Moore, a Denver Health Medical Center trauma surgeon. "But if the staff takes a half hour to deal with that injury, it takes 40 minutes."

In emergency medicine, 40 minutes can be the difference between life and death.

The gunshot call had come into Pridemark Paramedics in Arvada at 10:27 p.m. Eight minutes later, DeWolfe and Opp rolled into the 6400 block of Quail Street in Arvada.

The cops were already there.

Bruce Bersell was lying in the hallway of an apartment, unconscious and bleeding profusely from a head wound. A gun lay on the bed. The man's agitated wife, Ann, told DeWolfe and Opp he'd shot himself moments earlier.

The medics cut off Bersell's bloodied Avalanche jersey, made sure he could breathe and found a pulse.

As police and firefighters prepared to load Bersell into the ambulance, his wife hovered.

"Is he OK?" she asked. "Is he OK?"

The state health department knew little about the divert problem. One reason: Hospitals closely guarded the information, in part out of fear that patients would balk at using an emergency room that was frequently off-limits.

Gail Finley Rarey, director of the health department division that oversees emergency medical services and injury prevention, said the state had anecdotal stories then but no hard evidence of problems.

The state does not collect information on diverts. Hospitals don't have to report that information.

"We are a little bit blinded in that way," Rarey said.

Even if it had the data, the health department couldn't afford the computer programs or programmers to crunch the numbers, she said.

Only one person, Dr. Stephen Cantrill, director of Denver Health's emergency department, tracked metro-area hospital diverts - using a computer program he wrote a decade ago.

But Cantrill said he never had time to study the information closely.

Hospitals did give divert information to a central dispatch center, to be relayed to paramedics. But until December 2001, the hospitals demanded that the information be kept confidential, not only from the public but from other hospitals.

"Hospitals always want to be portrayed in the best light, and divert carries with it a very negative connotation," said Dr. Ben Honigman, an emergency room physician at University of Colorado Hospital. "There's always been an obstacle to providing data to the public."

DeWolfe knew the emergency room at St. Anthony'Central, 4231 W. 16th, the closest top-level trauma center, was swamped and diverting patients. He called anyway as he left the scene, asking for the T-10, a special operating room for severe trauma victims.

An emergency room doctor told him they were too busy to take Bersell.

It was 10:46 p.m. He was running out of time.

The Cinco de Mayo gunshot incident resonated with Brian Daley, chief of West Metro Fire's Special Operations Division. His crews weren't on the call, but he had heard of DeWolfe's hellish ride.

Mild-mannered and straight-shooting, Daley spent 15 years climbing the Fire Department's ranks, from paramedic to head of the state's elite urban search and rescue teams. He lived West Metro's motto: "Whatever it takes

... to serve."

But Daley was fed up with hospital diverts forcing his men and women, his rescue rigs, miles and sometimes hours out of their home district, while 911 calls poured in from neighborhood residents. He'd heard the grumbling, the growing frustration of his rescue crews as 2000 wore into 2001 and diverts kept climbing.

"We've got to keep this from being an issue, so we don't have the head-shot guy, so we don't have to start carting people everywhere," he recalled thinking.

"It was killing us. If I've got to drive a guy from Sixth and Kipling to St. Anthony North at 5:30, I'm out of service for three hours. Guys were being diverted away at the busiest times. Well, when (the hospitals) are busy, we're busy."

His plan: defy the hospitals and their politically powerful administrators.

Bring patients to emergency rooms, under some circumstances, even though those hospitals wanted them elsewhere.

Daley and his paramedics believed their patients were better off with a busy doctor than in the back of an ambulance. They knew that even when emergency rooms were jammed, the most serious cases seemed to get the medical attention they needed.

West Metro Fire Chief Bob Brown backed them up.

"I kept hearing the same old reports (from hospital administrators) about how difficult it was - the nursing shortage, the lack of beds," Brown said. "I never got a sense that anything was getting done."

So in late May 2001, the metro area's largest fire protection district, encompassing 110 square miles from Arvada to Ken Caryl Ranch and serving 265,000 people, changed the rules.

Now, West Metro paramedics out on a call contacted the closest appropriate hospital. If it was diverting patients, they called the next closest. If both were diverting cases, they went to the first.

DeWolfe knew the man he was trying to keep alive had only a fleeting chance for survival - and only if he got to a doctor fast.

But Cinco de Mayo had been crazy all over the northwest metro area. A gun battle at Federal and Eighth involving three teens had shut down highway exit ramps, and Interstate 25 was a parking lot in and around downtown.

At least five hospitals between Westminster and downtown Denver, including top-level trauma centers St. Anthony Central and Denver Health, were slammed. Denver Health had five gunshot victims, including the three teens, and all six of its operating rooms were full. It was diverting trauma patients to Swedish Medical Center in Englewood - but that was 20 miles south of DeWolfe's location on I-25.

Just before 11 p.m., DeWolfe dialed Lutheran Medical Center at 8300 W. 38th in Wheat Ridge, hoping for good news.

The move in 2001 by West Metro rescue to override divert policies infuriated many emergency room doctors.

"It was an incredibly dangerous and callous move," said Littleton Adventist's Dr. Eugene Eby, who also served as medical adviser to the Aurora Fire Department.

"It could have jeopardized a lot of patients. People would have been showing up when (emergency rooms) were crippled. What these guys were saying was, "We don't care about your protocols.' For everybody to go off and do their own thing is going to create chaos."

Five years earlier, Eby had founded the Metro Area Physicians Advisory Group to deal with issues of mutual interest to hospital emergency rooms. The doctors had tried without much success to improve patient access to emergency rooms and build cooperation among administrators, doctors and paramedics.

"I started this five years ago because I thought hospitals were acting irresponsible and self-serving," Eby said. "Irresponsible because they were putting pressure on the paramedic on the street and self-serving because they were going on divert without regard."

Early in 2001, the group created four geographical zones in the metro area and ruled that if all hospitals in a zone were diverting patients, patients would be dispersed among them until an emergency room opened up. The goal was to avoid long cross-town drives for ambulances.

But now West Metro had decided to disregard those rules. Other key fire districts, including Littleton, joined West Metro. The overtaxed system began to crumble.

As that revolt took shape, however, members of the physicians advisory group in May 2001 also heard powerful evidence that the system was deeply flawed.

They listened to a tape of DeWolfe's Cinco de Mayo ride.

They heard DeWolfe casting about for an emergency room.

They heard hospitals turn him down.

"Most of the docs aren't aware of what pre-hospital really deals with," said Dr. Art Kanowitz, medical adviser to Pridemark Paramedics, who played the tape.

Eby acknowledges that releasing the tape was "very important and helped us see the mistakes we were making."

The ambulance sped east on I-70, running Code Red, lights flashing, sirens wailing. Opp and DeWolfe had to decide: east to I-25 and south to Swedish or exit south on Wadsworth to Lutheran.

DeWolfe conferred with a Lutheran emergency room doctor, who told him the hospital had no neurosurgeon on duty. Around 11, the doctor offered to call around.

No time to wait. It was Swedish, a sure thing but half an hour away at best.

Opp swung left, and DeWolfe hung on.

Paramedics' refusal to divert got patients to emergency rooms more quickly but also caused havoc at hospitals. Patients now sat in waiting rooms or lay in beds wheeled into corridors until doctors could get to them. Sometimes that took hours.

"It's to the point where now it's OK to stack 'em like cordwood in the ER," Eby said. "Nobody is stretched as much as the emergency departments."

Littleton at times has had so many beds in hallways that it has had to label the rows A, B, C and so on.

"They've gotten into more letters of the alphabet lately," said Lt. Eric Sondeen, a Littleton paramedic. "I think they're up to H."

The problem, which persists to this day, wasn't only getting patients into the emergency room, it was getting them into a hospital bed after they were treated.

Inpatients at Swedish Medical Center sometimes take up emergency-room beds when they should be elsewhere.

"It reduces what you are able to offer," said Dr. Scott Branney, a Swedish emergency room doctor.

Karyn Kretzel, a supervisor at West Metro Fire Protection dispatch center, waited more than eight hours for a hospital bed when she broke her back in November.

She was initially taken to St. Anthony North but was transferred to St. Anthony Central four hours later so she could be treated by an orthopedic specialist. There she waited in the emergency room for an additional 41/2 hours until a specialist could look at her X-rays.

It was too familiar. On the job, Kretzel and other dispatchers would fight to get critical patients into emergency rooms clogged by patients who didn't need to be there.

"I'm saying, "Get me out of here,' " she said.

Dr. Mike Anderson, an emergency room physician at Porter and Littleton Adventist hospitals, said it's not uncommon for patients to get moved several times, from bed to bed and from hospital to hospital.

"A lot of people don't know about the citywide problem. It's a big eye opener" when they come to the ER, he said. "People who have a broken leg or broken wrist and need to be in the ER, they are going to have to wait."

Last June, Swedish added seven beds to its emergency room.

""We never felt the expansion," said Vicki Owens, the nurse who directs the Swedish emergency department.

As in other emergency rooms across Denver, Swedish doctors were spending hours on the phone, calling nearby hospitals, looking for beds for their patients. Nurses trained to treat emergencies were caring for patients who couldn't get into other floors of the hospital.

"It's burning out the ER staff," Owens said.

Regionally, "overcrowding got so bad it just reached a breaking point," said Honigman, the CU Hospital emergency room physician, who also serves as medical director of pre-hospital care for the state Health Department.

Finally, state officials took action.

Last fall, a council appointed by the governor to help oversee the emergency medical services system asked the health department's Rarey to craft legislation aimed at reducing hospital divert hours. The council also wanted emergency departments to publicly report each month on every divert and explain why it happened.

"These proposed rules got everybody's attention," Rarey said.

The ambulance was at the Mousetrap when DeWolfe's patient, still conscious, went into cardiac arrest a few minutes after 11.

DeWolfe started CPR.

Protocol at the time allowed paramedics to override a divert if a patient had a heart attack.

Five gunshot victims or not, Denver Health was getting a guy who had flat-lined.

Changes haven't come quickly or painlessly, and nobody claims all the problems are solved.

An Internet-based communication system put into place in June to allow paramedics, dispatchers and emergency room staffers citywide to instantly see which hospitals are diverting patients contributed to improvements, paramedics say. The system also created a database that can be analyzed and used to improve public safety.

Rather than let legislators dictate reforms, Denver-area hospital chief executives proposed their own set of divert rules. On Dec. 15, health-care and state officials adopted the changes.

Emergency rooms now can turn away ambulances only when all of the following conditions are met: two or more critical patients are already waiting in the emergency room for intensive care beds, no more staffers can be called in and the emergency room is out of beds.

Before, any one of the above conditions could have triggered a divert. Under the new rules, hospitals can no longer divert ambulances because intensive care units, operating rooms or psych wards are full or busy.

"There were times when people would be standing at the door of the hospital telling us, "You can't bring them in,' " said Daley of West Metro Fire. "Those days are gone."

Hospitals also are beginning to unclog emergency rooms by beefing up staffs, speeding up paperwork and other changes.

Hospital divert hours are now down dramatically across the metro area.

Two of the most sizable reductions in diverts occurred at Medical Center of Aurora, which dropped from a high of 80 hours in August 2001 to two in February, and Presbyterian/St. Luke's Hospital, which cut its divert hours from 80 in January 2001 to 27 in February.

"We've come up with a solution that's gotten us through the worst part of the winter," Honigman said. "We've begun to create a form of communication that is much better than we had before and that's allowed us to gather better data. We've finally realized that we have an interplay with other hospitals and with pre-hospital" caregivers.

DeWolfe and Opp pulled into Denver Health at 11:08 p.m. - 41 minutes after they got the call.

Before the sun came up, Bruce Bersell was dead.

His chances had never been good. When a bullet enters a person's head on one side and exits on the other, as with this patient, there is only a 1 percent chance of survival, said Moore of Denver Health.

But looking back, that night still frustrates DeWolfe.

"At the time, it didn't seem like it was something I should be doing

... talking on the phone," DeWolfe said at the Denver Health paramedics headquarters, where he now works.

"It's about just realizing you're an emergency room at a hospital and you need to take people. 'Cause I can't say, "I'm having lunch, hold on.' "

[hoolahan, ASN, RN]

THanks for posting this nightngale, I had no idea it was this bad out there for paramedics.

[NRSKarenRN, BSN, RN]

A wake-up call for many I'm sure.

We've had the same problem at the seven hospitals in my county. Now exacerbated by my health system closing one hospital due low usage--with ER that was 1 block from major interstate highway---but only had a 30 bed inpatient unit, sometimes with only 15 patients. Our flagship facility had closed two nursing units due to lack nurrrsing staff so they wanted to best utilize staff; ER opened 10 new beds for pickup in volume and only 10 min away from closed facility.

Telling our kids not to go into nursing is just shooting ourselves in the foot. Time to beef up mutual cooperation to solve area healthcare problems, working conditions and nuture students so there WILL BE SOMEONE to help.

Maybe days of FT nursing is too much to expect with today's acuity and 3 days/ week should be norm??

[nightingale, RN]

If you go to the URL, you will see a map of the city hospitals. At the end of the article is an area for your commentary.

B.

[Huganurse]

In my area One Large Hospital corporation came in and bought up as many hospitals and home care agencies as they could get thier hands on. Then one by one, they closed

[mattsmom81]

I believe this is a huge problem in many metroplex areas...it sure is here in the Dallas Fort Worth area.

It's time hospital administrators get some flack...for refusing to deal with the nursing shortage, for allowing money to be their prime focus, for supporting their own inflated salaries and not meeting the needs of the community.

I have reached the point though where as a critical care nurse I simply HAVE to say no or the ER would have my 12 bed unit full of critically ill patients with 2 nurses on duty and nobody else available....we can only do so much, IMO, and dangerous conditions can't be ignored. Seldom will a facility back a nurse up when something goes wrong due to negligence, and can your conscience really handle a patient dying on your watch only because you weren't able to care for him because you were dangerously short staffed?

Mine can't, and my Nurse Practice Act says I am responsible for safe care and must speak up if I cannot provide it for any reason....

The blame game has to stop....ER blames the floors (we should fill up our beds regardless of piss poor staffing because THEY have to). Paramedics blame hospital staff, ("They should never refuse patients because WE can't")

It's time the public knows who is REALLY accountable here, IMO.

[mattsmom81]

Oh, and I need to add: part of the reason we are always short of beds? Columbia HCA boought up several area hospitals then closed one down...it wasn't making enough money for them.

[whipping girl in 07, RN]

Columbia HCA boought up several area hospitals then closed one down...it wasn't making enough money for them.

Mattsmom,

Be careful using a particular corporation's name in your posts. You never know who might be reading it. My husband is a member of a saltwater reef BB and several of the members got sued by a certain company that they had bought supplies from and had been disatisfied with the service. When they complained about it on the BB, the owner of the company, rather than try to make things right, sued them for hurting their business. Now, if it had gone to court, it probably would have been thrown out. But the owner of the company had money and the guys from the BB really didn't, so they had to settle. I believe they each had to pay $5500 a piece, and there were 10 or 15 who were sued for defamation.

I love Allnurses.com, but anyone can join. Someone from HCA could be following this thread right now. I know I watch what I say and changed my profile just in case anyone I work with is watching. If I had been smart, I would not have used my name as my username (but I can never remember my log-in name on a website if I don't use my name! )

So be careful!