By Kimberly Vetter
The Advocate
Copyright 2007 Capital City Press
All Rights Reserved
NEW ORLEANS — People who call 911 in a medical emergency sometimes turn down an ambulance ride when they find out they won’t be taken to the hospital of their choice because of crowding.
“Some people get pretty upset when we are put in the position of refusing to take them where they want to go,” said Tommy Loyacono, chief of operations for East Baton Rouge Parish Emergency Medical Services. “Some have even refused transport when we felt it was not in their best interest to do so.”
In July, 1,099 people in the parish refused treatment for various reasons, including hospital choice, Loyacono said. That’s almost a quarter of the 4,639 people EMS responded to that month.
This is a result of the emergency practice known as “divert.” Once a safety valve to be used only in extreme situations, diverting ambulances from a crowded hospital to a less crowded medical facility has become common, creating a tense situation for both patients and hospital emergency department personnel.
But local hospitals are trying to ease the tension by relying on the practice less often.
Emergency department directors met in August with representatives from EMS and Acadian Ambulance Service Inc. and adopted a no-divert policy after a two-month trial period.
The policy limits a hospital’s right to divert to situations such as mass casualties or when a patient requires a certain service only offered at a specific facility.
“ED (emergency department) saturation is not an acceptable reason for diversion,” Loyacono wrote in a letter to his EMS staff.
EMS, which is governed by the Metro Council, is responsible for treating patients’ emergency medical needs and transporting them to appropriate emergency medical facilities within the parish.
Acadian, a privately owned medical transportation service, is available to help EMS and responds to emergency calls at nursing homes and rehabilitation facilities in the parish. Acadian also handles non-emergency transports.
Hospital emergency department directors said they divert patients to other hospitals when they think they can’t see any more people.
Dr. Jim Rhorer, medical director of emergency services for Our Lady of the Lake Regional Medical Center, said he frequently diverted patients after Hurricane Katrina.
“After Katrina, we became aware of how many patients didn’t have primary health care,” he said. “Health care in the area became strained.”
Dr. Michael Cuba, director of the emergency medicine department at Oschner Medical Center, said some people have waited days in the emergency department for an open bed.
Before the new policy, the rate of hospitals on divert was so high, Loyacono said, he heard of ambulance companies hiring people to baby-sit patients in emergency waiting rooms until they were admitted.
This past Mardi Gras in New Orleans, for example, paramedics from across the state got paid $45 an hour to stand in emergency rooms with patients, he said.
“This is a huge problem everywhere,” Loyacono said.
Diverting ambulances from one hospital to another began more than a decade ago with the Emergency Medical Treatment and Active Labor Act of 1986, Loyacono said.
The federal law prevents hospitals from refusing to treat uninsured patients, requiring them to examine everyone and stabilize or transfer them as needed. As a result of the law, emergency rooms became more crowded.
To avoid catastrophic delays in treatment of seriously ill or injured patients, the Metro Council approved an ordinance in the 1990s that provides general guidelines for the transport of patients by EMS.
The guidelines give paramedics the right to take a patient to the closest appropriate hospital under certain conditions, despite a hospital’s diversionary status.
Some of these conditions include “when a patient is being transported in a state of clinical death” and “when a patient requests transport to a hospital which cannot provide emergency stabilization and/or definitive care for the patient’s condition.”
Porter Taylor, operations manager for Acadian’s Baton Rouge area, said his company’s policy has always been to honor a patient’s request.
The only time Acadian paramedics wouldn’t take a patient to the hospital of his choice is if his condition demanded he be taken elsewhere, Taylor said.
Snowball effect
Initially, Loyacono said, diversion worked. But as the years went by, the situation began to change and more hospitals were on divert more often.
“We’ve had several situations where all were on divert,” he said of Baton Rouge hospitals. “If all are on divert, no one is, which defeats the purpose.”
Dr. Will Freeman, emergency department director at LSU Earl K. Long Medical Center, agreed.
“When you go on divert you not only affect your hospital but all hospitals in your community, creating a snowball effect.”
And that snowball, he said, eventually rolls down to people seeking emergency care.
Freeman, who started at Earl K. Long in March, saw a successful no-divert policy at University Medical Center in Lafayette, where he previously worked for two years in the emergency department.
When a hospital can go on divert only when there is a true catastrophe, Freeman said, “it makes you focus on yourself; it forces hospitals to look at their own processes.”
Dr. John Jones, assistant medical director of Baton Rouge General’s emergency departments at Bluebonnet and Mid City campuses, agreed and said, “It’s not the emergency medical services system that needs to improve, it’s the hospitals.”
Several hospitals are making internal changes or planning to make changes to move people through their emergency departments more efficiently.
Baton Rouge General-Bluebonnet recently opened a new emergency department, doubling its capacity. The new department features 21 private patient rooms, triage areas and trauma rooms.
Julie Madere, director of marketing and community relations for Lane Regional Medical Center in Zachary, said the hospital is about to open a walk-in clinic for patients who need nonemergency treatment. The hospital also is preparing to start bedside registration, which will speed treatment.
Cuba said he sets aside beds in the Oschner emergency department between 3 p.m. and midnight for patients with minor injuries. He also is changing the department’s triage and registration process to get patients in a bed sooner.
“When we are overcrowded, we have to start thinking of ways to deal with the surge,” he said.
Rhorer agreed and said finding the answer is “a work in progress.”
So far so good
The no-divert trial period, between mid-June and mid-August, either has proven successful or given people hope that it could improve things in the future, hospital and ambulance service providers say.
During the trial, Taylor said, his paramedics’ wait times with patients before they were admitted to a hospital hadn’t been so long.
“It’s worked out very well,” he said, complimenting EMS and the hospitals’ efforts. “It’s a team approach to doing what’s best for patients in East Baton Rouge Parish and its surrounding areas.”
From an EMS perspective, Loyacono said, it still takes a while to get a patient admitted into the hospital.
Ideally, Loyacono said, he would like to see paramedics have their patients seen within 15 minutes of arrival 90 percent of the time. Ultimately, he would like to see his people walk in and walk out.
Everyone would like to see that, Rhorer said.
“It’s not our desire to have prehospital care in our hallway,” he said. “We want them on the road.”