By Mary Ann Roser
The Austin American-Statesman
Patients from around Texas and even other states are increasingly being sent to Austin for emergency medical care, which officials at the largest hospital system in Central Texas say can put some lives at risk and strain a shrinking number of specialists willing to treat people at local hospitals.
In the past year, six Seton hospitals received 517 patients from outside their service areas, according to data from the Seton Family of Hospitals. Dell Children’s Medical Center serves 46 counties, while other Seton facilities, including University Medical Center at Brackenridge, the region’s only trauma center, serve an 11-county area.
In general, the patients transferred into Austin are either critically injured or seriously ill from a stroke or other medical condition, said Dr. Christopher Ziebell, University Medical Center’s chief of emergency medicine and president of Seton’s medical staff.
The number of transfer patients coming to University Medical Center and other Seton hospitals jumped 61 percent, from an average of 33 per month from June through November 2007 to an average of 53 per month from December through May. They are coming from as far away as Abilene and Lubbock but also from Dallas, Houston and San Antonio — larger cities that have multiple trauma centers.
A few years ago, Austin sent some patients who needed emergency brain surgery to San Antonio and Temple hospitals because of a lack of neurosurgeons on call, but Austin’s hospitals have since added neurosurgeons. Ziebell said few transfer out now. Seton transferred eight patients in the past year to hospitals out of the area: One went to a burn unit in Galveston; one went to the University of Texas M.D. Anderson Cancer Center in Houston for specialized leukemia care; three needed organ transplants they could not get in Austin; and three asked to be transferred back to hospitals in their hometowns for surgery, he said.
As more and more seriously ill or injured patients come from other parts of the state, specialists become increasingly unwilling to be on call for local hospitals, Ziebell wrote in an e-mail. “So, if Austin-based neurosurgeons are forced to provide care for an increasing number of patients from well outside of Austin, they are likely to reach a point where they will say, ‘Forget it; I’m just not going to take call anymore.’ ”
He said he didn’t have statistics showing how many doctors have stopped being on call but said that as head of the ER, he has more holes to fill on the call schedule.
San Antonio, which has three trauma centers, sent 37 patients to Austin between January 2007 (when Seton started collecting data) and April 2008. And the Alamo City’s trauma centers turned away patients from surrounding communities who also went to Austin. San Antonio officials said one factor leading to those transfers was the deployment of doctors to Iraq from two military hospitals with trauma centers.
Full hospital beds and a lack of available specialists are typically cited when hospitals send patients to Austin, Ziebell said.
When a small community hospital gets a case it can’t handle, its staffers start looking for the nearest specialist. If the closest trauma center says it’s full, they turn to Austin or other more distant cities.
Statewide, fewer specialists are willing to be on call for emergencies after hours, especially in such areas as neurosurgery, orthopedics, plastic surgery, ophthalmology and other fields, doctors in Texas said. That means that some hospitals pay certain doctors just to be on call — something that doctors a generation ago did as a community service.
Many expect the problem to worsen as a doctor shortage deepens, more surgeons leave traditional hospital settings and new doctors don’t feel obligated to be on call.
“This has been an issue that has been brewing for the last three years ... and the scale of the problem is huge,” said Dr. Ed Racht, medical director of Austin-Travis County Emergency Medical Services and chairman of the Governor’s EMS and Trauma Advisory Council. “It really became apparent in the (Rio Grande) Valley first. The Valley was sending patients who needed neurosurgeons to San Antonio because they had no neurosurgical coverage. It shifts the financial responsibility for care from one area to another.”
The law requires care
As a trauma center, University Medical Center receives the most critically injured patients and must have specialists on call 24 hours a day. And hospitals can’t turn down requests from hospitals that say they can’t care for a patient.
“Federal law says if a hospital declares an emergency and if we have the specialists and the capacity to care for that patient, we have to do it,” Ziebell said. “It’s hard to believe that out of two Level I trauma centers in Houston, that not one of them can provide care for one of their citizens.” Houston sent five patients to Austin during the 16-month period Seton analyzed, as did cities in Houston’s trauma region, such as Columbus, which sent 36.
Officials at other Texas trauma centers say they’re also facing more transfers.
Scott & White, which operates a trauma center in Temple, said in a written statement that the transfers it accepts from inside and outside of its region have “grown in double digits,” according to Dr. Stephen Sibbitt, associate chief medical officer.
“Scott & White, over a similar period of time, accepted more than 1,500 transfers from Killeen,” Sibbitt wrote.
Killeen, however, is part of the Scott & White trauma region; 52 patients from Killeen and 10 patients from Temple were transferred to Austin from January 2007 through April of this year, Seton said.
Sibbitt said Scott & White may transfer patients to Austin because the patient requested it or because its trauma center was full.
Ziebell said transfer patients have a higher mortality rate at Seton hospitals than other patients. He said 4.6 percent of the out-of-area transfer patients died at Seton hospitals within a week, compared with 1.5 percent of the regular patients who had been hospitalized for a week. He said though the transfer patients could have been more critical, he thinks travel time was the main factor.
In recent years, more doctors have invested in surgical hospitals where they can set their own hours and not worry about treating emergency room patients who can’t pay and could be more likely to sue, said Dr. Bruce Moskow, president of Emergency Service Partners, which provides the physicians who staff the ERs for Seton and about 20 other Texas hospitals. For those doctor-investors, stopping hospital work also means no longer getting called in the middle of the night to come to the ER.
Dr. Dan Peterson, a neurosurgeon at University Medical Center, is on the hospital’s on-call schedule 12 nights a month — six times as the primary surgeon and six times as the backup. He said he almost always gets called in when he’s the main neurosurgeon to do surgery or evaluate a patient with a head injury, aneurysm or brain tumor. Sometimes, he has to cancel his clinic work and elective surgeries the next day because he’s still dealing with the on-call load, he said.
The increase in transfer patients is “extremely frustrating,” Peterson said.
As an incentive to the doctors to take emergency calls, Seton is paying some specialists as much as $5,000 a night to be on the call roster, even if they don’t have to come in, Ziebell said.
“The patients of Austin are paying for that,” he said, noting that people pay through escalating health care costs, including higher health insurance premiums.
St. David’s HealthCare is paying for on-call specialists, too, but Dr. Steve Berkowitz, the chief medical officer, declined to say how much. St. David’s, which doesn’t have a regional trauma center but receives transfer patients at its hospitals, said it has also seen an increase in transfers but did not have data. “I don’t believe these transfers in are having any substantial effect on our system,” Berkowitz said.
Doctors turn away
In San Antonio, many neurosurgeons have stopped taking hospital calls, so the hospitals are sending stroke patients to Austin and other cities for treatment, said Suzanne Hildebrand, 61, who founded the Mothers Against Drunk Driving chapter in Texas in 1981. After her husband suffered a stroke April 16, she joined a committee that is trying to get a stroke center established in San Antonio.
More than seven hours after Ray Hildebrand, 68, collapsed at his job at the San Antonio district attorney’s office, where he worked as a criminal investigator, hospitals in the city said no doctor was available to treat him, Suzanne Hildebrand said. He was flown to Austin for treatment and was in a coma for several days, she said.
“We’re talking 7½ damn hours of basically holding him while (San Antonio hospitals) made phone calls,” she said. The hemorrhage in his brain “was inoperable by the time he got” to Austin. Her husband’s recovery has been slow, but he is regaining some speech and movement, she said.
Ziebell said none of San Antonio’s hospitals — including its three trauma centers — have obtained voluntary national certification to provide care to stroke patients. Four Austin hospitals have that certification, which means they can provide certain drugs and therapies in a coordinated way to stroke victims.
Dr. Ronald Stewart, a critical care surgeon and chairman of the Southwest Texas Regional Advisory Council on trauma issues, wrote to colleagues in a May e-mail that it was “unacceptable” that after a year of discussion, no San Antonio hospitals had obtained the certification “even though the stroke center requirements represent only the minimal standards required for stroke care.” Leni Kirkman, a spokeswoman for University Hospital, a trauma center in San Antonio, said hospitals can treat stroke patients without being certified — Kirkman said hers has doctors who do — but University’s beds are often full.
“It’s unconscionable to think we have so many resources in our community and we haven’t got this worked out,” Kirkman said.
Eric Epley, the executive director of the advisory council that Stewart belongs to, said doctors and hospitals officials in San Antonio are “working feverishly on trying to establish stroke centers and a regional stroke system.
“It’s unacceptable that the large urban centers are sending patients to other large urban centers,” Epley said. “The best thing for patients in San Antonio would be to stay in San Antonio, and the best thing for Austin patients is to stay in Austin.”
Ultimately, lawmakers may need to solve the problem, perhaps by establishing when patients can be transferred and requiring doctors to take emergency hospital calls in order to get hospital privileges, said Racht, the trauma advisory committee chairman.
Copyright 2008, The Austin American-Statesman