ERCrisis:Nevada :" People dying "
" We're going to have extended ambulance response times,
people climbing the walls in waiting rooms and people dying, "
lvrj.com
Thursday, August 17, 2000
Emergency rooms in crisis
Valley health officials say because the capacity situation
is now critical, people are going to die.
By Joelle Babula
Las Vegas Review-Journal
Las Vegas emergency room patients will needlessly die this winter because
local hospitals -- now in their slow season -- already are at capacity, health
officials warned Wednesday.
A confirmed flu vaccine shortage and a delay in the shipment of doses will
further compound the dire situation.
In the valley, "We're going to have extended ambulance response times,
people climbing the walls in waiting rooms and people dying," said Dr. Rick
Henderson, director of the emergency department at St. Rose Dominican Hospital.
"The public is just not aware of the degree of crisis we will be facing this winter.
We are already at capacity, and it's going to go up by 15 percent."
The facilities advisory board to the Clark County Health District met
Wednesday morning to discuss the hospital divert situation and the backlog of
patients waiting their turns in emergency room chairs or on ambulance gurneys.
Members of the board, made up primarily of hospital administrators, also
expressed concern over the nationwide flu vaccine shortage, delaying the local
supply and forcing the rationing of the vaccine. Rather than receiving doses in
September as usual, the Health District will not get its supply until November.
"We have to anticipate that come October, we're going to take this from a
crisis situation to a state of emergency," said Brian Rogers, director of operations
for American Medical Response. "Calls will increase by 10 to 15 percent, and
we could have a potential disaster. "
American Medical Response ambulance service keeps track of divert and
super divert status for all area hospitals. When a hospital goes onto divert status,
it means the emergency room is full and the hospital can no longer safely take care
of any more patients. Patients are then routed to other facilities.
When all hospitals are on divert status, they each rotate accepting patients
unless they are upgraded to super divert. When in super divert status, hospitals get
a one-hour break from receiving new patients.
"Right now, all of the hospitals have remained on divert status for the last
month. Every hospital in this valley is totally full, and we're not even in the busy
season," Rogers said. "Two weeks ago, I thought every hospital would be on
super divert. They were begging me, `Please don't bring anymore patients, it's not
safe anymore.' "
Hospital officials at the meeting agreed.
"We have no equipment, we have no space and we don't know where to go"
with emergency room patients, said Helen Vos, vice president of patient services
at MountainView Hospital. "It's a tremendous concern."
When hospital emergency rooms are full, patients transported by paramedics
wait on ambulance gurneys, tying up vehicles that otherwise could respond to
other emergency calls.
"Not only can the hospitals not take you, but you're not going to get an
ambulance either because we're sitting at the hospital," said Sandy Young, the
quality improvement nurse for Las Vegas Fire and Rescue. "This has never
impacted the pre-hospital transport community like it is now."
According to Rogers, as ambulances are forced to wait at crowded hospitals,
response times to other calls increase. Currently, American Medical Response
must respond within eight minutes and 59 seconds 90 percent of the time.
"We pay lots of fines when we don't make it, and we can't make it because
we're tied up at the hospital," Rogers said. "Last month, we paid $10,000 in
fines."
Henderson fears ambulance response time will increase to a dangerous level.
"At any given time, if half our ambulances are sitting in hospitals, people will
die because of this. We cannot meet our need for hospital beds with ambulance
gurneys," he said. "I feel a sense of dread for the community that they have an
expectation we cannot meet."
Walk-in emergency room patients often have to wait even longer for medical
attention than those brought in by ambulance. "Patients in the ER get so fed up
waiting they call 9-1-1 from the hospital," Rogers said.
Las Vegas Fire and Rescue is investigating an allegation that last week two
cardiac patients, frustrated with the excessive waiting time in two separate
emergency rooms, gave up and went home only to die, said Deputy Chief Ken
Riddle.
Late Wednesday morning at University Medical Center, James Griebe was
waiting for news of his mother-in-law, who was admitted for chest pains at 2
a.m., six hours after arriving at the emergency room.
"We got here at 8 p.m. and a doctor didn't see her until 2 a.m.," Griebe said.
"She almost went home, but she was in pain and was scared."
Claudia Martinez, also waiting at the medical center, said she'll never go
back.
"I was waiting over two hours for them to see my daughter with bad stomach
pains," Martinez said. "They finally took her blood pressure, saw it was low and
got worried and took her away. They call you right away for the bill, but not for
taking care of your health."
Patients in the emergency room at Valley Hospital also were frustrated on
Wednesday morning.
"If I was dying, I'd be dead by now," said Jay Coleman, who had been waiting
for three hours. "I had an anxiety attack and couldn't breathe and was numb all
over."
Officials know patients are disgusted, but have no answers.
The usual nostrum to add more beds will not remedy a system plagued by a
severe nursing shortage. According to a recent study, there is a need for more than
500 registered nurses in Clark County.
Although more beds may alleviate some of the pressure, currently there are
empty beds and simply not enough available nurses to staff them, said Karla
Perez, director of Desert Springs Hospital and chairman of the facilities board.
Suggested solutions include launching an intensive nationwide search for
nurses as well as offering greater employment benefits, and making the road to
becoming a registered nurse easier for licensed practical nurses and certified
nursing assistants.
Some also mentioned educating the community about when to use emergency
medical services and when instead to see a family physician or visit an urgent
care facility.
"Give a primary doctor a call, that's the first thing," said Dr. Donald Kwalick,
chief health officer for the Health District. "Even before something happens, make
sure you have all the resources in place so you can see a primary care doctor first
and not have to take emergency room transport."
Although no immediate solutions were implemented, the board decided to
create two task forces, one to focus on the nursing shortage and the other to
concentrate on the divert issue. The two groups should mobilize within the next
two weeks.
====================
This article toohttp://www.lvrj.com/lvrj_home/2000/Sep-21-Thu-2000/news/14435882.html
Thursday, September 21, 2000
Copyright © Las Vegas Review-Journal
EMERGENCY ROOMS: Experts pose changes for LV hospitals
Report by experts recommends routing certain patients
By JOELLE BABULA
REVIEW-JOURNAL
A Las Vegas paramedic can't get to the 911 call because his ambulance is stuck at the emergency room.
His ambulance is stuck at the emergency room because there is no bed for his patient.
A bed is empty, but there isn't enough staff to attend to the patient.
When there isn't enough staff, a patient waits -- and health care can be compromised.
To combat the valley's multifaceted emergency room crisis, paramedics must be allowed to route nonemergency patients to urgent care centers, and hospitals must use medical professionals other than registered nurses in emergency departments, a team of emergency medical experts said in a report released Wednesday. The report recommended those changes and others be made within the next 30 days.
But local health care officials say they aren't sure which agencies can make the changes, and they fear it will be impossible to alter the overburdened system in time for the winter flu season.
Trace Skeen, the chief executive officer of American Medical Response, said if changes don't happen soon, he fears a larger emergency room crisis as the flu season starts.
"I'm very, very concerned. If we stalemate and people get distracted by other issues, we'll have a very tough time this winter," he said. "If we go through the next 30 days and there's no movement, I don't know what we'll do. In a crisis situation, unfortunately what happens is it rises to the next level, and maybe government will get involved or the state can provide relief."
According to several valley health officials, making changes to the system in 30 days is hopeless.
"We don't have the power to adopt regulations," said Karla Perez, chairman of the Clark County Health District's facilities advisory board and director of Desert Springs Hospital. "We can make recommendations to make changes to the EMS (Emergency Medical System) ... but if it's a board of health regulation, it goes to them. If it's a state regulation, it goes to the Legislature."
Some of the report's proposed solutions include providing more flexibility for nursing staff in emergency rooms; allowing paramedics to route nonemergency patients to advice nurses or urgent care facilities; keeping drunks and the mentally ill out of emergency departments when there is not a medical crisis; and developing a uniform divert policy for all valley hospitals.
When a hospital goes on divert status, it means there are no empty beds available to care for more patients. Hospitals on divert status still receive ambulance patients, but they enter a rotation with other hospitals also on divert rather than receive a steady stream of patients.
"It's a very solvable problem for Las Vegas," said Mike Williams, president of the Abaris Group, an independent consulting firm from Northern California specializing in emergency medical systems. Williams and his team, hired by American Medical Response to evaluate the Las Vegas Valley, work with hospitals across the country to improve emergency medical services. Williams called the local emergency room crisis one of the worst in the nation.
To implement some of the proposed changes, Williams said a new local entity must be formed.
"Part of the difficulty in the Las Vegas market is that different people have control over different pieces," Williams said. "Most other communities have a central authority to respond to these kinds of issues."
According to Jane Shunney, program manager for emergency medical services for the Health District, some proposed changes would have to go through the Clark County District Board of Health, while others may have to go before the county's medical advisory and facilities advisory boards.
Williams recommends a committee be formed as quickly as possible to bring change and make recommendations to the appropriate authorities.
In the next 30 days, Williams said the new committee should change the ambulance policy and allow paramedics to route some 911 patients to an advice line or urgent care facility instead of the emergency room.
"We can figure out over the phone if a person even needs an ambulance," Williams said. "Certainly, if there's any question whatsoever, send an ambulance, but the idea is to keep the ambulance available for true emergencies."
Skeen said local ambulance services can follow the precedent set by other communities across the country, which already route patients away from emergency rooms.
"One of the perceptions from the public is that 911 is absolute fail-safe. They can call and end up in the hands of a caregiver, but it's not always the right caregiver," Skeen said. "We're not doing patients any favors by putting them into an environment that's overkill. People think the ER experience is one to two hours, but it usually ends up being eight to nine."
Besides altering ambulance service protocol, Williams also suggested expanding the capabilities of nursing staff in local emergency rooms. He said unlike most communities, Las Vegas emergency room nursing staff consist mostly of registered nurses, and that other nursing professionals and paramedics are rarely if ever used.
"A paramedic could do blood pressure and check for vitals," Williams said. "This would help with the RN staffing issue."
According to Perez, Shunney, and other health professionals, registered nurses make up the majority of the nursing staffs at local emergency rooms. At University Medical Center, 80 percent of the nurses are registered nurses, said spokesman Rick Plummer.
"Paramedics are prohibited from working in an ER," Perez said. "Once the patient hits the door, it becomes a hospital patient and they can no longer assist in providing care. We certainly see that paramedics play a very valuable role in the ER, and we are attempting to expand the role of the caregivers."
Another issue in the emergency room crisis is whether hospitals are efficiently routing patients through their facilities. Las Vegas hospitals average 1,200 patients per emergency room bed per year, but the national benchmark is 1,500 to 2,500 patients per year, Williams said.
"It's not that hospitals are doing a bad job, but this tells us up front they could better utilize those beds," he said. "Oftentimes they don't even know something is wrong or that there is an opportunity to improve things."
Williams recommends an independent review of each hospital to pinpoint bottleneck areas and make necessary changes.
Local medical professionals said they will review the proposed solutions and develop a committee to spearhead change in the next few weeks.HOW TO FIX IT
Potential solutions to the valley's emergency room crisis:
• Change the 911 system to allow nonemergency patients to be routed to advice nurses or urgent-care centers.
• Develop, monitor and enforce a uniform divert policy that makes all hospitals operate under the same guidelines and definitions.
• Change state law to allow more flexibility for nursing staff and paramedics in emergency rooms, such as allowing paramedics to take blood pressure and vital signs and transport patients within the hospital.
• Assemble a committee of local medical professionals to develop a plan of action and make recommendations for change.
• Assemble a bottleneck inspection team to conduct an independent review of each hospital to identify opportunities to improve patient flow and capacity. |
