Sunday, November 05, 2000

Hospital diversions set record


Staff, facilities can't keep up

By Tim Bonfield
The Cincinnati Enquirer

        Greater Cincinnati's biggest hospitals are turning away life squads more than ever.

        In fact, an Enquirer analy sis reveals that September set a record for hospital diversions, even though the traditional peak of the winter flu season is months away.

        “It's a problem. We've seen more diversions so far this year than we did all of last year. We've had as many as four hospitals on diversion at the same time,” said Steve Ashbrock, chief of the Madeira-Indian Hill fire de partment.

        According to records obtained from the Greater Cincinnati Health Council, 14 hospitals have gone on diversion 209 times through September of this year. That's 50 percent more than all of 1999, with two busy months to go.

        Sometimes, hospitals turn away ambulances because a rush of patients swamps the emergency department. But now, diversions are increasing without clear links to a communitywide illness.

        No single factor fully explains the increase in diversions. Contributing factors include hospital financial struggles, a national nursing shortage, recent hospital closings, rising numbers of uninsured people, and an aging population demanding more health services.

        The bottom line: turning away life squads indicates hospitals lack the staff and facilities to keep up with everyday care. And that raises questions about whether years of cost-cutting at Tristate hospitals have finally cut too deep.

        “I haven't heard of anybody that has died because of a diversion, but let's not wait for that,” Chief Ashbrock said. “We need to re-evaluate bed capacity in Greater Cincinnati.”

        In addition to concern among paramedics, nurses have been saying for more than a year that conditions have never been more strained at many local hospitals.

        “Patients are waiting for hours and hours in the emergency rooms to get admitted to the floors,” said Annie Hamilton, a nurse who works in the medical intensive care unit at University Hospital.

        “We had a patient come in today (Thursday) at 9 (a.m.) after laying on a stretcher in the ER since 11 (p.m.),” she said. “Is this the way we want to run the hospitals that serve this community?”

        The ability to track diversions began in May 1998, when Hamilton County hospitals started using a countywide emergency communication system to notify local life squads that they could not accept any but the most unstable patients, such as a person receiving cardiopulmonary resuscitation, or one who has major burns or uncontrolled bleeding.

        The diversion records reflect data from 14 local hospitals, all but two in Hamilton County. Those records show:

        • Since May 1998, the hospitals have called 375 diversions, 209 this year.

        • Two of the three worst months on record occurred in August (40 diversions) and September (43 diversions), neither of which are considered heavy months for hospital demand.

        • The previous high months were January 2000 (42 diversions) and February 1999 (31 diversions), both part of flu season.

        The frequency of diversions varies from hospital to hospital. Some have gone years without calling a diversion. Others turn away ambulances weekly. The financial picture at Greater Cincinnati's three big hospital groups plays a role.

        The Health Alliance of Greater Cincinnati has suffered considera bly deeper financial troubles in the past two years than did the Tri- Health or Mercy Health Partners groups.

        But records show that the three Health Alliance hospitals in the reports have called more than twice as many diversions than hospitals in the other two groups — 166 among the Alliance hospitals versus 79 at TriHealth and 40 at Mercy.

        In addition to money issues, the geography of past hospital closings has played a role.

        The sharpest increases in diversions occurred at three central city hospitals within blocks of Jewish Hospital (closed in 1997) and Bethesda Oak (closed in February).

        Cincinnati's Pill Hill once had seven full-service adult hospitals within a few blocks of the University of Cincinnati. Two have closed: Jewish Hospital in 1997 and Bethesda Oak this year.

        University Hospital — the area's only Level I trauma center — turned away ambulances twice in 1999 but 32 times already this year (none involved trauma cases). Diversions at Christ Hospital jumped eight-fold from six in 1999 to 49 this year. At Good Samaritan, diversions tripled, from seven to 21.

        “The closing of Bethesda Oak in particular has had an impact on Christ Hospital,” said Susan Wietholter, vice president of patient services at Christ Hospital.

        “Our ER volume is up 16 percent, our OB volume is up 20 percent,” she said. “We're short on telemetry beds (equipped to monitor cardiac patients) every day.”

        “We are trying our very best not to go on diversion. But a lot of beds have closed in Cincinnati, the population is aging and we're see ing a lot of very sick patients,” Ms. Wietholter said.

        A few hospitals have been able to reduce their diversions. Although they still get swamped, an emergency department expansion has helped at Bethesda North in Montgomery. A decision to close a birthing center to make room for more medical-surgical beds has helped at Jewish Hospital in Kenwood.

        “We usually have enough staff in the (emergency department), but with all the (staff) vacancies in ICU, telemetry and general med-surge beds, we can't get people admitted to the house,” said Sher McClanahan, chief operating officer at Bethesda North.

        “People are spending much more time waiting in the ED. Do patients and families want that kind of setting? No,” Ms. McClanahan said. “Are patients still getting quality care? Yes.”

        To Chief Ashbrock, the diversion statistics are the “tip of the iceberg,” a sign that years of hospital cutbacks finally have gone too far.

        “I've come to the realization that the hospitals aren't the enemy in this issue. They may be a victim also,” Chief Ashbrock said.

        To attract more staff, hospitals have offered signing bonuses and other perks. But hospital executives say years of cost-cutting pressure from employers and the government have made them less able to respond to patient demands.

        Nurses say pay has failed for years to keep up with the increasing intensity of hospital nursing work.

        “Hospitals need to put a lot more effort into retaining people. They may get people in with a signing bonus, but too many are leaving after a year to go to the highest bidder,” Ms. Hamilton said.

        The impact of understaffed, overburdened hospitals may be most intense in months to come. Rising numbers of diversions have occurred even as public health officials worry about a national delay in providing flu vaccines.

        “It could be really bad if the flu season is bad,” Chief Ashbrock said.
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