Hospitals seek ways to keep ER doors open

Some forced to turn away ambulances

‘‘We had to look at the flow of emergency department patients, and pinpoint where the bottlenecks were,” said Dr. Drew White, chairman and medical director of emergency medicine at Washington Adventist.

New processes included bedside triage — using one room rather than several to give a patient the requisite tests before seeing a physician — increasing staffing or shifting staffing patterns, and clearing beds in the hospital as quickly as possible.

Emergency departments under diversion, no matter how busy they are, remain open to walk-ins and ambulances transporting patients with life-threatening conditions, such as heart attacks.

Ambulance diversion is unique to each hospital and region, said Jim Alexander, technical director for the Washington, D.C., office of the Healthcare Financial Management Association, a membership group for hospital executives. Only the hospitals and regional health care agencies know ‘‘how far they should consider going” before taking steps to reduce diversion.

Of the 46 hospital emergency departments in the state, only three had no red or yellow alerts in 2007, according to a study released last September by the Maryland Health Care Commission. Yellow alerts mean a hospital’s emergency department is closed to incoming ambulances, and red alerts mean a hospital does not have open beds with heart monitors. During yellow and red alerts, hospitals are forced to divert ambulances until the situation improves.

‘‘In addition to the direct impact these alerts have on the patients, full and overcrowded [emergency departments] also mean that the ambulance and the medic crews stay at the hospital, and out of service, longer,” said Darian Unger, a volunteer firefighter with the Silver Spring Fire Department and Montgomery County Fire and Rescue Service.

Dr. James Del Vecchio, the medical director of the department of emergency medicine at Holy Cross, said a low number of yellow alert hours at Holy Cross was the result of the hospital’s ‘‘serious commitment to avoid it,” he said, by getting patients admitted more quickly from the emergency department and staffing physicians in triage.

But while yellow alerts were more significant to patients who may need to be driven to hospitals farther from their homes and local physicians, ‘‘red diversion” had a more significant effect on a hospital’s emergency department, Del Vecchio said. Holy Cross has had 131 hours on red alert this month so far.

‘‘When a hospital’s at 100 percent occupancy, you can’t really blame the hospital,” Del Vecchio said. ‘‘You can’t just open beds.”

Pamela Barclay, the director of the Center for Hospital Services with the Maryland Health Care Commission, said the agency was ‘‘absolutely concerned” by the increases in emergency department visits. In a report issued by the commission in 2006, increases in visits to Maryland emergency departments, which were described in the report as ‘‘the canary in the coal mine” for the health care system, or an early warning of system dysfunction, had surpassed the U.S. average.

The emergency department at Holy Cross has had a 15 percent increase in patient volume over the last year, with an average of 45 ambulances coming through each day, Del Vecchio said.

At the same time, hospital officials say there has been an increased reliance on emergency rooms for primary care, as evidenced by spikes in the winter months during flu season.

For patients visiting emergency departments with minor injuries or colds, satellite centers give them new options.

Washington Adventist President Jere Stocks said initiatives like the Mary’s Center clinic and Mobile Med units have significantly reduced the amount of ambulance diversion from his facility to its closest neighbors, Holy Cross and Suburban Hospital in Bethesda.

At a recent meeting of the Silver Spring Citizens Advisory Board, Eileen Cahill, vice president of government and community relations at Holy Cross, said her hospital plans to open a clinic in Gaithersburg and another in Wheaton to supplement an existing clinic in south Silver Spring in order to reduce the stress on the waiting room.

At the same meeting, Cahill went over the potential effects of Washington Adventist’s plans to move out of Takoma Park and into the White Oak⁄Calverton area of Silver Spring, particularly the potential for even more local patients to come to Holy Cross instead of traveling farther away to the new site.

‘‘It doesn’t do good to take one hospital out of the mix and paralyze another hospital,” she said at the meeting.

Del Vecchio said while Holy Cross was prepared to meet a slight increase in patients, a large influx seeking emergency services would not be handled easily, especially if Washington Adventist did not leave an urgent care center on its current site.

Stocks said Washington Adventist intends to leave some form of health care on the Takoma Park site, and said that every hospital needed to be concerned about the efficiency of emergency departments.

When the emergency room closes

The following is a list of the number of hours of red or yellow alerts that led to ambulance diversions from a sampling of area hospitals from May 1 until Tuesday morning, May 20. Yellow alerts mean a hospital’s emergency department is closed to incoming ambulances, and red alerts mean a hospital does not have open beds with heart monitors.

Calvert Memorial Hospital, Prince Frederick – 9 yellow; 111 red

Children’s National Medical Center, Washington, D.C. – 0 yellow; 0 red

Doctors Community Hospital, Lanham – 182 yellow; 241 red

Holy Cross Hospital, Silver Spring – 0 yellow; 131 red

Laurel Regional Medical Center, Laurel – 6 yellow; 0 red

Washington Hospital Center, Washington, D.C. – 114 yellow; 114 red

Montgomery General Hospital, Olney – 24 yellow; 14 red

Prince George’s Hospital Center, Cheverly – 201 yellow; 200 red

Shady Grove Adventist Hospital, Rockville – 8 yellow; 5 red

Suburban Hospital, Bethesda – 6 yellow; 4 red

Washington Adventist Hospital, Takoma Park – 24 yellow; 0 red

Source: Maryland Institute for Emergency Medical Services Systems