Flatlined

Emergency Services Failure

A Personal Story

One hot Saturday afternoon in the summer of 1999 I was on neurosurgery call at Memorial Hermann Hospital in Houston, Texas, one of the largest trauma centers in the United States. Houston is the fourth largest city in the country and its metropolitan area is home to five million people. The page operator connected me with an emergency room doctor in the little town of Lake Jackson, fifty miles south of Houston, and we began a routine conversation for a busy on-call weekend.

“Dr. Clifton, I have a forty-year-old woman who has a brain hemorrhage. The car she was driving struck a tree. She is unconscious but moving everything. Can I send her to you?”

“We’ll send the helicopter to get her,” I responded. “Is she intubated?” Intubation is a procedure in which a tube is put into the airway to control breathing and is standard practice in an unconscious patient.

“Yes, I intubated her and gave her mannitol as well.” Mannitol is a sugar solution that extracts water from the brain and decreases brain pressure for a little while until surgery can be performed to evacuate the blood clot. The doctor in Lake Jackson was competent.

Conversations at the hospital between two doctors about a transfer are always recorded and silently monitored by a nurse in the transfer center. The recorded conversation provides proof of compliance with federal law that governs the transfer of patients between hospitals. “Dr. Clifton,” the transfer center broke in, “We do not have any ICU beds. We are on diversion.”

These were not words I had heard before and my instant response was a question. “What do you mean we don’t have any ICU beds?”

“Dr. Clifton, we are full.”

After a moment’s thought I said, “Let me go through the unit; I am sure I can move someone out…Doc, I will call you back.”

Diversion is a term used when a hospital’s emergency room turns away ambulances because either the ER or the hospital is full and cannot accept any more patients. Diversion was a new word for me.

Memorial Hermann Hospital’s Neuroscience Intensive Care Unit (ICU) has twenty-eight beds and is one of the largest of its sort in the country. Memorial Hermann is the hospital in the region that has always cared for the worst neurosurgical emergencies any time every day, flying them over the city’s clogged streets by helicopter. The hospital’s ICU is the city’s core resource for emergencies of the brain and spine.

The charge nurse and I walked past one patient after another--ventilators pumping, heads wrapped, oxygen hissing, tubes coming from natural body openings and from openings we had made.

“Can this one be moved to the regular ward?”

“No, Dr. Clifton--too unstable.”

“What about this one?”

“No, she just had surgery.”

In every bed were patients too sick to move. I had been Chief of the Neurosurgery Service at Memorial Hermann Hospital for ten years, and this was the first time I had ever turned down a patient for lack of a bed. I thought this was strange.

I redialed the doctor in Lake Jackson. “Doctor, I went through our ICU and I can’t move anyone. I don’t have any place to put the patient.” I could feel his anger through the phone.

“Dr. Clifton, I have been turned down by three other hospitals--I cannot find a bed. What am I going to do? This lady needs surgery and she needs it soon!”

I gave him the name of two other nearby large hospitals with neurosurgeons. “I am sure they will help.”

He curtly responded, “OK, I hope she lasts.”

Several weeks later I was talking to Dr. Greg Bonnen, a neurosurgeon who practiced at The University of Texas Medical Branch in Galveston (UTMB) near Lake Jackson. “Greg, is UTMB turning away transfers?”

“Yeh, all the time now. I operated on a lady a few weeks ago, ten hours after she was injured. You would not believe what they did to get her in.” Greg told how the patient’s doctor in Lake Jackson could not find a neurosurgeon-staffed hospital with an available bed. He reasoned that if a call was made to one of the big hospitals from the scene of an accident rather than from his emergency room, then the hospital would fly a helicopter for a pick-up even though they were full. No hospital would leave a patient dying at the roadside.

Greg Bonnen told me that the emergency room doctor had put the patient in an ambulance and sent the ambulance to the tiny local airport. At the airport, the ambulance crew called UTMB hospital saying they were at the scene of an accident with a patient and could a helicopter be sent right away? At that time UTMB’s policy was to always accept a patient from the scene of an accident, regardless of the availability of beds. The helicopter flew and the patient was retrieved.

I asked Greg, “So what happened?”

“She herniated before she got there. She ended up vegetative state in a nursing home—left three children at home. It was pretty sad.”

How Did this Happen?

As resident physicians in the late 1970s training in a public hospital we became furious at groups of neurosurgeons in two Texas towns who would call us to refer patients with problems that they said were too complicated to manage in their hospitals. Hours later we would go down to the emergency room to receive some poor soul who was often medically unstable and had been transferred at his peril only because he lacked health insurance and could not pay.

These abuses became so outrageous and widespread that the media took notice and alerted a public that recoiled at the practices. A woman in active labor whose fetus did not have enough oxygen was dismissed from the emergency room of a private hospital and told to go to a county hospital across town where her baby died because of the delay in care. An injured patient bled to death after the emergency room of a private hospital transferred him in shock with low blood pressured to a county hospital only because he was uninsured. These were not isolated stories. (1)

This “dumping” of uninsured patients was a widespread practice prior to the Emergency Medical Treatment and Active Labor Act (EMTALA) signed into law in 1986. You won’t find the term “dumping” in any medical text. It is the practice of transferring uninsured and indigent patients from one hospital to another for no other reason than that they are uninsured.

EMTALA ended these practices by forbidding even inquiring about insurance in an emergency situation and by prohibiting hospitals and doctors from refusing emergency care to anyone at all. In a properly cared for emergency, no one has time to ask about insurance, and the information is often not available anyway. We all look alike injured, undressed, and covered in blood.

EMTALA has two qualifiers that relieve the doctor and the hospital of responsibility for emergency care. Hospitals are only required to accept patients who have an emergency if that hospital has the capability and the capacity to provide it. “Capability” means that if the hospital provides the service on a regular basis it must provide the service on an emergency basis. For example, if the hospital provides brain surgery during the day then it must provide it around the clock. “Capacity” means that emergency patients must be admitted if there is room, but not if the hospital is full. When hospitals are over capacity, they typically send out a diversion signal to notify ambulances that the hospital cannot take any more patients. Simultaneous diversion signals from every major hospital in the region doomed the lady from Lake Jackson to end her days in a nursing home, vegetative and fed by a tube.

Federal law makes an important distinction between emergency and non-emergency care. No hospital or doctor is compelled by law to provide care to a patient with a medical problem that is judged by medical personnel not to be an emergency. An emergency is a condition that if not treated promptly could reasonably be expected to place the patient in serious jeopardy. The routine medical care of the uninsured is, therefore, rationed and isolated from the routine care of the insured. For emergencies, though, there can be no distinction, and this led to the growing problem of ambulance diversion.

From 1994 to 1999, the number of medical/surgical beds declined 17.7 percent across the nation, mirrored by a decrease in intensive care beds of 2.8 percent. (2)The downsizing was the result of price cuts from managed care and Medicare. Declining hospital capacity has been met, in the worst possible timing, with an increase in demand for emergency services. In the decade prior to 2003, the US experienced a twenty-six percent increase in twelve percent decrease in the number of emergency rooms.(3) (4) Figure 1 shows the steady and dramatic increase in emergency room visits nationally beginning in 1999. The surge in visits began in 1999 coincident with the progressive failure of the emergency services system.

Figure 1 Number of US Emergency Room Visits

Source: Hospital Statistics. Health Forum LLC, an affiliate of the American Hospital Association. Various editions

How Dangerous is Ambulance Diversion?

My colleague at the nearby University of Texas School of Public Health, Dr. Charles Begley, examined the mortality rate from severe trauma for patients that were brought directly from the accident scene to one of Houston’s trauma centers. For these patients, ambulances ignored diversion status of the trauma centers. He compared this to the mortality rate of patients transferred from small hospitals into one of the trauma centers, who were likely to wait too long. On the days when both of the major trauma centers were on diversion for at least eight hours, the mortality rate of severely injured patients that needed transfer was increased by fifty percent.(5)

His work has been echoed by that of Dr. Linda Green in New York. In 1999-2000 in New York boroughs where more than twenty percent of emergency department time was spent on ambulance diversion, the mortality rate for heart attacks was increased by forty-seven percent.(6) Rapid access to definitive therapies is the reason that the death rate from trauma and heart attack has plummeted over the years, so the cause of the fatalities is sure to be delayed care. An ambulance driving around looking for the right hospital can be a death sentence for these patients and for others with time-sensitive emergencies.

Is Ambulance Diversion Still Happening?

Ambulance diversion was not a serious problem in the US prior to 1999 but by 2001 it was occurring throughout the country and has never receded.(7) An ambulance is diverted from an emergency room once every minute in the US.(8)

The Institute of Medicine provides science-based advice on medicine to the federal government using panels of medical experts to develop its conclusions and recommendations. The Institute’s findings are devoid of politics because it does not depend upon any federal appropriation and is scrupulous in maintaining its objectivity. In June 2006 the Institute of Medicine released a three hundred-page analysis entitled “Hospital-Based Emergency Care” that called for nationwide coordination of emergency services. The report’s subtitle was “At the Breaking Point.” It stated, “The emergency system itself appears to be crumbling in major cities.” (9)

A Hospital Financing Problem

A key to understanding the causes of diversion is to answer the question of why it first became common throughout the United States in 2001. Hospitals are primarily financed by private and public health insurance. Their revenues come from care of patients with 1) private insurance, 2) Medicare, and 3) Medicaid and its affiliated programs. Hospitals earn income from investment of their profits and from services such as cafeterias, parking and medical services that they contract out, but patient care is the core business. Private hospitals finance the care of the uninsured and low paying publicly-insured patients (Medicaid) by shifting their losses to increased prices for privately insured patients. Many hospitals also receive funds from a federal program called the Disproportionate Share Hospital (DSH) program. The DSH program provides funds to hospitals that care for a disproportionate share of low-income patients, and it is a substantial source of hospital revenue.(10)The only hospitals that receive direct tax revenue are public hospitals, which account for sixteen percent of hospital beds in the US.(11)While only six percent of the services that hospitals provide nationally are to the uninsured, a few hospitals in each region provide most of that care; these are usually emergency hospitals, and they are often financially unstable.

By the late 1990s Medicare’s cost to the federal government had been growing so fast that it threatened to bankrupt the Medicare program within the foreseeable future and push the country further into debt. Two public programs, Medicare and Medicaid funds account for half of hospital revenue.(12)The Balanced Budget Act of 1997 reduced DSH funds by seventeen percent beginning in 1999 and also sharply cut hospital payments for Medicare patients. These cuts in payment crippled some key emergency hospitals. This change in federal payment policy was timed with what was termed “managed care” which sharply reduced payments to providers by private insurance. The result was a decline in hospital profit margins and little money to cost shift from care of the uninsured.

Key evidence that diversion is in large part a hospital financing problem related to the uninsured is its geographic distribution. The southern and western states where uninsured rates are over twenty percent are affected the worst.(13), (14) For instance, in four populous regions of California, including Los Angeles County, hospitals diverted ambulances on average one-quarter of the time in 2005.(15)Ambulance diversion is concentrated in large emergency hospitals and trauma centers where hours on diversion are often much higher than in non-emergency hospitals and where uninsured rates are the highest.(16)

It’s Also a Primary Care Problem

The first notion most of us had was that the increase in emergency room visits was simply the uninsured flooding them because they had no place to go for primary care. The data, however, shows that the uninsured and the insured visit emergency rooms with about equal frequency; the uninsured, however, visit clinics much less often than the insured. Emergency rooms are often the only source of care for the uninsured.(17)A recent survey, in fact, found that the uninsured are less likely to visit emergency rooms than either Medicare or Medicaid patients, probably to avoid the expense. Communities with the highest emergency room use are not those with the highest uninsured rates but with the longest waiting times for a clinic appointment.(18)

The surge in emergency room visits is driven by everyone--privately insured, Medicare patients, Medicaid patients, and the uninsured.(19) It is no wonder---anyone who calls a doctor’s office at 5:00 pm or on weekends hears the same recording. “If you think you have an emergency, call 911 or go to your nearest emergency room.” In almost every survey, about forty percent of emergency room visits are non-urgent or semi-urgent and only Medicaid patients stand out in their use of the emergency room both for both urgent and non-urgent care. (20)

Avoidable hospitalizations are hospital admissions that could be avoided if preventive measures had been taken before the problem became an emergency. Minorities and the uninsured are always at more risk for avoidable hospitalizations, but the single factor that dwarfs all others in causing avoidable hospitalizations is lack of access to primary care.(21), (22), (23), (24)One -third of admissions of children to the hospital and to the ICU could have been avoided by primary care.(25), (26), (27)About fifteen percent of hospital admissions and ICU admissions of adults are avoidable.(28), (29), (30)

How to Fix the Emergency Service Problem

The United States once had one of the best emergency services systems in the world, if not the best. I doubt that is any longer true. The two steps to repairing the US emergency services system are to: 1) Cover the uninsured and 2) Resurrect primary care. If the uninsured were covered, then everyone in America would have financing attached to them when they are hospitalized. There would no longer be an economic case for hospitals to divert ambulances. This step would not be enough, however. As long as half of ER visits are for conditions that are treatable in a primary care setting or preventable by primary care, ER overcrowding and ambulance diversion will remain with us. (31)

  1. Mark M. Moy, The EMTALA Answer Book (Gaithersburg, Maryland: Aspen Publishers, Inc. 1999).
  2. Brewster LR, Rudell LS, Lesser CS. Emergency room diversions: a symptom of hospitals under stress. Issue Brief 38, Center for Studying Health System Change. May 2001.
  3. Linda F. McCaig and Catharine W. Burt, “National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary,” Centers for Disease Control and Prevention, Advance Data from Vital and Health Statistics no. 340, March 18, 2004.
  4. U.S. Census Bureau Housing and Household Economic Statistics Division population data in Health Insurance, 1992 to 1993. Table 1. All persons by sex, race, Hispanic origin, and health insurance coverage: Calendar year 1993, U.S. Census Bureau. Last revised December 7, 2004, and Historical Health Insurance Tables. Table H1A-1. Health insurance coverage status and type of coverage by sex, race and Hispanic Origian; 1999 to 2006, Last modified August 28, 2007.
  5. Charles E. Begley, YuChia Chang, Robert C. Wood, et al., “Emergency Department Diversion and Trauma Mortality: Evidence from Houston, Texas,” The Journal of Trauma 57, no.6 (December 2004):1260-1265.
  6. Linda Green, Shelly Glied, and Morgan Grams, “Ambulance Diversion and Myocardial Infarction Mortality,” Columbia University, Columbia Business School, Working paper, 2005.
  7. “Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities,” United States General Accounting Office report to the ranking minority member, committee on finance, U.S. Senate, March 2003.
  8. Catharine W. Burt, Linda F. McCaig, and Roberto H. Valverde, “Analysis of Ambulance Transports and Diversions Among US Emergency Departments,” Annals of Emergency Medicine 47, no. 4, (April 2006):317-26.
  9. Committee on the Future of Emergency Care in the United States Health System, Hospital-Based Emergency Care: At the Breaking Point, (Washington, DC: National Academies Press, 2006).
  10. Robert E. Mechanic, “Medicaid’s Disproportionate Share Hospital Program: Complex Structure, Critical Payments,” National Health Policy Forum Background Paper, Sept. 14, 2004.
  11. “Hospital Beds per 1,000 Population by Ownership Type, 2005,” Statehealthfacts.org. Kaiser Family Foundation. Accessed online November 2007: http://statehealthfacts.org/comparebar.jsp?ind=385&cat=8.
  12. “Health Care and Social Assistance Revenues Reach $1.3 Trillion, Census Bureau Reports,” US Census Bureau press release November 2004.
  13. “Taking the Pulse, the State of America’s Hospitals,” American Hospital Association, 2005. Available online (2007): http://www.hospitalconnect.com/ahapolicyforum/resources/content/TakingthePulse.pdf.
  14. “Emergency Department Overload: A Growing Crisis. The Results of the AHA Survey of Emergency Department and Hospital Capacity,” The Lewin Group, April 2002.
  15. “California Emergency Department Diversion Project, Report One,” The Abaris Group for the California Health Care Foundation, March 19, 2007.
  16. “Taking the Pulse, the State of America’s Hospitals,” 2005.
  17. “Emergency Departments Provide an Important Access Point for Traditionally Underserved Populations,” American Hospital Association Trend Watch 3, no.1 (March 2001).
  18. Peter J. Cunningham, “What Accounts for Differences in the Use of Hospital Emergency Departments Across US Communities?” Health Affairs Web Exclusive, July 18, 2006.
  19. Peter J. Cunningham and Jessica H. May, “Insured Americans Drive Surge in Emergency Department Visits,” Center for Studying Health System Change, Issue Brief no. 70, (October 2003).
  20. McCaig, et al., “National Hospital Ambulatory Medical Care Survey: 2002.
  21. Andrew B. Bindman, Kevin Grumbach, Dennis Osmond, et al., “Preventable Hospitalizations and Access to Health Care,” JAMA 274, no. 4 (July 26, 1995): 305-311.
  22. Michael L. Parchman and Steven D. Culler, “Preventable Hospitalizations in Primary Care Shortage Areas. An Analysis of Vulnerable Medicare Beneficiaries,”Archives of Family Medicine 8 (November-December 1999): 487-491.
  23. James M. Laditka, Sarah B. Laditka, Melanie P. Mastanduno, “Hospital Utilization for Ambulatory Care Sensitive Conditions: Health Outcome Disparities Associated with Race and Ethnicity,” Social Science & Medicine 57, no. 8 (October 2003): 1429-41.
  24. John Billings, Geoffrey M. Anderson, Laurie S. Newman, “Recent Findings on Preventable Hospitalizations,” Health Affairs 15, no. 3 (Fall 1996): 239-249.
  25. Asha Garg, Janice C Probst, Trina Sease, et al., “Potentially Preventable Care: Ambulatory Care-Sensitive Pediatric Hospitalizations in South Carolina in 1998.” Southern Medical Journal 96, no. 9 (September 2003): 850-858.
  26. Glenn Flores, Milagros Abrew, Christine E Chaisson, et al., “Keeping Children Out of Hospitals: Parents' and Physicians' Perspectives on How Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions Can Be Avoided,” Pediatrics 112, no. 5, (November 2003): 1021-1030.
  27. John F. Steiner, Patricia A. Braun, Paul Melinkovich, et al., “Primary-Care Visits and Hospitalizations for Ambulatory-Care-Sensitive Conditions in an Inner-City Health Care System,” Ambulatory Pediatrics 3, no. 6 (November-December 2003): 324-328.
  28. Gregory Pappas, Wilbur C. Hadden, Lola Jean Kozak, et al., “Potentially Avoidable Hospitalizations: Inequalities in Rates Between US Socioeconomic Groups,” American Journal of Public Health 87, issue 5 (May 1997): 811-816.
  29. John Burr, Glenda Sherman, Donna Prentice, et al., “Ambulatory Care-Sensitive Conditions: Clinical Outcomes on ICU Resource Use,” Southern Medical Journal 96, 2o. 2 (February 2003): 172-178.
  30. Laditka, et al “Hospital utilization for ambulatory care sensitive conditions,” 2003.
  31. John Billings, Nina Parikh, and Tod Mijanovich, Emergency Room Use: The New York Story, Issue Brief, The Commonwealth Fund, November, 2000,