CRISIS IN CARE
Hospitals struggle with overcrowding
More patients and a lack of beds and specialists mean people may wait hours in the emergency room
» FIRST OF THREE PARTS
AMBULANCES are rerouted daily from one hospital to another on Oahu because hospitals are full to capacity and emergency care systems severely stressed.
"It's not uncommon to have four or five hospitals on total reroute for two to six hours in peak periods," said Toby Clairmont, Healthcare Association of Hawaii emergency program manager.
This has a ripple effect, he said. When an ambulance has to bypass the nearest hospital and go to the next closest one, that hospital then becomes crowded and can't take more patients. And ambulances that have to go farther to drop off patients aren't available to pick up others.
CRISIS IN CARE
Hospitals are full, emergency rooms are busy and ambulances are constantly rerouted for lack of openings.
An emergency medicine chief talks about the hectic pace in the emergency room due to the backlog of patients waiting for open hospital beds.
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The Institute of Medicine and American College of Surgeons recently issued reports describing a national crisis in emergency care and problems confronting surgeons and patients because of the system's collapse.
Hawaii doesn't have some of the problems of mainland cities, Clairmont and Rich Meiers, Healthcare Association of Hawaii president and chief executive officer, said in an interview.
But hospital emergency departments are backed up because of increased patients, and lack of hospital beds and on-call specialists, they said.
Critically injured or ill patients have priority for emergency care while others may have to wait five to six hours, Clairmont said. But on the mainland, patients may wait 12 to 18 hours, he said.
Sunday afternoons are "very bad," with many people going to the ER because they don't feel well and want some medicine to go to work the next day, Meiers said. Or they didn't monitor their prescriptions and need a refill, he added.
But they may end up waiting for hours because patients arriving by ambulance or with chest pains have priority, he said.
CINDY ELLEN RUSSELL / CRUSSELL@STARBULLETIN.COM
Paramedic Teresa Allen worked a shift Thursday as a dispatcher at the Emergency Medical Services Communications Center located at the Honolulu International Airport.
Clairmont, a nurse, said people in the waiting room often are unaware of activity in the ER. "All they see is they're waiting, getting angry and frustrated. They wonder why the hospital doesn't provide more services. ERs are not good places to get primary care."
Patricia Dukes, Emergency Medical Services Division chief in Honolulu, said: "Ten years ago it was unusual for a hospital to be that full that often. Now it's becoming an issue for all hospitals."
She added: "We still need to drop off our patients somewhere. Thankfully, it's not to the level the mainland suffers, where ambulances are idling in the parking lot for an hour waiting to hand off a patient to somebody in the hospital. We may have to wait 15 minutes."
Once an ambulance is on hospital property, she said, the hospital must take the patient. But ambulances are "pretty much going around to all hospitals where there's an opening."
Everyone in the medical field must have "tolerance and understanding," Dukes said, explaining prehospital and emergency personnel meet constantly "to be sure they understand one side is not ignoring another and not deliberately trying to bring all patients to their hospital."
Patients often are held in emergency rooms because there are no beds for them in the hospital, the health officials said.
On the mainland, 700 hospitals and 435 emergency departments have closed in 10 years, with a loss of 198,000 beds, Clairmont said. No closings have occurred here, he said, but isle hospitals have been asked to report what has happened to the beds from 1993 to 2003.
Clairmont has been monitoring emergency departments in 19 Hawaii hospitals, as well as ambulance diversions, for 2 1/2 years.
"We looked at whether they can accept ambulances or can't at any given time. There's a middle ground called 'caution,' meaning the hospital is approaching capacity."
Hawaii was the second state after Texas to get an EM system to track capacity of emergency rooms and ambulances and coordinate emergency response resources, he said. The health care association installed and maintains the system and provides training.
Dispatchers are able to look at every hospital in the state on a big display in the Department of Emergency Services and see whether they are on reroute status and why -- whether they're full, under construction or for other reasons.
There are "some overrides," Clairmont said. For example, if Queen's is on reroute and a big accident occurs with serious injuries, patients can be taken there to the trauma center.
Every hospital with an emergency room was equipped with a computer and software two years ago so they can keep track of what's happening throughout the system, he said.
Data have been recorded every 15 minutes at every hospital for 2 1/2 years, Clairmont said, noting some "big reroute rates."
Emergency Medical Services is beginning to automate ambulance reports so when they get to the hospital, they don't have to write out a manual form, he said.
They're also using emergency response units--- a paramedic in a van -- to fill gaps, he said. These units can't transport anyone but can stabilize patients waiting for an ambulance to arrive.
EMS has 18 ambulances, two paramedic response units and about 200 field personnel, including paramedics and emergency medical technicians, Dukes said.
"We try not to take a patient to a hospital that isn't appropriate," she said. But, she pointed out, "Not only are there more patients, the acuity level, the illness or injury level, is climbing also.
"Yes, we still have people that go to ER because they feel they're going to get faster treatment, rather than make an appointment to go to the doctor. On the other hand, patients coming in by ambulance are sicker than they have been."
Perhaps not as many patients need to go to the hospital, Dukes said, but if somebody dials 911 and wants an ambulance, "We have a duty to respond and care for those patients."
She said Queen's will never close to critical traumas. "It doesn't matter how busy they are, they have said they will not close, and that is one thing paramedics can't fix in the field.
"We can't do surgery in the field, but do just about everything else. We deliver babies. We have medicines that will stop an asthma attack or help it. We can do things for people with heart attacks prior to getting to a hospital. There are a lot of things we can do to get the ball rolling and the hospital will pick it up.
"We don't save a life all the time, but what we do is make people feel better and we make them better," Dukes said. "And when we do save a life, that's a pinnacle right there."
Tomorrow: New challenges for hospital emergency rooms.