RICHARD WALKER / RWALKER@STARBULLETIN.COM
Dr. Daniel Smith, chief of emergency medicine at Queen's Hospital, and Shari Nakaoka, a registered nurse in the emergency room, work in a treatment room in the ER.
Hospital ERs fall victim to success
Efforts to keep people out of hospital beds are working, adding to tasks in emergency
Hawaii's emergency rooms are swamped with patients and suffering from a shortage of on-call specialists and available hospital beds.
How the state is preparing for a possible avian flu pandemic, with hospital admissions already high and emergency rooms already full.
They are victims of their own success, emergency physicians say.
When he started 23 years ago, said Dr. Craig Thomas, president of Hawaii Emergency Physicians Associated Inc., "if someone came in with a heart attack, there was no treatment, and we put them in the hospital."
But medical technology, diagnostic and therapeutic capabilities "have changed astonishingly," said Thomas, whose firm has 26 emergency physicians working at Castle Medical Center and Wahiawa General Hospital on Oahu, and Hilo Medical Center and North Hawaii Community Hospital on the Big Island.
"Now what happens, more people come in because they're getting something they really can't get so easily in some other avenues of medicine. Everybody deserves access to health care. Sometimes the only way is through emergency departments," Thomas said.
All Hawaii emergency departments report increasing patient volumes. Yet Hawaii has the lowest utilization rate of emergency services in the country, with about 250 emergency department visits per 1,000 population, said Dr. Dan Smith, chief of emergency medicine at the Queen's Medical Center.
Washington, D.C., has the highest rate -- 600 per 1,000 population -- and the national average is 380, he said. "If we just got up to the national average, we would see over 50 percent more emergency visits." As it is, patient visits at Queen's ER have leaped by a couple thousand every year, he said.
The result: a "dramatic increase" in waiting time for patients, and ambulance diversions to other hospitals, Smith said. "The first part of 2006 indicates it is even worse than last year, which was not a good year."
"It's multifactorial," Smith explained. "There's more pressure to keep people out of the hospital. We have to do more involved evaluation and treatments in the emergency department. Many elderly people with multisystem diseases need extensive evaluation and treatment before they are admitted."
As the only trauma center in the Pacific, Queen's also must take critically injured patients. Only about 3 percent of patients are admitted for trauma, but they require a lot of resources immediately, which are diverted from other patients, he said.
Fewer specialists are willing to treat patients in emergency departments, because patients often are uninsured or underinsured and pose the highest risk for lawsuits.
Smith said patients should have legal recourse if something goes wrong, but "tort reform is critical to the environment physicians work in."
"Most suits are settled for doctors, but the cost of defense and time is incredible," he said.
The reimbursement system should be restructured to help address the on-call specialist shortage, ER doctors say. "Somebody doing a simple elective procedure he can schedule a month ahead of time should not be (paid) as much as someone taking care of a critically ill patient at 3 in the morning," Smith said.
Queen's has about 30 orthopedic surgeons on staff, but only two are taking ER calls, "basically covering the entire state for trauma," he said. A corps of neurosurgeons is available, "but coverage is getting more and more difficult in all areas."
Critically ill patients are seen quickly, "but not everybody comes in with a label, 'I am really sick,'" Smith said. Some people with abdominal pain, for example, could have stable vital signs but be feeling the first sign of something serious. They might not be seen for several hours if they do not appear to be ill, yet their condition can get worse, he said.
Queen's emergency department increasingly is holding patients for many hours waiting for a hospital bed. One day recently, Smith had eight or nine patients waiting. "Eventually we got them all upstairs, but it was many hours."
"If I could get every patient out of the emergency department into the hospital after it is decided to admit them, we would be far better off. It is a big part of the issue."
Queen's, as well as other hospitals statewide, has backups of patients who cannot be released because long-term care or other facilities are not available, Smith said.
"The whole health care system is a victim of success," said Dr. Bill Lee, emergency physician in charge of the ER at Straub Clinic & Hospital. "We do such a good job keeping people alive, we have sicker people alive. ...
"The underlying problem is we have more patients every year. They're older, sicker and requiring longer hospitalization. There are no nursing home beds. It's a capacity problem."
Straub's 12-bed ER has had a 10 to 15 percent increase in patients per year, Lee said.
He said insurers have created a situation where hospitals and doctors' offices are supposed to be run more like businesses, and to be efficient they have to be full nearly all the time.
"There is no capacity to handle a crisis," he said.
"We can't get patients out of the hospital, and we can't get them in the hospital and we have backup in the emergency room. ... There are multiple reasons why there is overcrowding, and you just couldn't build a big enough emergency room to accommodate everybody."
A domino effect occurs as ambulances are rerouted from one ER to another because they are full, a CAT scanner or something is not working or a specialist is not available, the ER doctors said.
"Suddenly you're getting another hospital's patients, and suddenly your capacity is overrun," Lee said, noting the added difficulty of caring for patients whose records and doctors are at another hospital.
Castle Medical Center routinely monitors a statewide EM system to keep track of hospital re-routes across the island and adjust staffing, said Barbara Penniall, director of the 18-bed emergency department. The EM system tracks capacity of emergency rooms and ambulances and coordinates emergency resources.
"With limited access to health care on the Windward side, this is very important to us," Penniall said.
She said Castle's ER patients have increased 31 percent in five years, and more than 18 percent require hospital admission for acute care. A project is under way to convert some beds used for behavioral health programs to acute care, she said.
St. Francis Medical Center-Liliha, a kidney dialysis center, has a core group of very sick patients going to the 10-bed emergency room, said Dr. Valorie Ammann, medical director.
"We don't have many people that walk in and go home," she said, adding that patient volume in the ER is up more than 10 percent this month.
St. Francis-West has double problems: getting specialists and sending patients to other hospitals, Ammann said. "They're on the phone calling different facilities to find a doctor who will accept a patient."
Kapiolani Medical Center at Pali Momi's emergency room jumped from 16,000 patients a year in 2000 to 28,000 a year now, said Pat Oda, Kapiolani Hospital spokeswoman. It has a daily average of 10 to 15 patients waiting to go to a skilled nursing facility, she said.
Patients also must be held a little longer at times in the ER at Kapiolani Medical Center for Women & Children because hospital beds are not available immediately, she said. Getting ER specialists is another challenge.
Thomas said emergency rooms are dysfunctional when they become holding areas for patients waiting for hospital beds or specialty services, and the situation is worsening. But he hesitates to call it "a crisis," although he hears other doctors calling it that.
"Overall, I think there are a lot of things to be proud of," Thomas said, referring to the successes of Mothers Against Drunk Driving and other organizations to stop destructive health behaviors. "It doesn't look like emergency medicine, but it is and I'm thrilled about it. If a guy doesn't drive a Harley into a guardrail in the first place, we're all ahead of the game."
With the emergency care system already in trouble, an avian flu pandemic or event causing massive casualties would be overwhelming, emergency doctors said.
Better coordination is needed between all hospitals and pre-hospital care, Smith said. "In the end it's the doctors who take care of patients, and there are a lot of reasons why physicians may not be available at certain places, and so many patterns develop."
While Hawaii's emergency care problems do not compare to big places on the mainland, Smith said, "the handwriting is on the wall. Capacity has been reached. There is nothing now to suggest the forces that created this situation are changing. ...
"I just see it as sad, really ... people waiting so long to be seen or admitted to the hospital. We can't do the job at times that we'd like to do and can do."
Tomorrow: Hawaii's stressed health care system prepares to cope with a potential disaster.