Critics: VAs More Frequently Divert Patients

The Bay Pines VA Medical Center called it a rare mistake last June when it turned away a nonveteran who suffered a fatal heart attack 200 feet from its emergency room.

In fact, care at the two Department of Veterans Affairs hospitals in the Tampa Bay area is hardly guaranteed, even for veterans.

For thousands of hours in recent years, Bay Pines in St. Petersburg and the James A. Haley VA Medical Center in Tampa have closed their doors to paramedics because the facilities were having patient overload, forcing veterans to other hospitals.

Diverting patients, usually from emergency rooms, has become a fact of life in American health care. But some critics say the problem may be more acute at VA facilities because of the sheer pressure on the system. Haley is the nation's busiest VA facility, Bay Pines the fourth busiest.

The VA says it cannot assess how local hospitals compare to others nationally. But officials at both Haley and Bay Pines say they are making it a priority to achieve better performance.

"There's no intent to deny veterans care," said Dr. George Van Buskirk, chief of staff at Bay Pines. "I like to think we're as compassionate as possible. We'd rather send them out to a place that can take care of them than have them languish on a gurney in the hallway."

But some question the VA's resources.

"The VA has never dealt with its capacity issues seriously," said Bill Geden, district director in west-central Florida for the Blinded Veterans Association. "They're underfunded, undermanned and overloaded."

Haley has been on "divert" status for critical patients 27 percent of the time since Jan. 1, 2006, or the equivalent of about 170 days, VA figures show. The hospital diverts all patients regardless of condition 16 percent of the time.

The number of affected patients is unclear, though county emergency service officials say VA hospitals tend to have less emergency traffic than other facilities.

Since 2000, Bay Pines has diverted patients far more frequently than any other hospital in Pinellas County. Last year, it diverted veterans during 1,150 hours (about 48 days), or 13 percent of the time, Pinellas paramedic records show.

Those numbers are a sharp improvement. In 2003, for example, Bay Pines diverted paramedics 2,464 hours (about 102 days), or 28 percent of the time. Similar statistics were posted in 2004.

This year, Bay Pines is diverting about 7 percent of the time, roughly 500 hours so far.

Simple, brutal math works against both facilities.

Haley treated 133,000 veterans last year who visited the hospital on an outpatient basis about 1.5-million times. That's up from 48,000 patients visiting about 1-million times in 2000.

"It's like putting your finger in a dike, actually," said Dr. Edward Cutolo, Haley's chief of staff.

Bay Pines treated 49,800 patients in 2000 and tallied 516,000 outpatient visits. In 2006, the numbers increased to 95,000 and 1.1-million, respectively.

"It doesn't seem right that a veteran's hospital can ever be filled up," said Dick Shockey, 77, an Army veteran who was turned away from Bay Pines three years ago. "But veterans end up with a big surprise."

Hospitals face many challenges to keep diversion down.

Increased patient loads, lack of staff and an inadequate number of critical care beds lead a majority of urban hospitals to go on divert status at some point, according to the American Hospital Association.

About 36 percent of all hospitals reported going on diversion, an AHA 2007 survey shows. And just more than one in 10 of those hospitals reported being on diversion at least 20 percent of the time.

"It's a crisis across America, not just the VA," said Michael O'Rourke, assistant director of veterans health policy at the Veterans of Foreign Wars. "There's a shortage of emergency room physicians, and there's a shortage of beds, and there's a shortage of nursing staff."

Despite numerous calls in recent weeks, VA officials in Washington would not grant interviews or provide details about patient diversion. Several VA hospitals around the country did not return calls.

The VA hospital in Portland, Ore., said it diverted patients 75 percent of the time last fiscal year - down 10 percent from a year before.

Comparing Haley to other Hillsborough County hospitals isn't possible. County officials, unlike Pinellas, do not track diversion figures.

After Van Buskirk became chief of staff at Bay Pines three years ago, diversion numbers quickly caught his attention. In busier months, he said, Bay Pines diverted paramedics 50 percent of the time.

"I was quite taken aback," Van Buskirk said.

A closed emergency room can be a sign of problems elsewhere in a hospital. If a facility's intensive care unit is full, for example, the ER may be forced to close, even if it isn't crammed.

Van Buskirk said the hospital expanded its ER, hired a "bed czar" to make the most efficient use of bed space and used statistical formulas to manage patient flow and allocate resources.

"The goal is maintaining the highest quality of care while remaining as efficient as possible," he said. "There's no question that several years ago we had a problem."

Haley's diversion numbers have not improved in recent years, though it also has expanded its emergency care and hired three "bed czars." That hospital faces a few different challenges.

Haley is a referral center for other VA hospitals in the region, so patients often are sent there to receive specialized care.

"It seems the more beds we open, the greater the need that's out there," said Cutolo, the chief of staff.

EMS officials on both sides of the bay say the VA's diversion numbers place no extra strain on other hospitals.

In addition, diversion doesn't affect a hospital's walkup traffic. Patients aren't turned away if they bring themselves in. In fact, if a patient insists on being taken to the VA, paramedics will oblige.

The VA says it will cover eligible expenses if a patient is diverted to a facility outside its system, though some veterans report fighting a complicated bureaucracy to get reimbursed.

Navy veteran Robert Davey Jr., 64, of St. Petersburg, said he was diverted by Bay Pines last year after he had trouble breathing. Another hospital admitted him and performed a heart catheterization. Later, the VA refused to cover part of his bill because it said he should have transferred to Bay Pines once he was stabilized, he said.

"I didn't know I had to do that," said Davey, who faced bills of more than $9,000. "How would I know that they'd even have room to take me?"

William R. Levesque can be reached at levesque@sptimes.com or (813) 226-3436.

FAST FACTS

By the numbers

16 Percent of time, since Jan. 1, 2006, the James A. Haley VA Medical Center in Tampa diverts all patients regardless of condition

27 Percent of time, since Jan. 1, 2006, that Haley has been on "divert" status for critical patients

13 Percent of time Bay Pines VA Medical Center in St. Petersburg diverted veterans last year