5 Years Later, St. Louis ERs Still Diverting

Dispatchers reporting patients with chest pain, seizures, stroke, gastrointestinal bleeding, pregnancy problems, abdominal pain and injuries from motor vehicle accidents were told to find another emergency room.

During those three hours in February, nine hospitals on the Missouri side of the river were accepting ambulances. None of them was in North County; in St. Charles County, there was just one, an emergency room in a psychiatric facility in Wentzville.

Five years after Missouri hospital officials vowed to get a handle on the problem, many emergency departments in the St. Louis area still regularly turn away ambulances. Half of the time in the first seven months of this year, at least one hospital was diverting ambulances, according to a Post-Dispatch analysis.

The Post-Dispatch first reported on ambulance diversions in a series of articles more than five years ago. At the time, ambulances were circling the streets, and in some cases, pulling over to the side of the road, as paramedics scrambled to find an emergency room that would accept a patient.

Hospital administrators said they were working to fix the problem. Some hospitals have made progress. Barnes-Jewish Hospital, St. Alexius Hospital, Christian Hospital, St. Louis University Hospital and Northwest HealthCare all cut their diversion hours by more than 50 percent from 2001 to last year. But in St. Charles County and parts of St. Louis County, diversions have been rising, in one case by 785 percent.

"It started out as a minor nuisance, but it's gotten to the point where it happens daily at some hospitals," said Bob Stewart, a paramedic for 30 years who works in the St. Charles County Ambulance District.

In 2004, 31 percent of the time at least one hospital in the region was on diversion. Last year, it was 39 percent. And in the first seven months of this year, at least one hospital was on diversion 48 percent of the time, according to the analysis.

National experts say hospitals should not divert ambulances at all.

Diversions can be disastrous, said Dr. Robert R. Bass, an emergency room physician and president of the National Association of State EMS officials.

"It means ambulances have to travel farther, and that can delay care to the patient," Bass said. "It also delays the amount of time that an ambulance is out of service, and that means it is not available to other people in the community who might need it."

A recent Institute of Medicine report says there are only two reasons a hospital should divert an ambulance: a crisis within the hospital, such as a fire or power outage; or a mass casualty incident, such as a plane crash.

Patients who are conscious -- or family members, if they are not -- are supposed to have some say in deciding which hospital to go to, even in an emergency. But when an ambulance is diverted, patients can land in a hospital that doesn't have their medical records or grant their personal physicians privileges, or where the patients have limited insurance coverage.

When patients ask to go to a specific hospital and hear it's on diversion, "you get that blank stare, like: 'What do you mean? It's an emergency room. It's open 24 hours a day, seven days a week,'" said Brad Hatfield, a paramedic-firefighter with the Pattonville Fire Protection District in north St. Louis County.

Data from the Missouri Hospital Association show that after a dip earlier in the decade, the number of diversions regionwide has climbed.

Fifteen hospitals hit record highs in diversion hours last year or this year. There were no ambulance diversions in the same time period in the Metro East area. Regulations are stricter in Illinois, where no more than three hospitals in a defined area can go on diversion at the same time and ambulance transport time cannot exceed 15 minutes.

The Missouri Hospital Association says it does not analyze the data it collects, but believes the situation has improved.

"As far as trends go, there has been a decline, with periodic upsurges," said association spokeswoman Mary Becker.

No room

The Post-Dispatch reviewed reports of hospital diversions for the past five years. The newspaper also analyzed hourly reports from the most recent 40 months, the period for which the most detailed information was available.

For its analysis, the Post-Dispatch contacted officials at each of 22 Missouri hospitals in the St. Louis region that diverted ambulances in the time period. Officials at nine of those hospitals declined to be interviewed.

The hospital recording the most diversion hours between April 1, 2003, and July 31 of this year was St. Mary's Health Center in Richmond Heights. Next was DePaul Health Center in Bridgeton, followed by St. John's Mercy Medical Center in Creve Coeur and Barnes-Jewish St. Peters Hospital in St. Peters, in that order.

Hospital officials said that diversion was only an advisory, and that after the pros and cons of going to a crowded emergency room have been explained, patients will be taken there if they insist.

Paramedics said few people wanted to be taken to an emergency room that lacked specialized beds, equipment or doctors.

Federal law requires hospitals to assess and stabilize every patient who comes in. They can't control the flow of walk-in patients, and they cannot turn away trauma patients and those with other immediate life-threatening conditions. Hospitals also cannot turn away patients based on their ability to pay.

So to manage crowding in emergency rooms, administrators redirect ambulance crews headed their way.

Diversions happen in nearly every metropolitan area in the country.

Ambulances bypassed crowded emergency departments nationwide more than half a million times in 2003, the Institute of Medicine reported.

"It's a matter of safety," said Dr. Arthur Kellermann, an emergency room doctor in Atlanta who is an expert on diversions. "What is amazing to me is the lack of public outcry and political action."

There are a number of reasons for the crowding.

With the population aging, more older and sicker patients are seeking care. People sometimes think they have to wait too long to get an appointment with a doctor. Sometimes, staffing is an issue.

A survey this year for the American College of Emergency Medicine found that three-fourths of emergency rooms lacked enough on-call medical specialists, which included neurosurgeons, orthopedic doctors, and ear, nose and throat experts.

But the No. 1 reason is a shortage of inpatient beds, a number of studies have reported.

At DePaul, the demand for inpatient beds has intensified because the hospital has expanded some of its services, including cardiac surgery and bariatric surgery, said Dr. Stephen Larson, medical director of the emergency department.

"The same beds that the cardiac surgeons and the intensive care unit doctors need for their patients are the same beds that patients in the emergency department need," he said.

Hospitals often discharge patients late in the day or in the early evening, exacerbating the bed shortage.

"The patients haven't left their beds yet, but more are coming in," Larson said. "We run into this situation between 3 p.m. and 7 or 8 p.m., when we are in a crunch from both sides."

Years ago, when hospitals were 40 percent full, efficiency wasn't so critical, said Bass, of the association of EMS officials. But now that hospitals have reached occupancy rates of 80 percent and higher, it's important for them to get patients in and out efficiently.

"Otherwise, it causes a backup in the ER," Bass said. "And the backup causes diversions and slows down the ability of the emergency department to process patients, regardless of how they are coming in."

Several area hospital officials said their goal was to lower the time on diversion to 20 hours or less a month.

But meeting that goal is at least partly dependent on the actions of other hospitals.

During the July storms, DePaul officials tried to stay off diversion for as long as possible, but other hospitals stayed on, said Cory Elliott, DePaul's vice president of ambulatory services. "We got slammed."

Weighing both sides

Michelle Liston, clinical director of St. Mary's emergency department, said larger problems in health care -- sicker patients, lack of access to doctors, changes in hospital reimbursement that favor outpatient care -- made it difficult for administrators to address diversion.

"Until we fix a lot of the problems in the health care system," she said, "it's really difficult to say you can get rid of diversion."

Sometimes, diversion is the best course, she said.

"I think you have to look at both sides of it," she said. "You have to weigh making patients sit out in the waiting room up to 12 hours."

This year, officials at SSM Health Care directed administrators at its seven hospitals in the area to reduce their diversion hours by half from February through June, and by 20 percent more by the end of this year.

"We seem to be making good progress," said SSM spokesman Neil Kiesel.

Larson said: "I would hate to tell a hospital they couldn't go on diversion if they felt unsafe. On the other hand, we could all learn from each other. There's nothing like peer pressure."

Like DePaul, St. Mary's is an SSM hospital.

The goal set for St. Mary's is 26.7 hours on diversion a month, Liston said. The hospital had 61 hours in July.

She said officials were considering ways to reduce emergency room crowding, including establishing a checkout time for patients, discharging patients earlier and setting up an area for patients to wait for rides, so they are not occupying much-needed beds.

On average, up to 40 percent of the 130 people treated in St. Mary's emergency room every day are admitted, almost double the national average.

Encouraging doctors to write medical orders earlier, offering extra pay to off-duty personnel to help staff the ER in peak periods, and improving communication among staff throughout the hospital would also help "because (diversion) is a hospital-wide problem," Liston said.

Veterans face unique problems when turned away

Veterans don't get a pass when it comes to diversions.

From January through June of this year, the St. Louis VA Medical Center-John Cochran Division turned away ambulances 478 hours, or 11 percent of the time. During those months, there were five times when the hospital diverted ambulances for the entire day, and 21 days when the hospital was on diversion for more than 12 consecutive hours. VA officials acknowledge that veterans who are diverted from the VA hospital are more than inconvenienced. It can cost them.

"Veterans may have co-payments to outside facilities in connection with outside private insurance," a statement from VA officials said.

Diversions also separate veterans from their medical records because non-VA hospitals do not have VA records, "and VA often does not get outside records for later follow-up," the statement said. "Treatment plans can be disrupted for chronic problems, such as cancer workups and treatments. There can be added time and expense to the veteran for extra transfers from an outside facility to VA."

The VA statement said officials were working to lower the number of hours spent on diversion. One strategy involves taking a multidisciplinary team approach, which improves patient flow throughout the hospital and frees up available beds for new patient admissions.

Diversion hours fell to 18.1 hours in August and 22.8 hours in September, the lowest number of hours per month in the years diversions have been tracked, officials said.

WHAT THE HOSPITALS ARE SAYING

* Mary Becker Spokeswoman, Missouri Hospital Association

"You are going to see spikes, as you do every year. We would characterize the issue as being managed, being successfully managed."

* Dr. John Peter

Medical director of the emergency department, Cardinal Glennon Children's Medical Center

"The last time we went on diversion, we had a limited number of surgeons available and they were all in the OR (operating room). ... We always felt it was better to go on diversion briefly and then come back on."

* Dr. Mike Mueller

Vice president of patient care, St. Joseph Hospital of Kirkwood

"We're fortunate because with our staffing and the sizing of our emergency department, the vast majority of the time we can meet the demand. Our diversion numbers are very, very low."

* Michele Meyer

CEO, Des Peres Hospital

"(Diversion) is the last, last resort. It is never the first decision. You look at all the resources you have and it is a collaborative decision. We do not make the decision lightly because we know how it affects the community. Our goal is zero diversion."

* Dr. Michael Meinzen

Co-director of the emergency department, St. Luke's Hospital

"When everybody else is on diversion, it's kind of a cascade. First thing in the morning, you look at how many reds are the screen, and as the day goes on, you can see the cascade as one hospital after another goes on (diversion). We can predict when we are going to get hit."

* Dr. Alan Umbright

Executive medical director of emergency services, St. Joseph Hospital West, St. Joseph Health Center-St. Charles and St. Joseph Health Center-Wentzville:

"We are having rapid growth, huge population changes. We've had a 10 to 15 percent increase in ER visits this year at Hospital West. ... Mainly it's a bed problem -- too many admissions and not enough beds in the hospital."

* Dr. Dennis Keithly

Chairman of emergency medicine, St. John's Mercy Medical Center in Creve Coeur:

"Emergency department visits have been steadily going up -- up 6 percent over last year's 62,500. That stresses the system. ... Additional patients put us in a precarious situation. Hopefully with more room, we'll be able to manage it better." (Note: The hospital recently opened a new and expanded emergency room.)

ABOUT OUR SERIES

The Post-Dispatch created a database from Missouri Hospital Association hourly reports of hospital diversions from April 1, 2003, through July 31, 2006. The reports counted diversions of 30 minutes or longer as an hourlong diversion; diversions less than 30 minutes were not counted. The Post-Dispatch analyzed the database with more than 18,000 records of hourly diversions to find totals and trends.

Hourly reports were not available before April 2003. The Post-Dispatch used paper and electronic reports of monthly totals to determine hours on diversion from Jan. 1, 2001, through March 31, 2003.

Reports for the St. Louis VA Medical Center-John Cochran Division were provided by the hospital and were analyzed separately, but with the same standards applied to Missouri Hospital Association records. The Post-Dispatch also researched individual hospital diversion plans, state regulations and the St. Louis Metropolitan Community Ambulance Diversion Plan.

DIVERSION SNAPSHOTS

Number of times on diversion for 12 or more hours in one day:

* DePaul Health Center 44 * Barnes-Jewish St. Peters 31

* St. Mary's Health Center 31

* St. Joseph Health Center-St. Charles 19

* Missouri Baptist Medical Center 13

* Des Peres 12

On seven occasions, a hospital turned away ambulances for an entire day:

* DePaul Health Center May 30, 2006

* DePaul Health Center March 14, 2006

* St. John's Mercy Medical Center Jan. 12, 2006

* DePaul Health Center Feb. 9, 2005

* Barnes-Jewish St. Peters Hospital Jan. 4, 2004

* Barnes-Jewish St. Peters Hospital Jan. 3, 2004

* St. Joseph Health Center-St. Charles Jan. 3, 2004

SOURCES: Missouri Hospital Association Research by Jaimi Dowdell | Post-Dispatch

Coming Monday

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