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Victor Freeman
Response to the Mayor's Health Care Task Force Report, Health Care Alternatives for Reservation 13 and Eastern Washington
August 1, 2006




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Mayor's Health Care Task Force Report Mayor's Press Release on Task Force Draft Report

Responding to the Mayor's Health Care Task Force - Press Conference Summary
Victor G. Freeman, MD, MPP - 202-997-5515

"Emergency (ED) Closures / Ambulance Diversions"

Since DC General was closed, the total number of hours of "Diversion/Closure" for DC's eight major admitting hospitals has increased 60% to >9400 hours annually.

According to DC Fire & EMS 2005 statistics, Howard University Hospital, one of two of the city's adult Level-1 trauma centers, requested an average of >20 hours per week of "Diversion/Closure".

The 800-bed Washington Hospital Center requested an average of >40 hours per week of "Diversion/Closure".

When all or most of the DC hospital EDs are "closed", FEMS ambulance patients are rotated to the overwhelmed ED staffs anyway--- After all, the patients must still be seen.

Given the number of hours of "Diversion/Closure" in the city, it is conceivable that a patient could end up at different hospitals for subsequent hospitalizations. Clearly, the `patient scatter' problem raises concerns regarding consistency and continuity of care.

Emergency Department "Closures" Result From Admitted Patients That "Bottleneck" in the ED

At the heart of "Diversion/Closure" is the patient issue of "ED Boarders". "ED Boarders" are patients that are sick/injured enough to be admitted to hospital, but who are stuck in the ED awaiting a hospital bed.

Sometimes these patients may have to wait 5-10 hours or more on uncomfortable stretchers with little privacy. Patient dignity issues and patient safety issues arise.

The major reason for this bottlenecking of patients in the ED is inadequate numbers of available ICU and medical/surgical beds in the given hospital. Non-urgent patients are simply sent to the ED waiting room--- they do not cause the ED to close.

National Reports Confirm That Emergency Dept. Closure is Caused By Lack of Hospital Beds

In June 2006, the Institute of Medicine (IOM) published a study, Hospital-Based Emergency Care: At the Breaking Point, documenting the increase in ED visits, the greater sickness of patients who are seeking ED care and the major problem of inadequate inpatient beds in cities experiencing ED overwhelm.

The American Hospital Association (AHA) did a 2005 national hospital survey and published their results in Taking the Pulse: The State of America's Hospitals. Over half specifically reported that the lack of staffed critical care beds or general beds was the "number one reason" for "Diversion/Closure" (44% and 13% respectively).

According the AHA survey, one in six urban hospitals spend more than 20% of the time on "Diversion/Closure" (i.e. > 1752 hours per year). DC has the dubious honor of having one of those hospitals, namely Washington Hospital Center at >2300 hours, as well as a hospital running very close behind the 20% mark, namely George Washington at -1700 hours.

Ambulance Pt.s At The Hospital May Wait More Than An Hour To Be Seen By ED Staff

A FEMS study revealed that the average time for a patient to be transferred to ED staff and for the ambulance to get back on the road was >40 minutes. This time is referred to as "drop time".

Examples of patients who be waiting for long periods to be seen would include: a middle-aged man with deep bleeding scalp wound from a fall; a young fast food worker with a large grease burn on his arm; an obese woman with severe ankle pain after tripping on stairs. These are the types of patients that must wait, often in pain, to be seen by ED staff who have been too overwhelmed to get to the ambulance.

According to DC-FEMS, DC's "drop time" numbers are more than double the national average.

Emergency Department Overwhelm Affects DC Ambulance Availability

ED "Diversion/Closure", "ED Boarders" and prolonged "drop times" all have a major negative effect on DC ambulance service across the city. During busy times, ambulance may stack up at hospitals waiting to transfer their patients to the ED staff.

If a 24-hour ambulance does 11 transport runs per day (with an average drop time of 40 minutes), it will spend about eight hours (one-third) of the day out of service, waiting to transfer patients to ED staff.

The ambulance will be unavailable for 911 calls during that wait. In addition, the ambulance will most likely need to be dispatched from the hospital as opposed to from its neighborhood fire station.

"Why the Inova Healthplex Concept Works In A Northern Virginia Suburb"

Inova Healthplex, located in Springfield, VA, contains a full-service emergency department, primary care and specialty physician offices, an ambulatory surgery / outpatient procedure center and outpatient diagnostic services, including lab and radiology.

Inova Healthplex's success is related to it service to a largely privately insured patient population and its close operational integration with the Inova Fairfax hospital.

With less than 10% Medicaid and charity care patients, the Inova Healthplex is not only a financially lucrative Inova investment, but an attractive partnership opportunity for physician investors as well as care providers.

The emergency department of the healthplex is fully integrated with Inova's flagship hospital. In order to ensure optimal care during ambulance transfers, the healthplex uses an expensive private ambulance service for the one in ten patients that must be transported to the hospital. Inova Fairfax hospital has very little ED closure, so transfers are never a problem.

Why the Inova Healthplex Concept Would NOT Work In Eastern DC

A healthplex established in an eastern DC area of need is likely to receive a patient population that is ~30% uninsured patients or patients with low-paying Medicaid or DC Health Care Alliance coverage.

Why the Inova Healthplex Emergency Department Would NOT Work In Eastern DC

Eastern DC patients tend to be a sicker patient population than those found in the northern Virginia suburbs. In addition, eastern DC has disproportionately more patients with substance abuse or mental health issues that complicate their clinical presentation and transfers to hospitals.

Private ambulance transfers would be expensive and the use of DC governmental ambulance service is problematic, given how tied up those ambulances are at overwhelmed DC hospital EDs.

The American College of Emergency Physicians (ACEP) issued a press release entitled, "Gridlock in Nation's Emergency Departments Caused by Lack of Inpatient Bed Capacity, Not Patients with Non-Urgent Medical Conditions" that speaks to problems with urgent care centers.

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