Responding to the Mayor's Health Care Task Force - Press
Victor G. Freeman, MD, MPP - 202-997-5515
"Emergency (ED) Closures / Ambulance
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
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
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
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
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
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
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
"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
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
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