Injured Man Dies After Rejection by 14 Hospitals

Mari Yamaguchi
Associated Press
2009 Feb 4

TOKYO -- A 69-year-old Japanese man injured in a traffic accident died after paramedics spent more than an hour negotiating with 14 hospitals before finding one to admit him, a fire department official said Wednesday.

The man, whose bicycle collided with a motorcycle in the western city of Itami, waited at the scene in an ambulance because the hospitals said they could not accept him, citing a lack of specialists, equipment, beds and staff, according to Mitsuhisa Ikemoto.

It was the latest in a string of recent cases in Japan in which patients were denied treatment, underscoring the country's health care woes that include a shortage of doctors.

The man, who suffered head and back injuries, initially showed stable vital signs, but his condition gradually deteriorated. He died from hemorrhagic shock about an hour and half after arriving at the hospital, Ikemoto said.

Ikemoto said the victim might have survived if a hospital would have accepted him more quickly. "I wish hospitals are more willing to take patients, but they have their own reasons, too," he said.

The death prompted the city to issue a directive ordering paramedics to better coordinate with an emergency call center so patients can find a hospital within 15 minutes.

The motorcyclist involved in the Jan. 20 accident was hurt too and was also denied medical care by two hospitals before one accepted him, Ikemoto said. He was recovering from his injuries.

More than 14,000 emergency patients were rejected at least three times by Japanese hospitals before getting treatment in 2007, according to the latest government survey. In the worst case, a woman in her 70s with a breathing problem was rejected 49 times in Tokyo.

Patients turned away

MARIAN GAIL BROWN mgbrown@ctpost.com

Posted: 05/15/2005 04:21:00 AM EDT

Connecticut has no idea how often any of its 32 hospitals find themselves so overwhelmed that they can't treat any more ambulance patients in their emergency rooms.

That's because neither the state Department of Public Health, the state Office of Health Care Access or the State Office of Emergency Medicine do not require hospitals to tell them when they go on diversion or for how long they refuse to accept ambulances. "Diversion" occurs when hospitals are so inundated with patients they turn ambulances away because they can no longer safely handle any more patients.

Yet, even without statistics, anecdotal evidence shows that Connecticut is one of 22 states across the nation where ambulance diversions stemming from overwhelmed emergency rooms are so frequent and of such long duration that a congressional committee says they impede access to vital services.

In 2001, a congressional subcommittee suggested that diversion affected the ability of 75 million people to get critical medical care in a timely fashion in metropolitan areas. It's a situation that the American College of Emergency Physicians calls "symptomatic" of the nation's health-care system in crisis.

Picture a bunch of ambulances with sirens activated and paramedics scrambling to treat their patients.

Inside one is a teenage driver bleeding from the head after wrapping his new car around a utility pole. Another carries an elderly man with a weak pulse who stands on death's doorstep after

taking somebody else's nitroglycerin. And the last one contains a woozy guy with a golf-ball-size lump from a bowling ball that slammed into his forehead.

All of the ambulances are en route to the nearest hospital. Then a dispatcher's voice crackles over the radio. With the relay of a one-word announcement from the hospital — "Diversion" — everything changes. It means none of these ambulance patients will ever arrive at that hospital.

"Diversion is one of the last things you ever want to hear when you're transporting a patient," says Corey Clabby, a paramedic supervisor with American Medical Response. "It means that you can't go to the closest hospital. They can't handle any more. So, you have to hope that the next [closest] one can."

That's the situation Genevieve Geisel of St. Louis is all too familiar with. Geisel was injured in October 2000 in a car accident on her way to work.

"The paramedics arrived at the hospital and they had my mother almost out of the ambulance, Geisel's son, Tony, says. "The paramedics were already out and they had the doors open and were pulling her out when some nurse ran out and told them they couldn't take her there, that they had to go someplace else."

In the time it took to find another hospital that would accept her, Genevieve Geisel suffered a heart attack in the ambulance.

"I would never have thought that a hospital could refuse to treat somebody who was already on their property," Tony Geisel says. "I remember thinking this has got to be against the law."

He was right. When the Health Care Financing Administration delved into what happened to his mother, it determined that the hospital breached the federal Emergency Medical Treatment and Active Labor Act. EMTALA, as its known, requires hospitals to screen and stabilize every emergency patient that arrives on their property.

Geisel was fortunate. She recovered from her heart attack. To be sure, not every ambulance patient who winds up being diverted suffers additional harm. But in Connecticut, at least, there is no direct way of tracking what happens to ambulance patients who don't get treated at the nearest emergency room. No Connecticut agency with jurisdiction over hospitals, health care or emergency medicine professed to have investigated any case of any hospitals diverting ambulances in the state.

When the federal General Accounting Office investigated emergency-room crowding in 2003 it found that two out of every three hospitals around the country asked ambulances to take their patients somewhere else at least once during the year. And 10 percent of those hospitals admitted to being on diversion at least 20 percent of the time.

"There are cities throughout the country where you have a lot of ambulances with lights flashing zooming around with nowhere to bring these sick or injured people," says Mike Williams of the Abaris Group in Walnut Creek, Calif., a national expert on hospital emergency department policies and structure. "It's akin to having a lot of planes in the air in a holding pattern."

In Connecticut, neither the state Department of Public Health, the Office of Health Care Access, the Connecticut Hospital Association nor the state Office of Emergency Medical Services keep any record of how often hospitals divert ambulances.

"To get at those numbers you really have to drill down to each of the hospitals in the state," Williams says. "It shouldn't be that hard. But that's the way they've made it."

In addition, though the state Department of Public Health has an "adverse incident" reporting mechanism for medical mistakes in hospitals, it has no directmethod for tracing fatalities connected to diversions.

Bridgeport Hospital's statistics show that its emergency department has declared diversions 1,725 hours so far this year, with an average duration lasting 7.2 hours — indicating its emergency room was closedto ambulances for that length of time.

Compared to its track record a decade ago, Bridgeport Hospital is on diversion more than three times more frequently and for at least 5.7 hours longer than the 1.5 hours it previously averaged.

"That means the hospital is on diversion nearly 20 percent of the time and that's totally unacceptable," Williams says. "It's very high — even for a busy, urban hospital. The figure that we consider reasonable [for a hospital of this size and with this patient volume] is five percent."

Repeated efforts to reach Patrick McCabe, a Bridgeport Hospital administrator, for comment proved unsuccessful.

St. Vincent's Medical Center, also in Bridgeport, produced records showing that so far this year it went on diversion for 521 hours. And Milford Hospital, a smaller suburban facility that also draws some patients from Bridgeport, Stratford, Orange and West Haven, had 129 hours of diversion.

"In the old days, diversion was supposed to be a temporary response to a logjam in the emergency room where you couldn't see any more patients," Williams says. "Now, in some communities, it's turned into a routine way to hide inefficiencies in hospital protocols and procedures."

In fact, Williams says, the practice of going on diversion is way too easy at most hospitals. In some facilities, he notes, it's not the emergency room director that declares a diversion, it's a nurse.

And with multiple parties having the power to declare diversions, Williams says, some hospitals forget to notify their central dispatch system when they are no longer on diversion.

"Believe it or not, there was this one hospital in Sacaremento that was on diversion for 12 hours and then failed to notify the dispatch center when it was over," Williams says. "Twenty-one days later, the dispatchers turned around and contacted them [the hospital] about it, and that's how they discovered why they had such light traffic in their E.R."Dr. Michael Carius, director of Norwalk Hospital's emergency department and an officer with the American College of Emergency Physicians, drafted the state's original diversion policy more than a decade ago. Carius believed it would ensure that emergency rooms treated patients in a timely fashion.

"Nowadays, the reality is more and more hospital [emergency rooms] are overwhelmed," Carius says. "There is no surge capacity. Yet once one hospital that's over capacity goes on diversion, it often pushes another one over capacity, so that both may go into diversion. That puts the onus back on the original hospital on diversion to lift its ban on taking ambulance patients."

The Amercain Hospital Association estimates that 51 percent of the nation's hospitals are either in the process of expanding their emergency rooms or have designs to do so.

But that might just be a quick-fix that's only a Band-Aid solution.

According to Williams, who teaches a course at Harvard's School of Architecture for architects and hospital planners, simply expanding a hospital emergency room "doesn't change the underlying processes and procedures. It's just a way of moving bad practices into bigger space."

In California and Nevada, where the Abaris Group has overhauled and reorganized emergency room operations, "ambulance diversions decreased 90 percent within a year."

Abaris accomplished that, Williams says, by installing a physician out front in the hospital emergency department waiting rooms.

"Triage was originally set up as a war-time activity. But at most hospitals early in the morning, there is no bonafide reason why a patient should have to wait hours and hours to get in and be seen by a doctor," Williams says. Some of the new best practices at hospitals include having a doctor see and evaluate patients within 15 minutes of their arrival for a rapid medical evaluation.

"Thirty percent of those patients ultimately seen by that doctor wind up going home," Williams says, "and as a result, we've seen diversion decrease dramatically." Meanwhile, in Connecticut, Carius says he knows of some hospitals where "it's not uncommon for an E.R. patient to [stay] in the emergency room on a gurney in the hallway for up to a week before a bed becomes available," Carius says. "Even at Norwalk Hospital, there are times when we will have a patient that has to stay in the emergency room for a day or two until we can get them into a room."

Local hospital officials say that having a patient stay in the emergency department doesn't affect patient care. They receive the same care that they would if they were in the intensive care unit.

But Dia Gainor, president of the National Association of State EMS Directors, feels the situation has a reached crisis level.

"We have lost the capacity of [emergency rooms] and hospitals to care for patients on a day-to-day basis," Gainor stated in written testimony to the House Committee on Government Oversight. "Where hospitals have reduced the number of beds so close to the daily average needs, in times of increased demand, a sudden influx of patients is difficult or impossible to accommodate."

Paramedics often battle traffic, and even patients

MARIAN GAIL BROWN mgbrown@ctpost.com

Posted: 05/15/2005 04:21:00 AM EDT

The ambulance sirens scream as Corey Clabby weaves through traffic that refuses to acknowledge his flashing lights and the not-so-subtle, get-out-of-the-way meaning of the blaring horns.

The rain pours out of the sky like a dam unleashed. It's late at night. Yet there are plenty of cars slip-sliding along the wet highways and local roads. It's Saturday night. And nobody is staying home. In the realm of paramedic care, this is the perfect storm. It makes for accidents galore. For Clabby, a seasoned paramedic, and his colleagues at American Medical Response, it guarantees a busy night. At the same time, it raises the chance that area hospital emergency departments with packed waiting rooms will scream "diversion."

In hospital parlance, "diversion" is the word emergency rooms use to announce that they are overwhelmed and can no longer safely treat any more critically injured or sick people. It's a growing problem in many states, including Connecticut.

But, as today marks the start of National Emergency Medical Services Week, it isn't the only problem. Just ask Clabby.

"Every second counts in this job and when they don't pull over, well, that might mean the difference between life and death," Clabby says as he grips the steering wheel tighter. "I will never get used to the fact that people don't pull over when they hear these sirens. It's a rare event when somebody actually does."

In front of him an SUV driver in the center lane of

Interstate 95 decides to "heed" the sirens by coming to a dead stop in the middle of the highway. It's enough to make a law-abiding motorist entertain some road-rage fantasies that involve shoulder-fired missiles.

Clabby passes 87 vehicles en route to a bloody car-versus-telephone-poll accident in downtown Fairfield. It takes him all of six minutes and 35 seconds from his starting point near the Bridgeport/Stratford line, a trip that takes the ordinary motorist about 20 minutes. Another ambulance from AMR is already on the scene, and Clabby's job, as paramedic supervisor, is to oversee the crew and provide any extra emergency medical care if needed.

"Nobody knows where the passenger is," one of the Fairfield cops tells him. "He just took off — running."

Inside the ambulance, one emergency medical technician takes the teenaged driver's blood pressure. The other taps the inside of his arm for a vein to prick and get an intravenous line flowing. The kid on the stretcher moans.

"Hey, bright eyes, look at me," paramedic Bernadette Handel says, matter-of-factly. Hers is a calming, noncondescending voice with nary a hint of worry. "You're doing just fine. Stay with me."

She gives her partner the good-to-go sign, kneels down next to the kid, and pulls the backdoor of the ambulance closed. It heads to St. Vincent's Medical Center in Bridgeport, which has an uncharacteristically empty emergency room for a Saturday night.

"It's slow. Real slow," a triage nurse tells Clabby and his colleague, Marilyn Goldstone, when they arrive a few minutes later as part of their rounds. "I don't want to jinx us," she says. "I just hope it stays this way for the rest of my shift."

Behind her in the waiting room are a handful of queasy patients who have flushed complexions. Some of them are alone. A few, however, have an anxious, toe-tapping relative or friend with them. They stare at the television.

Somebody in a white coat and squeaky sneakers walks by and they all try to make eye contact. It doesn't work. One guy sighs loudly. Nobody pays attention to him. So, he lets out a longer, even louder one, crosses his arms and then stares at the ceiling.

Under the federal Emegency Medical Treatment and Active Labor Act (EMTALA), hospitals can refuse to accept ambulance patients if they are too busy and unable to safely treat them. But they can't turn away anyone who arrives on their own or is driven there by someone else.

Congress passed EMTALA to ensure that hospitals evaluated and stabilized all patients regardless of their ability to pay. But that's not how it always works.avvy health-care consumers know how to get around diversions. They just show up at the emergency room using their own transportation or having someone else drive them. They know the federal law guarantees all walk-in emergency room patients the right to a medical screening.

That quirk puts a paramedic or EMT in the position of acting as a middleman between patients and emergency rooms that are diverting ambulances.

Take the time Clabby responded to a Stratford cardiologist's office on a 911 call for a young woman suffering a heart attack.

"She was in her 30s, and she knew what was happening to her. The doctor had diagnosed her. And let's just say that without naming names, she wanted to go to Hospital A. But that hospital was on diversion and not taking any patients. We told her we needed to go to Hospital B," Clabby says. "So, she tells us: then let me out here. There's no way I am going there. I'd rather die by the side of the road.' "

Not only did Clabby have to provide critical emergency medical care, he also needed to marshal the diplomatic skills of a Middle Eastern peace envoy, and get the defiant patient to come round to his way of thinking.

Did anybody say there might be 911 calls like this during EMT training? Maybe. But who'd believe it?

Instead of speeding the patient to the nearest hospital taking cardiac patients, Clabby spent the time trying to persuade the woman to go the alternate hospital. Still she refused. He pleaded that she might be right: that if paramedics released her, she could die in her car or on the side of the road.

To be sure, the negotiation wasted precious time. In the end, Clabby convinced the patient's first-choice hospital to take her. But he concedes that doesn't always happen.

Sometimes, patients will get out of an ambulance and decide to drive themselves to the emergency room where they want to be treated.

"When a patient refuses to go [to the hospital that is not on diversion], assuming they understand the risks to themselves, there is nothing we can do to keep them against their will," Clabby says. "They know that the hospital [they want to go to] can't turn them away when they show up in the ER on their own."

Instead of solving one problem, however, it's easy to envision how such determined patients buy boatloads of trouble that can be fatal to them — and to others.

"These people get in a vehicle, knowing they are experiencing a heart attack, a stroke, and they are in no shape to be on the road," Clabby says. "Single-handedly, they can cause their own demolition derby, endangering themselves, you and me and everybody else they encounter en route."

And that just adds to the problem of crowded emergency departments.