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Ambulances in D.C., Md. Often Diverted; Some ERs Too Crowded

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By Lori Aratani
Washington Post Staff Writer
Sunday, May 31, 2009

Hospitals in the District and Maryland must frequently divert ambulances carrying all but the most critically ill and injured patients because of emergency room overcrowding, forcing many less-critical patients to travel farther for care, increasing costs and potentially causing dangerous delays.

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Health-care analysts say ambulance diversions in the Washington region illustrate a national problem that has led some states to ban the practice. But detailing the extent of concern is difficult because of the limited information available in many states, including Virginia, about how often those redirections occur and a lack of national standards.

Since 2004, some District and Maryland hospitals have had to divert ambulance traffic with increasing frequency because they lacked the beds, equipment or staff for patients. Some D.C. hospitals diverted ambulances the equivalent of one out of five days in 2008, and some Maryland hospitals' emergency rooms diverted ambulances at least 15 percent of the time last year, according to a Washington Post analysis of data from District and Maryland health authorities.

"That delay could be a matter of life and death," said Bruce Siegel, research professor in the Department of Health Policy at the George Washington University School of Public Health and Health Services. "We should be very worried there are no national rules."

At the very least, the practice increases the cost of health care. When ambulances are diverted from crowded emergency rooms to less crowded ones farther away, the patients' records are often not available, leading to duplicate tests and procedures. And patients' regular doctors might not be able to treat them at hospitals where they usually practice.

The reasons for the crowding often vary by hospital. Some, especially in the District, are overwhelmed by poor patients for whom the ER has become their family doctor's office. Some suburban hospitals have not kept pace with population growth. And in many instances, internal management problems are to blame, such as when hospitals don't move patients out of emergency rooms and discharge them or admit them for care elsewhere in the facility fast enough to prevent a backlog.

Different jurisdictions use different criteria about when to limit ambulance traffic. Maryland has two categories -- yellow alerts for when emergency rooms are too crowded to accommodate additional patients and red alerts for when emergency rooms lack beds for patients who require monitoring, such as those with cardiac problems.

Hospitals and local health authorities have tried to improve but have come up short.

Howard County General Hospital was on yellow alert 8 percent of the time in 2004 and 26 percent last year, The Post analysis found. It is the county's only hospital, so during those alerts, ambulance patients might be sent to Montgomery, Prince George's or Baltimore counties. Depending on where the patient is picked up, travel could take twice as long and tie up emergency medical service crews longer than authorities would like. Hospital officials said that despite the alerts, they rarely send patients to other hospitals but that those who are less critically ill face longer waits because of crowding.

Hospital officials in Howard said part of the problem can be attributed to population growth in the county, especially among elderly residents seeking care. This summer, Howard General will expand its emergency room for the second time in eight years, adding 18 beds. But that probably will not be enough with 5,500 new homes planned in Columbia and significant growth expected around Fort Meade because of military base realignment in the region. The issue has prompted the Howard County Citizens Association to form a task force to examine emergency care in the county.

"We're trying to make [the emergency room] as streamlined and efficient as possible to see the maximum number [of patients] we can see, but space continues to be a limitation," said Walter Atha, head of the hospital's emergency room.

In the District, The Post analysis found that Providence and Washington Hospital Center diverted ambulances from their emergency rooms the most. Providence diverted ambulances more than 25 percent of the time in 2007, and Washington Hospital Center diverted traffic 33 percent of the time. They are the busiest emergency rooms in the District, which experts said underscores the importance of their doors being kept open to ambulance traffic. Both hospitals improved last year because of internal management changes but are diverting ambulance patients at least one-fifth of the time.


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