Overcrowding is leading to long wait times for emergency-room patients, according to first-responders and hospital staff. A newly released report on the need for more beds also addresses the issues.
Emergency departments in Monroe County hospitals are struggling to care for the increasing numbers of patients flooding in. Hospital administrators and those on the front lines say the triage system is buckling as patient volume climbs and state and federal aid to hospitals falls.
Since Genesee Hospital closed in 2001, hospitals such as Strong Memorial Hospital say the number of patients they see has steadily gone up each year.
According to suburban ambulance companies, delay can threaten lives. That’s because if an ambulance crew is waiting for hours at the doors of the emergency room with one patient and someone else goes into distress in their community, they are not able to respond.
And this happens often, particularly on runs to Strong Memorial Hospital, which is a regional facility — the one that often takes the most life-threatening cases as well as patients from other counties. Most times, backup and mutual-aid crews pick up the slack in picking up patients, but it is obvious that emergency-room workers are struggling to keep up, paramedics and hospital staffs say.
And that struggle encompasses more than wait times.
In a letter to Dr. Jeremy Cushman, medical director for Perinton Volunteer Ambulance and emergency medical services director for the county, Steve Watters, president of the Perinton Volunteer Ambulance Corps, described finding an emergency-room backboard used to transport patients to Strong “covered with blood and pieces of skin,” in among other backboards waiting to be used.
Tom Kirchoff, operations manager at Irondequoit Volunteer Ambulance, and Mary Hollenbeck, a volunteer with the St. Paul Fire District in Irondequoit, said it’s not uncommon to pick up their own backboards and find blood or other debris on them.The bigger problem, Hollenbeck said, is going to the locker the hospital uses to store their backboards and not finding them. She said she recently she went to Strong to retrieve six backboards she expected were there but found only one.
Kirchoff attributed the backboard situation to miscommunication. In the case of the backboard with blood and skin on it, he said, “Maybe it — cleaning and disinfecting the board — was just overlooked ... because the hospital gets so busy.”
In a written response, Strong addressed the complaints about the backboards.
“On any given day, dozens of backboards are used with patients being transported to Strong Memorial Hospital. It is our policy to do a superficial cleaning of those boards that are clearly contaminated and place them in the storage area where they are then recovered and sanitized by EMT crews. In rare instances, a staff member might either overlook an area that needs cleaning and mistakenly put it into the storage area, or a board might be taken from the cleaning area before it has been properly cleaned. Upon receiving Mr. Watters e-mail, staff were re-educated on our backboard cleaning policy, and it is certainly our intention not to repeat this unfortunate incident.”
In his e-mail, Watters also suggested ways to possibly cut delay time for the ambulance crews and offered to help work on the situation.
Strong’s reply stated that “we have encouraged him, along with all other EMTs, to attend our monthly EMT meetings. We have found these meetings to be very helpful in developing, in partnership, solutions to issues that are driven by our hospital routinely operating at capacity.”
Cushman, who is also senior instructor for emergency medicine at Strong, also responded to Watters letter:
"Those same concerns are shared by everyone in our community," said Cushman. "A lot of people are working to improve that, but the challenge is very very great and is rooted in a number of challenges within our current health-care systems."
‘We desperately need the beds’
The patient volume on March 10 was so taxing for Monroe County hospitals that administrators and health-care workers at Strong Memorial Hospital met at the end of that day to discuss how to better handle what could be called a life-and-death challenge.
At one point on that Monday, Strong’s roughly 120 emergency doctors, nurses and support staff saw 60 patients in three hours, according to the hospital.
“On that day there were major backups,” said Mary Comerford, associate director for emergency and medical surgical nursing at Strong. “We are used to dealing with multiple patients coming in, but that day we were at 110 percent occupancy, and we could not get patients into the units because we were over capacity.
“We desperately need the beds,” she added. “Ever since Genesee Hospital closed, we all, all of the hospitals locally, have been dealing with occupancy problems.”
Strong has 739 beds — 95 of which are in the emergency department.
And Irondequoit’s Kirchoff fears the occupancy problems could threaten patients’ well-being.
Crews take patients into the hospital, where they’re “stacked” in a hallway, Kirchoff said. “It’s like a holding pattern.”
He recalls a recent Wednesday when he waited with a patient needing a cardiac monitor for one hour and 15 minutes. During the same period, two calls came into the district that Irondequoit Volunteer Ambulance was unable to respond to.
That particular patient did remain on the ambulance’s cardiac monitor, Kirchoff said, but acknowledged, “any delay could pose a threat to a patient.”
The wait time has gotten so long, he said, he knows of some crews that have ordered pizza while they wait.
‘Hospitals are just overbooked’
Also in mid-March, an ambulance from Penfield Volunteer Emergency Ambulance sat outside Strong for nearly five hours waiting for a bed to open so a patient could be cared for, said Tom Tracy, vice president of administration for the organization.
As the ambulance crew sat waiting to transport the patient inside to the hospital, another call came in about a patient having heart trouble.
“We did not have another ambulance,” Tracy said. “All of our ambulances were out on calls.”
Crews from Walworth, Wayne County, were able to respond to the call, Tracy said.
The West Webster Fire District has had similar issues, according to Chief Mark Cholach. He said his district has seen an increase in calls over the last few years; it responded to 2,400 calls in 2007. And that number keeps growing.
“Right now, we’re about 130 calls ahead of where we were last year,” Cholach said.
John Fabela, an emergency medical technician for Spencerport Volunteer Ambulance, said communication between hospitals and emergency crews is sporadic. Sometimes hospitals will page out and let ambulance crews know when they’re very busy, but not on a consistent basis, he said.
Fabela, who also works for Rural Metro, said this year has been particularly busy.
“It’s not all the hospital’s fault because there’s more calls coming in, and sometimes the hospitals are just overbooked,” he said.
Curing the ills that plague Rochester’s hospitals
For local ambulance companies, as well as the hospitals, it’s also about the revenue.
Kirchoff said that cost is another factor with wait times. He noted that if crew members are paid $20 an hour, and two usually go on a call, that’s $40 for each hour they wait at a hospital with a patient.
Then, he said, if Irondequoit Volunteer Ambulance misses a call due to a wait, and another group has to pick it up, that means a call the Irondequoit corps can’t bill insurance companies for. In the case of a call that requires advanced life support, that’s an additional $649 fee that’s lost, he said.
In Irondequoit Volunteer Ambulance’s case, it receives no tax dollars. It counts on all private funding and billing. They are hurting financially and announced earlier this year that they may have to close by the end of 2009.
That could mean Irondequoit residents may no longer have community services Irondequoit Volunteer Ambulance provides and would have to rely on higher-priced commercial ambulances
Comerford said that in Strong Hospital’s case, it is a high-demand, regional facility, and that is primarily what contributes to the overcrowding.
“It’s up to the EMS crew to divert patients to other hospitals. We are the regional center, additional responsibility is more pressure on Strong and all the EMS crews know that,” she said, explaining that critical patients, like those transported by Mercy Flight Central helicopters, will only go to Strong.
“They know there are certain patients we absolutely have to take,” she said.
Brent Downing, vice president of operations for Perinton Volunteer Ambulance Corps, said he believes the solution lies with the politicians. He recalls a night several weeks ago when seven patients brought in by different ambulance companies were waiting on gurneys to be seen in the emergency room at Strong Memorial.
“We left the hospital almost four hours later. The solution is going to be the Department of Health and the state Legislature approving more beds for hospitals so when patients come into the emergency room, they can go upstairs.”
Downing said the emergency room is becoming like a doctor’s office for many residents, particularly those without insurance.
“I don’t think too many people fault the triage nurses and the people who do the triage, but the system isn’t working very good,” Downing said.
He said his ambulances can get to anyone in Perinton in about six or seven minutes, a bit longer in bad weather. Downing said it rarely happens that Perinton can’t respond because all of its ambulances are tied up, but the potential is there.
Managing ‘door to doctor’ times
Unity Hospital, formerly Park Ridge, in Greece has 351 beds. It is not as taxed as Strong, which has the region’s only trauma center. However, according to Dr. Robert Biernbaum, chairman of the department of emergency medicine, Unity continues to address the wait time issues.
He said Unity doesn’t let ambulances line up outside. The hospital makes room, no matter how it has to.
“Those are our sickest patients. You can’t have an ambulance wait in a line to be seen. That just doesn’t make any sense to me,” Biernbaum said.
When Unity was building its new emergency center, which opened in 2006, it consulted with EMS about a better design. It has its own room to grab a drink and food, fill out paperwork, storage for equipment, a place to wash backboards, computers and a bathroom.
Ambulances also have their own entrance/loop, so you don’t have regular vehicles pulling up to drop off people competing with ambulances.
One asset Unity has is an LCD screen that lists spaces for incoming patients. If medics call in advance, as most do, they just look at the screen and can quickly see what room is assigned to them. It helps expedite things, Biernbaum said.
“EMS really likes it because they know if they come in they’ll be back on the roads faster,” Biernbaum said.
Another big help is that Unity does “mini-registrations” when patients come in to get them into the system quicker. They get basic information such as date of birth and name to get people treated faster. It takes two minutes, tops, Biernbaum said. Then, once the patient gets a room, a more extensive registration is logged.
But, Biernbaum admitted, the system is not perfect at any hospital.
“It’s a countywide problem right now in terms of the Code Red (in effect, no beds availabe) situation that has been ongoing for quite some time, and it’s getting worse and not getting better for all of the facilities,” he said.
Code Red relates to the percentage of patients in the ER. Hospitals are supposed to alert EMS that they are reaching occupancy to cut down on the number of people EMS is bringing in. But, if EMS keeps bringing people, you get longer wait times.
Code Red happens often at Unity. In March, there were times they were at Code Red for days. The “door to doctor time” (how long from arrival to visit from doctor) is about 45 minutes. Biernbaum said it used to be a lot better. About 45 minutes is standard with other hospitals, but Unity can do better.
Hospitals try to find a bed anywhere in the hospital and move people around to get patients admitted from ER into hospital. Lack of hospital beds affects ER, and ER crowding affects the whole hospital because of the ripple effect.
“It’s part of the reason why all of the hospitals have asked for more beds,” Biernbaum said.
On Thursday, April 17, Unity’s ER had 34 beds, and 32 were full. The ER’s volume has increased 24 percent over the last two years, Biernbaum said.
“It would be difficult for anybody to say we’re meeting (patients’ needs) perfectly,” he said. “Anytime someone has to wait, we’re not meeting their needs,” said Biernbaum.
Who has the solution?
The problem of crowded emergency rooms in Monroe County is being studied by the Finger Lakes Health Systems Agency along with hospitals, ambulance providers, doctors, long-term care providers and insurers.
They are building on work commissioned by former County Executive Jack Doyle after Genesee Hospital closed in 2001. The closing came on the heels of the 1997 merger of St. Mary’s and Park Ridge hospitals, greatly reducing the number of available beds.
“The backdrop of the situation is that there are arguably not enough inpatient hospital beds to care for the current demand,” said FLHSA Associate Director Sarah Trafton, noting the agency is also looking at whether the beds are being used most efficiently.
“Who are in the Monroe County beds?” she said. “Are they residents of Monroe County or from surrounding counties? One of the things that’s happening is a considerable number of people from Ontario County are being hospitalized in Monroe County Hospitals.”
According to a bed-need report released by the agency in February, about one half of the growth in patient volume in Monroe County hospitals since the closure of Genesee Hospital are out of county.
Between 2000 and 2006, Monroe County hospitals saw a 33 percent growth in the number of patients from outside the county.
Members of the task force agreed that a substantial portion of the migration of patients from outside counties into Monroe was due to a lack of physicians in outlying areas, particularly specialty physicians.
Trafton said some of that is understandable because some patients need specialized services or advanced care not available in outlying hospitals.
She said a lot of them could be cared for at Thompson in Canandaigua, Clifton Springs or Geneva General, but many patients prefer Strong Memorial, Rochester General or Unity hospitals — emergency situation or not.
“Should patients get to choose where they’ll be hospitalized?” Trafton said. Other factors include a shortage of nurses, a possible shortage of rural doctors, an aging population that requires more care and whether people using the beds could be moved sooner to a lower level of care.
According to the bed-need report, Monroe County may need up to 147 more beds by 2015. The study was commissioned a year ago because hospitals in the county were running at 100 percent occupancy.
It shows the state is slightly below the national average of 2.5 beds per 1,000 people in its service area. Monroe County has fewer than 2.25 beds per 1,000 population.
Trafton said Monroe County is licensed to have 1,918 beds, but not all are set up and some of the hospitals are struggling to have enough staff for available beds while the outlying counties have empty beds with hospitals usually running at 60 to 70 percent capacity.
The second part of the bed-need study is the Community Health System 2020 Commission which Trafton said is looking at whether more beds are needed and where they should be placed throughout the region.
It will also evaluate the building and equipment needs of the aging hospitals, including projected costs and what the region can afford.
Recommendations are expected by the end of June.
Meanwhile, emergency workers will continue to play a serious juggling game.
“The regular needs of the community are still happening,” Perinton’s Downing said. “That doesn’t change because your ambulances are waiting in a parking lot.”
Messenger Post staff Linda Quinlan, Denise Champagne, Colleen Farrell, Bryan Roth, Jessica Gaspar, Robert Barlow and Amy Cavalier contributed to this report.