Cleveland Pressures Hospitals To Keep ERs Open To All Ambulances

When East Cleveland's emergency medical squad gets called to treat a man with a severe nosebleed, it's a pretty run-of-the-mill case.

The patient walks woozily out to the ambulance from a tan house on a tree-lined street. Anthony Savoy, the head medic, calls ahead to University Hospitals, which has the closest emergency room. Savoy wants to make sure the ER has space for the patient.

The man gets in that day, but it was by no means guaranteed. For years, it's been common practice for University Hospitals to switch its status to diversion.

That means when Savoy would call the hospital, people in the emergency department would say they didn't have the room or the staff to handle the patient. The EMS team then would have to drive to another hospital — often the Cleveland Clinic — about a mile away.

"If we get diverted and then we get a call while we're at the hospital, our response time will be lengthened by maybe a minute, maybe two minutes," Savoy says.

A minute or two delay may not seem like much, but it can be crucial for some patients, says Dr. James Feldman, an emergency medicine doctor in Boston. "We have strong evidence that people who have critical illness or injury who have a delayed time to treatment do worse," he says. Patients who have had a stroke or a heart attack are prime examples.

A study released earlier this year found that heart attack patients whose ambulances were diverted from crowded emergency rooms to hospitals farther away were more likely to be dead a year later. And before that study came out, the Institute of Medicine had taken a look at the increasing use of diversions by hospitals nationwide, and recommended against that sort of rerouting.

Yet, emergency departments across the country, including those in Cleveland, continued to divert patients — often stepping up the frequency. Boston's Feldman says hospitals across the country routinely operate with thin staffing and find themselves coping with too many patients.

In Cleveland this year, University Hospitals temporarily closed its main campus emergency room to certain patients for more than 550 hours. Another large health system, MetroHealth, clocked more than 400 diversion hours.

Jane Dus, chief nursing officer at University Hospitals, says an aging population and hospital closures have increased the demand on emergency departments. "We've seen a 56 percent increase in our squad volume over five years," she says. "So we're getting many more squads coming to us."

Dus recently joined Cleveland-area hospital leaders in negotiating an agreement to stop ER diversion. Indeed, all four major health systems in Cleveland say they will accept all ambulances starting Feb. 15.

If the hospitals are successful, the region will join a select few that have tackled the issue. After years of trying, the Seattle area has stopped nearly all diversions.

Under federal law, every hospital is required to evaluate patients who arrive in the ER, and stabilize them before transferring them elsewhere. But the law doesn't cover patients in ambulances that are diverted before patients are ever seen.

Massachusetts passed regulations in 2009 to ban ambulance diversions after voluntary attempts failed. Feldman says hospitals there had to reevaluate operations, in some cases urging doctors and patients to schedule elective surgeries closer to the weekends to free more hospital beds throughout the week.

But changing the way an ER responds is complicated because emergency departments routinely operate with minimum staffing and beds, Feldman says. "The staff are reasonably fearful that the next critical patient is going to push them over the brink of patient safety," he says. "They really can't handle another patient."

Dr. Alfred Connors, MetroHealth's chief clinical officer, says there are things the hospital can do to be better prepared. "This does obligate us to take steps to correct problems that are correctable that will allow us not to go on diversion," Connors says. "It's not just simply, 'We're not going to go on diversion,' and everybody just sits and hopes that everything will be better."

Adding bed capacity and refocusing on staff are part of the fix, he says. "It's an issue of, do we have enough beds open, do we have the proper staffing, do we have the capacity in the emergency room."

MetroHealth is frequently the busiest emergency department in the city, and the hospital has struggled with diversions before, logging nearly 1,000 hours of diversion in 2013. Connors says the hospital worked to reduce that number, getting down to less than 150 hours of diversion status in 2014. But in 2015, diversions rose again.

There are two hospitals in Cleveland that rarely if ever go on diversion: the Cleveland Clinic's main campus and St. Vincent Charity Medical Center.

The Cleveland Clinic's main campus logged more than 500 hours of ambulance diversions in 2013, but reduced its diversions to two episodes lasting a total of about 10 hours in 2015.

Dr. Stephen Meldon, a leader in the emergency department at the Cleveland Clinic, says change has to happen beyond the emergency department. The clinic has diversions at other regional hospitals in its system and will have to stop those as well, if it's to meet the demands of the new ban.

The ban will "drive people to actually address efficiencies throughout the day," Meldon says, "and not use diversion as a crutch, to not be doing the work they should be doing."

The small St. Vincent Charity Medical Center in downtown Cleveland hasn't gone on diversion since 2012. "It's a matter of working together as a team," says Beverly Lozar, the hospital's chief nursing executive. "It starts every morning at 8:30. We have a huddle of all the nursing directors and all of the other clinical and support directors just to kind of review the day."

Still, Savoy is skeptical that University Hospitals and MetroHealth can end diversions. Just hours after Savoy dropped off his nosebleed patient, University Hospitals stopped taking all but the most critical injuries for nearly four hours.

"My concern is, all of a sudden you guys are willing to put this on paper and say that you're going to do this," he says. "What was stopping you guys before? You know, why now?"

Savoy and others on the squad are worried that the emergency departments will stay crowded. It's something local leaders say they'll work to avoid.

This story is part of NPR's reporting partnership with WCPN and Kaiser Health News.