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Sunday, January 22, 2006

Byline: Jennifer C. Smith

Jul. 10--McALLEN -- The white-haired, stretcher-bound man weakly opened his eyes as he waited with paramedics for admittance to the hospital emergency room in the evening hours.

An older nurse surveyed the man and a stretcher rolling in behind him, then wiped off the glasses hanging around her neck.

"There's no room at the inn," she said. "Take a seat."

But seats -- or, in this case, hospital beds -- are in short supply from October through March in the Rio Grande Valley due to a surging population, a limited number of beds and an ongoing nursing shortage.

Hospitals respond to the overwhelming demand by declaring "ambulance diversion." When a hospital radios an ambulance company they are at capacity, ambulances on the road are notified by central command to find another location to transport a patient.

Diversion is understood to be an eight-hour period; a hospital ward or an entire facility can go on diversion, although the latter is rare.

The elderly man from Mission had to be transported to Rio Grande Regional Hospital because Mission Regional Medical Center's emergency room had declared diversion earlier in the evening. At Rio Grande Regional, he was admitted after 20 minutes and treated.

Hospital administrators say diversion saves lives and reduces prolonged waits in the emergency room that could jeopardize patient care.

Several patients said they preferred diversion to sitting in ERs waiting for treatment.

Minnie Karnes of McAllen recalled her husband's two-day wait in a hospital holding room last November because the ER was swarming with patients.

Staff members eventually treated her husband's bronchial problems, but said she saw patients "die in front of her."

"I think it (diversions) would save someone's life," said the 65-year-old McAllen Mobile Park resident.

About 58 percent of 131 hospitals in a July 2002 Texas Hospital Association study reported that patient care is being compromised, to a degree, because of diversions.

"I think anytime we go on diversion, it has to impact patient care in a way we would not like to see," said McAllen Medical Center Chief Operating Officer Rebecca Ryder.

The most common repercussion of diversion is patient inconvenience, not that their lives are at greater risk, said Amanda Engler, a spokeswoman for the Texas Hospital Association.

About 60 percent of hospitals forced to go on diversion did experience problems, including excessive wait times, delay of elective procedures, transfer of patients and delay of elective admissions, the THA study reported.

"The reason hospitals go on diversion is to not overburden staff," said Mission Regional COO Mario Garza. "If you just kept the doors open and kept people in hallways and floors, that would be overwhelming."

In the peak season of October through March, it is not unusual for hospitals to declare limited or full diversion for several days, said Rene Perez, director of transport at South Texas Emergency Care Foundation, a nonprofit medical transportation company based in Harlingen.

"Over the last couple of years, some facilities have come across as they're not taking patients," he said, but refused to name hospitals. "We've had EMS crews reporting they're not letting them come in.

"A patient is unstable and a hospital has said they have been busy."

But Engler maintains an overwhelmed hospital cannot serve critical patients safely.

"It's not like they don't feel like taking care of anyone," she said. "If you cannot care for a patient in a proper manner, then the patient is much better off going to a hospital that can provide the level of care the patient needs."

Hospitals have tried to avoid diversion by constructing new facilities and partitions, but more bed space is still needed during winter months, administrators said.

"Even in my best efforts, we can't dictate how many people come into the ER or how sick people are going to be," said Rio Grande Regional Hospital COO Steve Hyde.

The Valley's population continues to grow, creating additional pressure on regional healthcare facilities.

As of July 1, 2004, U.S. Census estimates, Hidalgo County's population of 658,248 grew 10.6 percent in four years, said McAllen Chamber of Commerce President and CEO Steve Ahlenius.

The sea of older Minnesotans, Ohioans and Canadians who arrive in October swell population numbers and inevitably translate into more ER visits. The winter months -- and their accompanying colds, flu and infections -- always mean a busy season.

MedCare, the ambulance service that contracts with McAllen, Mission, Edinburg and Pharr municipal governments, fields thousands of calls each winter. It gets 64,000 calls a year, a number that increases by 3 percent annually, said MedCare president Candelario Ontiveros. Sixty percent of those calls are between October and March.

Rapid growth means diversions are increasingly likely to happen, Engler said.

"The problem will continue," Engler said. "I think until something is done for people who have no alternatives to primary health care, it will get worse."

"Hospitals can only handle so much," she said.

Diversion does not surprise former Winter Texan Sandy Bagot, 65, who now lives permanently in Valhalla Mobile Home Park in Edinburg.

She said she knew of a patient delivered via ambulance to McAllen Medical and then diverted to Edinburg Regional Medical Center.

"If you're going to get sick down here, January, February and the first half of March is not the time to do it," she said. "The hospitals are stuffed."

Diversion Factors Diversion incidents fluctuate weekly, especially in the less-busy months of April through September; the ebb and flow of patients in hospital emergency rooms and specialty care beds means staff can be swamped at one point and idle the next.

On a recent Friday, Mission Regional declared diversion at 5:10 p.m.

"Mission is on diversion because it is a Level 3 trauma center and because of patient choice," said Edward Cordova, a MedCare intermediate medic, as he steered an ambulance toward a radio call.

Patient preference and the facility's designation as a Level 3 trauma facility, meaning it has as a surgeon on call 24 hours a day and can handle serious accidents, meant it reached capacity quicker than other hospitals that night, he explained.

A walk through McAllen Medical Center's emergency room at the same time showed empty beds lining the walls, an unheard-of scenario come December, said MedCare supervisor Jon Lewis.

Winter sniffles and booming birth and immigration rates mean those empty beds usually are occupied; a growing uninsured clientele who uses the emergency room as their primary medical care creates additional pressure.

Even if ER beds are cleared, a full intensive care unit, monitored cardiac care bed area, or ob-gyn unit could force a hospital to go on limited diversion for a few hours. This limited diversion is lifted once a unit bed is cleared or a nurse is assigned to a patient.

"Let's say the ER is full," said Garza, of Mission Regional. "Then we have to evaluate all the patients we have, and whoever is the most stable gets moved to a regular bed."

But regular beds, too, must be adequately staffed by nurses, who are in high demand and short supply in the Valley and nation.

"Though we might have a bed up there, if we can't have a nurse up there, it would not be safe," said Hyde, of Rio Grande Regional. About 35 registered nurses are needed in the facility, he said.

It is possible a hospital, lacking adequate nursing staff, might have to go on diversion even if there is an empty bed, hospital administrators said.

ICU beds have two to three patients to every nurse; step-down beds, three to five patients to every nurse; telemetry (cardiac monitoring care), four or five patients to a nurse; and medical-surgical, five or six patients to one nurse.

"We need to have enough staff to run those beds," said Gilbert Torres, regional administrator for the Rio Grande Valley Trauma Regional Advisory Council. The Harlingen-based nonprofit organization coordinates funding of area trauma centers and conducts medical service and hospital training.

Mission Regional is looking to hire 40 registered nurses, Garza said.

Doctors Hospital at Renaissance is seeking to hire 70 to 100 licensed vocational nurses and RNs by the year's end, said the hospital nurse's recruiter Gracie Fosler.

But even the hiring of all nurses would not eliminate diversion, she said.

"We can have the staff but if the patients keep coming in there's only so much we can do about it," Fosler said.

There is an 11 percent to 18 percent nursing shortage across Texas, Engler said, especially in specialized areas such as surgery, ICU and critical care.

The border's need for nurses is twice that of the state, said Dr. Vicky Borrego, program developer and director of the Valley Initiative for Development and Advancement. She has a doctorate in public administration.

"We're in the most impoverished area in South Texas," she said. "The rate scales (salary) makes it really hard to attract nurses. Also, it's a different culture."

VIDA is a Weslaco-based nonprofit organization that offers job training for the manufacturing and technology, education and social services, nursing and allied health fields.

"One-third of the nurses in the area have to be recruited outside the United States, most often in the Philippines," she said.

A lack of physicians in specialties like orthopedics, pediatrics and may force a hospital to declare diversion, hospital administration said.

"If we don't have an orthopedic specialty on call, or neurosurgery or any other specialty" for an injured patient, an ambulance is told to send him or her to another facility, said Doctors Hospital CEO Skip Courtney.

Certain hospital designations, such as Mission Regional and McAllen Medical Center for pediatric specialties, require ambulances to override diversion for critical patients needing those services, said MedCare's Lewis.

Technological mishaps, such as broken phone lines or CAT scan equipment, can also cause diversion, said Perez, of South Texas Emergency Care Foundation.

"It doesn't very often but it does happen," he said. "They (hospitals) can't use machines to diagnose conditions on patients; it's going to be difficult to take care of patients as fast because internal communication is slower."

Austin hospitals stopped refusing ambulances, no matter how busy the facility is, in the last week. The policy has brought hospitals' administration together to discuss patient overload and strategies to avoid diversion, according to the Austin American-Statesman.

Diversion could be eased in Hidalgo County if hospital heads combined, said Courtney, of Doctors Hospital.

"I think now that we are getting closer to dealing with the underbedded situation, it makes sense for us to come together to develop a communication system to handle diversion," he said.

Still, the county's diversion woes have yet to reach the level of Los Angeles, where ambulances "literally drive around" with patients as they search for hospital bed space, said Ryder, of McAllen Medical.

"I think there will be ongoing challenges with diversion as we continue to grow with the community," she said. "We need to minimize the need to divert patients."

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