Trauma drama

Feb. 22: The night shift had just begun. The number of emergency patients was climbing like mercury in a sun-blasted thermometer. Washoe Medical Center put the call through to other local hospitals and the ambulance company—they were “going on divert.”

Driving a white Suburban equipped with siren and flashers, Steve Kopp got the message: Don’t transport to Washoe Med.

“Divert status is designed to protect patients,” he said, “so they’ll get the appropriate level of treatment they need.” It diffuses patients among the area’s emergency rooms when one gets too busy.

With the warning of an overfull emergency room, the Regional Emergency Medical Services Authority (REMSA) ambulances that Kopp supervised would take patients to either St. Mary’s Regional Medical Center or Northern Nevada Medical Center.

In a community-wide effort, Washoe Med, St. Mary’s, NNMC, the Veterans Administration hospital and REMSA mapped out the ambulance diversion policy for Washoe County in 1998. At the time, administrators thought they’d never need it, but, beginning in 2000, the diversions began and have been increasing in frequency ever since.

“It took almost a year,” said Judy Davis, Washoe Med media coordinator, “so that we could assure the safe and timely care of every patient.”

Kopp said the hospitals are good about communicating with one another—and his ambulances. They send out an update every hour or so and inform other emergency rooms when they go off divert status.

Even while on divert, Washoe Med, the county’s designated trauma hospital, will accept patients suffering unstable blood pressure, unmanageable airways or cardiac arrest. Patients are not redirected when “a minute or two can make a difference in a patient’s outcome,” said Diane Wicklund, RN, Washoe Med ER manager.

While diversion does ameliorate hospital overcrowding for the moment, it’s not a permanent solution. The larger problem is that existing hospital space can’t accommodate Washoe County’s burgeoning and aging population.

Overall admissions at Washoe Med have increased 22 percent in the last two years. St. Mary’s and NNMC have experienced comparable increases, and transports by REMSA have increased 8 percent in the same amount of time.

To have matched the increase in hospital admissions, the population of Washoe County would have had to grow by nearly 75,000 during the last two years. In reality, it has grown less than a quarter of that—14,000 people, or 4 percent over 24 months.

The contradictory numbers suggest that more people are using hospitals instead of family doctors in non-emergency situations. Administrators would like to see something done about it, as emergency rooms are the most expensive places to receive care, and non-emergency cases may tie up doctors whose time could be better spent saving lives. The use of emergency rooms for primary care raises medical costs for everyone.

Even though Nevada is the nation’s fastest growing state—more than 7.5 percent during the last two years—most of the growth is concentrated in Clark County. Other factors explain the disparity between Washoe County population growth and increased hospital admissions.

The largest component is the aging baby boomers who live in and visit northern Nevada. Boomers are reaching the age at which they require more regular and extended medical care. People older than 65 visit the hospital more than any other group.

“The impact of that is just beginning,” Davis said. “I think we’ll see the full effect in the next 10 or 15 years.”

Lesser factors include lack of insurance and the inappropriate use of ERs. Failed HMOs have left poor people without health coverage, yet hospitals are required by law to treat them, often without payment. As a result, patients visit the ER for ailments as minor as a sore throat. The uninsured also tend to put off medical care, so simple diseases left untreated can deteriorate into something more serious or even life threatening—which again strains the emergency medicine system.

Washoe Med offers a 24-hour Health Hotline as a partial solution to overcrowded ERs, Davis said. It works like this: A nurse collects information over the phone—medical history, current medications, cause of injury and duration of symptoms—and then recommends a treatment.

“It’s a resource that might prevent patients from misusing the ER,” she said.

The same factors that have contributed to Washoe County’s frantic hospital growth are echoed throughout America.

“Compared to California, Reno is doing extremely well,” Wicklund said. “And Las Vegas gets inundated, especially during the peak tourism season.” She said Reno has far fewer diversions.

“I used to work in southern California,” said Martin Varrelman, swing shift supervisor at REMSA. “Somebody was always on diversion.”

“Same in New York,” Kopp said. He worked on Long Island, N.Y., before moving to Reno.

Susan Hill, director of marketing at NNMC, said that nearly every day she hears of another hospital’s expansion plans, as far away as the East Coast, as close as Carson City.

In other parts of the country, smaller hospitals have gone bankrupt because HMOs dictated the nature of health care and reduced hospitals’ autonomy to the point that they could no longer function. In addition, the entire nation is facing a nursing shortage. Davis said housing for patients is higher on her priority list, though.

“We have the staff but not the beds,” Davis said.

Soon they will have the beds, as well. Washoe Med will be augmented in January 2004 by Washoe Medical Center South Meadows, a full-service medical center.

“We will now have a facility in an ideal location to serve not only Reno, but all of south Washoe County,” said Jim Miller, president and CEO of Washoe Health System, in an October 2002 press release.

Expansions will ease overcrowding in the next few years. Until then, the amount and duration of diversions will likely increase.

“When I first came here six years ago,” Varrelman said, “hospitals never went on divert. But [diversions have] been increasing steadily, especially in the last two and a half years.”

“Hospitals have stayed on divert for 18 out of 24 hours for two or three days straight,” Kopp said.

A corollary is the increased number of calls to REMSA.

“If the number of calls hits 100 three years ago, it was big news,” said Kopp. At that time, four units stayed on duty during the least-busy period of the day (beginning at 2:45 a.m.); now it’s five, six on weekends.

A couple of months ago, REMSA received 25 calls in 45 minutes. “That would’ve been 25 percent of daily call volume three years ago,” Kopp said. Of those calls, about two-thirds were actual transports to hospitals.

Referring to the Feb. 22 diversion, Kopp said, “If the day had been unseasonably warm, I would’ve expected a higher call volume.” He was surprised to find out that that chilly Saturday had produced 92 transports to Reno’s ERs. The current daily average was 73.

The record, set last August, is more than 210 calls and 101 transports. The number climbs with the temperature and reaches a new height as the thermometer hits triple digits.

“People come out and play when it’s warm," Kopp said, stopping at a red light. "Hot August Nights, Burning Man—that’s the time of year when we get the most calls."