ER crowding leaves city ambulances waiting

Task force studies ways to get patients into hospital beds faster and get crews to the next emergency


A task force made recommendations yesterday to alleviate crowding in Baltimore's hospital emergency departments, saying among other things that hospitals should do more to quickly admit patients.

City Health Commissioner Joshua Sharfstein helped assemble the panel of city, state and hospital officials after Fire Chief William J. Goodwin Jr. called him in April, saying he was concerned that ambulances were waiting too long to unload patients outside full hospital emergency rooms.

As of last year, the most recent for which figures are available, ambulances were waiting an average of about 44 minutes, the report said. During that time, crews were not free to go to their next calls.

Waits generally affect patients who do not have life-threatening problems, and the task force did not document any harm to patients caused by the delays. But both Goodwin and Sharfstein said preventive action is needed.

Goodwin said that during the past 18 months or so, it had become increasingly routine for the city to have five of its 22 ambulance crews available. Reaching that level prompts the department to shift firefighting crews to ambulance duty.

They are converted to four prepositioned reserve medic units. That ensures the city is adequately covered, he said.

In its own analysis of what caused the drop to only five ambulance crews, the department found the cause wasn't a greater demand for service. Instead, it turned out, many crews simply were waiting at the hospital with patients deemed less urgent than those the emergency departments were handling, Goodwin said.

While he noted the problem is a national one, it didn't turn up as quickly in Baltimore as in other areas because the city has 11 hospitals with emergency departments, he said.

A Government Accountability Office report released in March 2003 found that the most common factor of overcrowding was the difficulty of transferring emergency patients to inpatient beds.

A report to be released this week by the Institute of Medicine is expected to address emergency room overcrowding, among other issues.

Nationally, emergency departments have been suffering from the number of uninsured people who use them as a health care provider of last resort. Locally, Sharfstein and Goodwin said, area population growth has put pressure on city hospitals because the number of new hospitals or hospital beds hasn't kept up.

Howard County, for example, has one hospital - Howard County General, in Columbia. "When their hospital gets busy, all their patients come to St. Agnes," Goodwin said, referring to the community hospital at 900 Caton Ave. in Southwest Baltimore.

The 11 city hospitals with emergency rooms participated on the task force, as did representatives from the Maryland Institute of Emergency Medical Services Systems (MIEMSS), the state agency that dispatches helicopter ambulances and coordinates emergency medical response statewide. An effort to reach one of the hospital representatives, from the University of Maryland Medical Center, was unsuccessful.

Dr. Robert Bass, executive director of MIEMSS, said his agency is taking steps but that hospitals must improve, too.

"If you look at the increased volume, it's modest," he said. "As hospitals have lost beds, their ability to get patients out of the ER has suffered. To resolve that, the hospitals have to make a commitment."

MIEMSS already operates a system that enables ambulance crews to look on a Web site to see which hospitals are too busy. A "red" alert means they have no electrocardiogram-monitored beds. A yellow alert means the hospital has requested it get no patients in need of urgent care.

But the system is passive, allowing ambulance crews to look and choose whether to bypass the nearest hospital. MIEMSS is developing a pilot program that would actively call ambulances in the Baltimore metropolitan area, telling them where to transport the patients they have picked up.

The agency also has pledged to follow recommendations to allow ambulance services to alert hospitals when they are straining under the number of calls. Currently, there is a system under which hospitals can alert emergency medical services, but not one that works the other way around.

The task force report found that emergency department crowding is "growing out of proportion to the number of city ambulance transports and the total number of patients seen in city emergency departments." From 2002 to 2005, it found:

City ambulance transports increased by 8 percent to 84,169 from 77,719, while patient visits to emergency departments increased nearly 11 percent to 611,345, up from 552,299.

The average time that ambulances have waited to return to service has increased 45 percent to nearly 44 minutes, up from 30.2 minutes in 2002.

The total hours hospitals have spent on "red alert" status, meaning they have no cardiac-monitored beds, has increased nearly 36 percent to 11,983 hours from 8,824.

Goodwin indicated that the statistics might help hospitals make a case for expanded capacity to the Maryland Health Care Commission, the regulatory body that governs hospital services.

Sun reporter Stephanie Beasley contributed to this article.

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