Emergencies at the VA

Dr. Charlie Ross, the former director, said that after being hired in November 2007 he began noticing areas of his department, and the rest of the medical center, where changes were needed to make operations run more smoothly. Ross said he voiced the need for more emergency beds, an ultrasound machine, 24-hour lab and X-ray services on campus and increased staffing, particularly after regular office hours.

“I decided that the vets are really getting shortchanged,” he said in a recent interview.

Ross said the deficiencies at the center are causing patients to be diverted to other medical centers in emergency situations. Diversion refers to patients who would normally be treated at the VA Medical Center being turned away because space or staffing needed to accept the patient isn’t available.

Ross examined the Emergency Department log book for one month late last year. That month, the department received 33 calls from ambulances requesting to bring a veteran to the VA. Of those calls, 12 were accepted and 21 were diverted to another hospital, Ross said.

VA administrators said diversions are uncommon, although they were unable to provide statistics.

“Diversion in terms of they don’t come here because the ED is filled or because our ICU beds are filled, that rarely happens,” VA Chief of Staff Dr. Jamie Buth said.

During the past four months, 10 percent of patients were diverted to other medical centers for inpatient treatment — which includes acute medicine, intensive care and psychiatry — because the VA did not have room, said Shannon Carlson, staff assistant to the director. If the patient was diverted simply because the VA does not offer the needed medical services, the diversion was not counted, she said.

The 10 percent rate also does not include the number of patients who are diverted from the VA Medical Center’s Emergency Department because beds were not available, Carlson said. The VA does not track the number of patients who are diverted from the ED because of a lack of space, she said.

Ross believed many of the issues causing the diversions were not being addressed by the administration, so he reached out to legislators, but no significant action was taken as a result, he said. In July 2008, Ross resigned his post as head of the department but remained on the schedule, working about four days per month as an ED physician. Ross said he stayed on board because he wanted to see that the needed improvements were addressed by the administration.

Recently, however, Ross was told that he would no longer be needed on a regular basis, but may be scheduled if the ED were shorthanded. Ross’ VA e-mail account was disabled days later, he said.

Staffing issues
The main contributor to the high rate of patient diversions — in Ross’ eyes — is staffing, or rather, the lack thereof. The inadequate staffing levels have also negatively affected the availability of services and the quality of care offered at the center, he said.

Ross said he believes veterans during the day receive care on par with private hospitals, but by early evening, the quality drops. After 4 p.m., only one physician is on duty and is in charge of the medical needs of the campus. That physician manages the psychiatric, transitional care and intensive care units, along with the Emergency Department, Ross said.

“Most of the time you can get away with it,” he said, “but at times it’s not safe.”

By about 4 p.m., the hospitalist on duty — responsible for admitting patients and lower-level medical duties — also leaves for the day, leaving the Emergency Department physician responsible for those tasks, Ross said.

VA administrators said they have addressed some of the staffing issues in recent months. Buth said the medical center now has a hospitalist on duty at night to admit patients. The center is also recruiting for a nurse practitioner who would manage the flow of patients in the ED and transport patients to other departments, she said.

Nurses have also been cross-trained so they can float between various departments when need increases, Chief Nurse Executive Tracy Weistreich said. During the Emergency Department peak time or times of the year when staff anticipates a jump in ED visits, additional nurses are scheduled to help meet the demand, Weistreich said. The medical center has also extended its relationships with academic partners in order to bring nursing students into the ED part time, she said.

“We have more coverage now than we’ve ever had,” VA Director Susan Yeager said.

But Ross said inadequate staffing in other areas of the medical center is also impacting the ED. For example, a technician has to be called in from home when an X-ray is needed after hours. Also, lab and other tests cannot be analyzed on campus around the clock; those services are halted at the end of the standard work day, Ross said. When blood draws, EKGs or other tests are taken after hours, they are sent by taxi to Mercy Medical Center for analysis, he said.

In December, the VA hired two additional lab technicians to help fill the gaps. Yeager said now the lab is available about 20 hours a day, seven days per week. And the administration is continuing to work on increased availability of in-house services, she said.

“Just in the last 16 months, in terms of the level of services in the emergency room, the quality has just gone way up,” Yeager said.

Progress reported
The Roseburg VA has dedicated additional resources to improve other aspects of the ED as well, Yeager said. Several offices in the Emergency Department were recently converted into three additional exam rooms and an observation room. The department also has some new equipment and computer software that allows physicians to dictate information into a patient’s medical file.

“We’re so much better than we used to be,” Yeager said. “But we still have a ways to go in terms of our true vision of where that ED needs to be.”

The expansion of the Emergency Department was a needed improvement Ross said he was happy to see completed. But when patients need to be admitted to other departments, such as the Intensive Care Unit, and nursing staff is limited, admittance to the unit is capped and patients are sent elsewhere, he said. Patients are also transferred to other hospitals because the services they need are not available at the VA, he said.

Buth said the VA does transfer patients to other VA hospitals or community hospitals when the patient has medical needs that the center can’t meet. For example, a patient with a serious heart condition or who has had a stroke would likely be transferred elsewhere because the VA does not offer catheterization services. The priority is patient care, not keeping patients in Roseburg if they would be better served elsewhere, Buth said.

Collateral damage
In many instances, though, those diverted patients are left responsible for the costs of their medical care at the facility to which they’re sent, Ross said.

One such patient is 78-year-old Robert Lopes.

Lopes, a Korean War veteran, was diverted from the VA to Mercy when he had a heart attack because the VA’s Emergency Department did not have a bed available, he said.

When Lopes was discharged days later, he was handed a bill for $43,000. Medicare paid $42,000, and Lopes is responsible for the remainder. But Lopes said he doesn’t intend to pay the bill because had he received care at the VA, the cost would have been covered.

Lopes appealed to legislators for help, and Rep. Peter DeFazio contacted Yeager about the case. In a response letter, Yeager said that Lopes did not qualify for VA coverage for the incident because he does not have service-connected disabilities and has health coverage through Medicare. She also said in the letter that Lopes was diverted due to his cardiac condition and the VA’s inability to provide acute cardiac services.

The VA does purchase care for veterans who are sent to other facilities when the Roseburg center doesn’t provide the needed services or the veteran is in an emergency situation but lives closer to a private hospital than the VA, in certain circumstances, Yeager said in a recent interview.

In the 2007 fiscal year, about $10 million of the center’s $83.5 million budget was spent on outside care for veterans. The following year, purchased care increased to about $11 million, Yeager said.

The number of cases in the private sector and the number of days in which patients are staying at outside facilities are climbing, Yeager said. The increase, she said, is because patients are going to the hospital with more acute conditions and need higher levels of care, not because of anything taking place in the Emergency Department.

Work left to do
Ross acknowledged that some of the changes have helped improve the Emergency Department, but said the problems are far from solved.

“That’s good to a point,” he said, “but that’s not good enough.”

But Yeager and the other administrators said they’re not finished making changes and improvements, and Ross’ suggestions have not been ignored. While funding is always a challenge, additional funds have been set aside for the ED, she said.

The VA is actively recruiting physicians and nurses for various departments at the medical center. The goal, Yeager said, is to try and eliminate the times during the day when the medical center is vulnerable, such as evenings.

“We’re not satisfied that we’re totally where we need to be at this time,” Yeager said. “... We believe in continuous quality improvement here. We’re never done, really.”

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