Ambulance diversion is commonplace and can cause treatment delays
New Brunswick, N.J. Following a national trend, New Jerseys hospitals have experienced declines in capacity, measured as maintained beds, from 1998 to 2005, a fact underscored by the frequency of ambulance diversions about once every hour in the Garden State.
During peak periods, the states hospital capacity appears to be extremely constrained, according to a study by Derek DeLia, assistant professor and senior policy analyst at the Center for State Health Policy (CSHP) at Rutgers, The State University of New Jersey. The report is the third in the series Emergency Department (ED) Utilization and Surge Capacity in New Jersey, commissioned by the states Department of Health and Senior Services (NJDHSS). The research includes analysis of recent trends in ED utilization, hospital occupancy, potentially avoidable hospital use, as well as ambulance diversions.
Using hospital case studies, it also provides qualitative analysis of patient flow management and surge capacity, the latter being necessary to respond to manmade or natural disasters.
The report found 47 days in 2005 when more than 95 percent of all maintained hospital beds in the state were occupied, up from 29 days in 2004 and 11 days in 2003. On these days, DeLia noted, there would be almost no surge capacity available to respond to a major emergency without displacing existing patients.
He added that from 2003 through 2005, on more than 75 percent of the days, there were
fewer than 500 empty staffed beds available per million residents, which is the surge capacity benchmark developed by the federal Health Resources and Services Administration. Northwestern New Jersey was most likely to have a limited number of empty beds relative to population.
The frequency of ambulance diversions in New Jersey underscores the stress on capacity often experienced by hospitals in the state. Data from December 2006 and January 2007 reveal that, on average, an ambulance diversion occurs once every hour in New Jersey. Although ambulances may sometimes override hospitals diversion requests, these requests provide a clear signal that the hospital staff does not feel completely ready to treat additional patients.
During the study period, the annual hospital occupancy rate statewide was about 70 percent. For intensive and critical care units, annual capacities were below 85 percent, leaving at least 15 percent for unexpected volume, or surge. DeLia said those figures dont necessarily portray an accurate picture of the supply and demand for hospital services because individual hospitals, and groups of hospitals in the same geographic region, experience peaks and valleys in their occupancy.
While the likelihood of experiencing high occupancy is quite varied among the states hospitals, DeLia observed that closure of lower-occupancy facilities could potentially overload the remaining facilities, especially during their peak periods. Since 1995, 17 general care hospitals have closed in New Jersey, he said. While continued consolidation may be appropriate in some areas, the ability of remaining hospitals to absorb additional volume will eventually diminish as closures occur.
Besides diminished capacity, bottlenecks in the flow of patients through various hospital units can also lead to ED overcrowding. Case study participants that have been successful at streamlining their patient flow to avoid overcrowding are able to communicate information rapidly across units and respond quickly when a particular area is reaching capacity. Other hospitals, while attempting to do this, report a greater number of problems in breaking down silos across the facility. Some of the more crucial areas of concern include ability to track patients through the entire hospital in real time, coordinating the discharge schedules with the incoming volume of inpatients and coordinating use of resources between elective surgery and ED patients.
Part of the rise in emergency department utilization and subsequent admissions is attributable to conditions and medical episodes that may have been avoided through better access to primary care, DeLia said, citing acute episodes of asthma and congestive heart failure as examples of ambulatory care sensitive conditions. These admissions 186,284 in 2005 accounted for 31 percent of all ED admissions. Also in 2005, there were 1.24 million potentially avoidable treat-and-release ED visits.
Some case study participants have responded with fast track systems to separate emergent from other cases in the ED. Two inner-city hospitals responded to their large number of ambulatory care sensitive patients by developing special case management and chronic disease management systems within the ED. These facilities decided the community need and patient preference have made this departure from the traditional ED role necessary, DeLia said.
Along those lines, DeLia noted that New Jerseys hospitals also have become important providers for mental health and substance abuse patients, especially through the ED. Case study participants have found it much more difficult to provide care for these patients due to a lack of space, clinicians and other resources, as well as the psychological discomfort their presence causes other patients.
After a slight drop in 2004, total ED visits in New Jersey resumed their upward trend in 2005, with 3.36 million visits, compared to 2.67 million visits in 1998. ED visits per capita followed a similar pattern, with 385 visits per 1,000 residents in 2005 compared to 329 residents per 1,000 in 1998. Growth in ED visits has paralleled population growth in regions of the state, which has been highest in west-central New Jersey. On a per capita basis, southern and northeast New Jersey had the highest rates of ED use throughout the study period.
All hospitals face periodic strains on capacity, and this should be factored in to evaluate the adequacy of hospital capacity in a given community, DeLia concluded. Stress on hospitals can be understood and managed by factors that affect the flow of patients through the ED and other hospital units, DeLia said. In general, hospitals can use established techniques to control patient flow, but a variety of broader health system issues, including hospitals fear of losing profitable elective surgery patients and the inability of patients to gain access to primary and other specialized care outside the hospital, can be limiting factors.
Contact: Steve Manas
732-932-7084, Ext. 612
E-mail: smanas@ur.rutgers.edu