Emergency departments nationwide have been quietly deploying a controversial tactic of turning ambulances away.
Bill Schulz, Milwaukee Journal Sentinel
MILWAUKEE – As she got ready to work the breakfast shift at the Medical College of Wisconsin cafeteria, Tiffany Tate didn’t feel well.
Tate, 37, was a fixture on the cafeteria’s “hot line,” where she worked behind a steaming grill. She knew the names of many workers and their kids, always sharing smiles and small talk.
With a teenager and 8-month-old at home, recent months had been an exhausting blitz for Tate. That morning, she told some of the other kitchen workers she had a headache and felt weak. She figured it was because of a new medication for her back pain.
Shortly after 8 a.m., as Tate and a group of workers came off a break, she felt worse. Tate asked for a piece of bread with honey. A co-worker hustled to get it. She returned to find Tate leaning against a counter, supporting herself with one hand. The left side of Tate’s face drooped; she was slurring her words.
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A customer walked up. Both could see what was happening and said the same thing, almost in unison:
“She’s having a stroke.”
At its most basic level, a stroke is an attack on the brain. Typically, it’s the result of a clot becoming lodged in an artery, choking off vital blood flow. Every minute blood flow is interrupted, it can cause irreversible damage to millions of brain cells.
A stroke can rob a victim’s ability to speak or to see and cause brain damage and paralysis. More than 140,000 people die each year in the United States from strokes, making it the fifth leading cause of death. It is a leading cause of serious, long-term disability.
The latest research says sending patients directly to top-level stroke centers – hospitals that can administer clot-busting drugs or go in through arteries to physically remove clots – offers the best chance at survival. The ideal window for care is within the first three hours.
On that morning four years ago, Tate was having a stroke on the grounds of the Milwaukee Regional Medical Center, and 350 yards from Froedtert Hospital, the area’s most advanced, experienced stroke care center.
It would be a quick ambulance ride.
If only the ambulance had taken her there.
Little-known practice of diversion
Every day as thousands of ambulances zig-zag through city streets, along congested highways and rural roads across the nation, it’s easy to imagine they’re headed to the nearest hospital or to the emergency room best suited to care for the sick or injured person on board.
Turns out, that’s not always so.
Emergency departments in hospitals nationwide have been quietly deploying a controversial tactic, turning would-be patients away.
Officially, it’s called ambulance diversion.
Hospital officials decide they are too busy and essentially hang a “temporarily closed” sign on the emergency room door, telling ambulances to go elsewhere.
In some cases, the crowding is due to a surge of patients. In others, the problem is a poor system for moving patients through the hospital, creating bottlenecks elsewhere that hamper the ER. In other words, hospitals sometimes create their own problem.
The ambulance carrying Tiffany Tate was sent to a hospital three miles away that offered only limited stroke care.
Law doesn’t apply
Federal law requires hospitals to treat patients who arrive in their emergency room and make sure they are stable before releasing or transferring them. That applies to everyone who walks in the door of any of the nation’s 5,500 hospitals.
But if you’re in an ambulance that’s ordered not to come, the law is irrelevant.
Maria Raven, an emergency room doctor and professor at the University of California at San Francisco who has studied hospital diversion, said Tate should have been taken to Froedtert because it was the top stroke center in the area.
“To my mind, they shouldn’t be a Comprehensive Stroke Center if they can close,” Raven said. “Either you can be one or can’t be. People can’t control when they have their stroke.”
Milwaukee County officially ended diversion in 2016. Yet the practice continues elsewhere in Wisconsin and across the nation.
A Milwaukee Journal Sentinel review of the 25 largest cities found 16 of them – including nine of the 10 largest – allow ambulance diversion of some kind, though rules governing when patients can be diverted vary widely.
They include cities such as New York, Phoenix, Chicago, Los Angeles and Knoxville, Tenn.
No uniform set of rules governs how or when ambulance diversion is used by America’s hospitals.
No single agency tracks the practice, or measures how frequently hospital doors are closed. No one tracks what happens to the patients who have their treatment delayed.
In some places where diversion is allowed, officials require hospitals to accept stroke patients even during periods of diversion.
All the while, study after study has concluded that ambulance diversion poses serious dangers for patients and doesn’t actually solve overcrowding.
The practice emerged in the 1980s, at a time when many hospitals began to find themselves so jammed that patients might lie on beds in emergency room hallways after initial treatment for hours, even days, before they could be discharged or admitted.
The problem was compounded by another common occurrence that had nothing to do with emergency rooms, and which continues today at some hospitals.
Surgeons schedule operations and procedures earlier in the week, allowing for weekday healing time and discharge before the weekend when many hospitals have skeleton crews.
That meant intensive care units were often crowded early and mid-week. Patients treated in the emergency room who needed to be admitted to the ICU would have no place to go.
At the same time, ERs were forced to deal with an influx of psychiatric patients, the result of a federal court-ordered shift from institutional care to community placement.
In the years that followed, emergency rooms became the first-stop for many kinds of care, often minor ailments – fever, dizziness, sprained ankles. Over the past 15 years, emergency room visits have jumped 20 percent, to 137 million last year alone, from 114 million in 2003.
The crowding problems can be especially acute in urban areas, where many hospitals nationwide have closed, putting extra pressure on the ones that remain.
A 2001 report from the U.S. House Committee on Government Reform found diversions were so widespread they represented a threat to emergency medical readiness, including in the event of a terrorist attack.
A 2017 study found that African-American patients had an increased chance of dying from heart attacks and strokes as hospitals in largely minority neighborhoods were going on diversion more often than others.
“Diversion has been aggressively abused,” said Corey Slovis, chair of emergency medicine at Vanderbilt University and the medical director for the Nashville Fire Department.
Hospitals might turn away ambulances if equipment breaks down or if there is an unexpected problem, such as flooding or electricity being out.
Still, the vast majority of diversions, experts say, are because of overcrowding.
Defenders describe diversion policies as “a necessary evil” intended to protect patients from long, dangerous waits at a crowded hospital. The key, they acknowledge, is to get the ambulance patient to another less-crowded hospital that has the same capabilities.
The problem: When one hospital closes its doors, it simply spills more water – and sends extra ambulances – onto the next hospital, which may then have to close its doors. Indeed, sometimes hospitals close simply in anticipation of getting more patients.
“You really don’t want to be brought to a hospital that doesn’t think they can do the job properly,” said Lewis Nelson, a doctor and chair of emergency medicine at Rutgers Medical School in New Jersey.
A tragic sequence of events
It is less than four football fields from the cafeteria where Tate suffered her stroke to the emergency room at Froedtert. A skywalk connects them.
Had Tate been wheeled into the emergency room, doctors would have been required under federal law to care for her, even while ambulances were being turned away. Instead, she was taken to Aurora West Allis Medical Center, about three miles away.
The paramedic commander on the call with Tate said he probably drove right past the entrance to Froedtert’s emergency room, “close enough to spit on the driveway.”
Aurora West Allis could not handle the case. They decided to transfer Tate to Aurora St. Luke’s Medical Center. She arrived about three-a-half-hours after she first started showing signs of stroke.
David Tate talks about his sister, Tiffany, who died after suffering a stroke
Bill Schulz, Milwaukee Journal Sentinel
Using a catheter, doctors tried to reach the clot lodged in Tate’s neck through an artery in her leg, medical records show. The procedure didn’t work. Tate would die three months later.
Her family’s biggest question: Why wasn’t she cared for at Froedtert?
“It didn’t make any sense to me,” her brother, David Tate said in an interview. “Damn, she was at Froedtert. She works there. She was right there.”
Several health experts had the same question.
“To me, if someone is on the grounds of your hospital, they are yours,” said Raven, the San Francisco ER doctor. “It is really sad. There were so many failures.”
Michael Carome, a former top official in the U.S. Department of Health and Human Services and now medical director of Public Citizen, a public policy group, said the delay in getting Tate to a top-level stroke center diminished her chances of survival.
“I would think there is a very high probability that the (delay) reasonably contributed to her adverse outcome given what we know about the golden window to quickly treat an ischemic stroke,” Carome said.
The experts said it is impossible to know whether Tate would have survived if she had gone straight to Froedtert.
But they were unified in this: She would have had a better chance.
Diversions still a problem
Diversion is still a problem around the country including in Los Angeles County where hospitals can – and do – divert ambulances regularly.
Cathy Chidester, director of the Los Angeles County Emergency Medical Services Agency, said surrounding counties have “banned” diversion but have not changed their operations. That has resulted in chaos, she said, with patients having long waits or swamping Los Angeles County hospitals.
Chidester said hospitals and officials have discussed making improvements, but nothing concrete has happened.
It might be different if there were a case similar to what happened with Tiffany Tate in Milwaukee County, she said.
“Efficiency is talked about all the time here,” Chidester said. “But without something horrifying happening, like what you had up there, it just reverts to the way it was.”
Contributing: Kevin Crowe and Cary Spivak, Milwaukee Journal Sentinel. Follow John Diedrich on Twitter: @john_diedrich
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