Hawaiian Paramedics Concerned About Hospital Closings

Jan. 08--The shutdown of two Hawaii Medical Center hospitals on Oahu has resulted in longer waiting at hospital emergency rooms, longer travel times in ambulances, and the rerouting of noncritical EMS patients away from overcrowded hospitals.

Patricia Jones, a district operations supervisor for the city Division of Emergency Medical Services, said she hasn't seen a situation like this in 30 years as a Hawaii paramedic.

"It's difficult when you have a major hospital that just goes away," Jones said. "That is something I don't think any of us ever thought would occur."

Yet Oahu's emergency service providers say they are managing the fallout of losing two hospitals.

Honolulu EMS makes an average of about 132 ambulance transports a day, said Dr. James Ireland, city EMS director. Of that, about 17 were going to HMC West in Ewa and three to HMC East in Liliha daily, he said.

"What we're seeing now is most of the other ERs, instead of getting seven to 10 ambulances a day, their load has increased "because those 20 (from the two HMC hospitals) now are being distributed among the other hospitals," Ireland said.

It became a perfect storm of sorts when the shutdowns occurred around the holidays and as the cold-and-flu season began, which invariably leads to more illnesses and ambulance calls, the emergency care experts say. Last week, vog caused by Kona winds blowing volcanic haze onto Oahu wreaked havoc on those with respiratory problems, further exasperating the burden on ambulances and emergency rooms.

"There's no doubt that the system is stressed," Ireland said.

The concern is greatest in West Oahu. The 1990 opening of what was then the St. Francis Medical Center West facility, at what many deem the entryway to Ewa, was a gleaming beacon of maturity for the fastest-growing region on Oahu.

Its closure is now a source of worry for area residents, said state Sen. Will Espero.

"I am concerned that residents are being negatively impacted by the closure, and with life-and-death situations, the time factor could be critical," he said.

Emergency health officials insist, despite the added loads, that that is not the case.

Immediately after the HMC emergency room closings, the city added two temporary ambulances to its existing fleet of 19 islandwide -- a 24-hour rig out of the Kapolei Fire Station and a 16-hour truck out of Kuakini Medical Center.

Ireland said the move was important, especially in West Oahu, where, without HMC West, ambulances would need to travel farther to transport their patients, significantly adding to the time it takes for them to return to service for the next patient.

"Without the additional ambulances, it would've been really tough," he said. "With the additional units, we feel we have pretty good coverage now."

Ireland said he is paying for that out of his existing EMS budget but is asking the state Department of Health for additional funding. He estimated it would cost about $1.5 million to operate the two additional units annually.

"It's very clear that this is essential while that hospital out west is closed," he said.

Ireland's department also is short about 25 emergency medical technicians out of a staff of about 200 EMTs and paramedics. A class of EMT trainees graduated last month from Kapiolani Community College and Ireland said he hopes to fill many of his vacancies from that crop.

He said he has also asked KCC to add a third EMT class to its schedule beginning this summer.

Until then, many EMTs and paramedics are working overtime.

On Thursday, paramedic Ashley Ruff, 27, and EMT Jonathan "Jojo" Abuan worked lengthy shifts with the "Airport I" ambulance temporarily based in Kapolei.

Ruff began at 11 p.m. Wednesday and normally would have clocked out at 7 a.m. Instead, she was to work until 3 p.m.

"They couldn't find me relief," she said.

Abuan was supposed to start at 3 p.m. Thursday and finish at 11 p.m. Instead, he did a "pre-shift" that began at 7 a.m.

Both seemed OK with working overtime.

"It's either feast or famine," Abuan said.

After picking up some lunch to take back to their station about 2 p.m., the two were sent on their third call in three hours. The report came in as an "altered mental status" for a woman, 39, at a Ko Olina condominium.

When they got there, they found a normally athletic woman suffering from a weakness to her body that left the crew with many outstanding questions about her condition.

Her case a priority 2 emergency, the woman normally would have gone to Hawaii Medical Center West. With Wahiawa General Hospital and Pali Momi Medical Center on reroute status, the crew was directed to take the patient to Kuakini Medical Center. Their lunches went with them.

Officials from three Oahu medical centers said they've seen a significant increase in their emergency room visitors since the HMC shutdowns three weeks ago. They've also seen an increase in all acute care patients.

Wahiawa and Pali Momi, the two hospitals closest to West Oahu, have been getting the brunt of the increase.

Ray Vara, executive vice president and chief executive officer of operations for Hawaii Pacific Health, which runs Straub Clinic & Hospital, Kapiolani Medical Center and Pali Momi, said the Pali Momi emergency room volumes have increased about 28 percent since the HMC shutdowns.

Vara said some of that increase is due to the closings, and some is because of the holiday/winter season. "All of our facilities have increased their staffing to accommodate the increase in volume. We've tried to minimize the amount of time we're on reroute."

As for ER space, "we've squeezed people in, wherever we had space," Vara said.

But the hospitals and the emergency system on the island have coped, he said.

"I don't believe it's reached crisis proportions," he said. "We've certainly seen an increase in volume. It has certainly stretched our capacity where we need to increase our staffing, and increased the need for collaboration among facilities."

Ireland, the EMC director, echoed that spirit of cooperation. Kaiser Moanalua Medical Center is now seeing many more non-Kaiser patients while Tripler Army Medical Center has increased the number of its nonmilitary patients, he said.

"We're at capacity," said Don Olden, Wahiawa General chief executive officer. The hospital, before the HMC shutdowns, admitted an average of five acute care patients a day. That rose to about eight daily admissions the week after the closings, he said. This week, it has been admitting an average of 12 a day, he said.

As he was being interviewed Friday morning, Olden said eight patients were in the emergency room area waiting to be placed into acute care beds.

"We need to discharge patients to be able to move our patients from the emergency room to our medical/surgery units," he said, adding that his staff has been able to do that pretty efficiently in recent weeks.

"We're having to ramp up our utilization management," he said.

HMC's shutdown has been a mixed blessing for the Wahiawa General staff. Olden said the hospital was just weeks away from laying off or reducing hours for up to 20 percent of its non-nursing staff due to budgetary issues. That plan is now on hold.

The Queen's Medical Center is Oahu's only trauma intake center. As a result, Queen's cannot turn away trauma patients, reroute status or not. It also does not turn away acute heart attack patients.

Queen's also accepts the by far largest share of emergency room patients.

Dr. Matthew Ing, medical director of the Queen's Emergency Department, said emergency room patient volume has increased between 20 percent and 25 percent since HMC closed.

Ing said Queen's began anticipating an HMC shutdown in October and began preparing contingency plans.

"Mostly, we're just using our resources more efficiently," Ing said. "I think any time you have that large of an increase that quickly, there is going to be stress on any system, ours included. So, doctors have had to see more patients per shift per hour, and that's just inevitable. So people are working harder, working busier, but that's kind of expected, I guess."

Officials at Queen's, Pali Momi and Wahiawa all said they do not turn away walk-in patients, although they acknowledged it may now take a while longer for a person with a low-priority ailment to be seen.

Emergency care officials insist that, for the most part, patients' emergency care needs are being met.

"It's been a tremendous stress on the system. I think everyone recognizes that," said Linda Rosen, the state Department of Health's Emergency Services Branch chief.

Rosen applauded the city's EMS staff and hospital ER rooms for helping mitigate the situation.

"That's been very, very helpful," she said. Rosen said she knew of no situation in which a patient's adverse outcome was attributable to the shutdowns.

"The more severe or injured you are, the shorter the waiting time," Rosen said. "But when you've got more ill and injured people than you can take care of, the ones that are not quite (as ill) can wait quite a long time and, of course, that's unpleasant."

As for the additional funding necessary to keep the two temporary ambulances operating through the next year, Rosen said the Health Department is not yet committed.

"We need to go on the data," she said. "We have been monitoring the ambulance transports to each of the facilities. All of the hospitals are getting more than they used to get."

George Greene, executive director of Healthcare Systems of Hawaii, said there's no question the closures have put a strain on the system.

"It's a strain on top of an already stressful situation," Greene said. "But although the system has been strained, everyone is stepping up to the plate to help the patients that need help."

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