Baltimore VA Hospital Faulted for Lengthy ER Stays

Sept. 27--Shortages of beds, doctors and nurses in the Baltimore VA Medical Center's emergency room resulted in nearly half of a sample of patients spending more than 6 hours at the facility, including one who waited more than 24 hours, according to a critical inspection report released this month.

In that case, a 59-year-old woman who reported a racing and pounding heartbeat waited 24 hours, 8 minutes before being admitted to a unit where her heartbeat could be continuously monitored. In another example, a 52-year-old man with schizophrenia who expressed desires to kill himself or others waited 22 hours until he was transferred to a non-VA hospital for treatment.

The Department of Veterans Affairs inspector general's office detailed the shortcomings in a report that criticized the hospital's leadership for lacking policies to provide on-call doctors and nurses to boost staffing when patient volume surged. Backups in treating patients led to some being examined in the emergency department's triage area, without privacy, the report said.

The findings come to light as Baltimore's VA office is scrutinized for being second-slowest in the country at processing disability claims. Earlier this month, Sen. Barbara A. Mikulski demanded that the agency immediately develop an action plan to improve efforts at speeding claim processing.

The inspectors visited the hospital in November 2012. In a response written in July to the report, VA hospital officials pledged changes, some of which it put in place this past spring. Veterans' advocates said they plan to closely monitor conditions at the hospital to ensure that patient care is improved.

"The concern is that they're not able to get up to the ICU or to be in an inpatient unit without the proper staffing levels," said Jacob Gadd, deputy director for health care for the American Legion, which monitors veterans' health care quality across the country. "We're thankful no veterans were harmed because of the staffing levels."

The inspection found that of a sample of 20 patients on high-volume days, nine spent more than six hours in the emergency department, and six spent more than 20 hours, with an average length of stay of 7.9 hours. Veterans Affairs standards require that no more than 10 percent of emergency patients spend longer than six hours in the facility, the report noted.

Inspectors found that patients often complained about the lengthy wait times. While hospital leaders routinely reviewed patient data each day, they did not review data on patients' length of stay, the report said.

The backlogs frustrated staff too, the report said.

"Although we did not find examples of patients suffering adverse events due to staffing shortages, we did find a dedicated staff that felt frustrated by what they perceived as an inability to provide the quality of care their patients deserved due to staffing shortages," the report said.

The inspectors found that the problems stemmed from an inability to boost staffing during busy times and a lack of a policy outlining how the department would handle patients when it lacked the appropriate beds or enough staff to care for them.

In responses to the inspection appended to the report, leaders at the Baltimore hospital concurred with the report and said improvements were underway. The hospital added extra beds in a unit capable of cardiac and other monitoring, changed schedules for doctors and physician assistants to accommodate expected periods of high patient volume, and improved its on-call systems. The number of nurses assigned to the emergency department also was increased, the response said.

Hospital officials said patient waits have already improved in the emergency department. During the first six months of 2013, the average visit time for patients who were not admitted to the hospital was between three and four hours and the proportion of patients staying six hours or longer fell to 12 percent, they said.

They added that their own assessment of data for patients who stayed longer than six hours revealed that, in many cases, a patient's stay was lengthened because of a need to treat for intoxication before a mental health assessment can be performed.

VA officials did not respond Thursday to requests for comment.

The West Baltimore hospital, adjacent to the University of Maryland Medical Center, has about 700 beds and sees about 8,300 patient admissions and 622,000 outpatient visits annually, according to American Hospitals Association data.

The Baltimore VA office, meanwhile, has been under fire for statistics showing it is one of the poorest-performing in the nation at processing veterans' disability claims quickly and accurately. As of May, more than 81 percent of the 16,000 disability claims at the office were more than 125 days old. The national average is about 67 percent.

It took the Baltimore office six months on average to process a fully developed claim; the national average is four months. The error rate here was the highest in the country at 25.8 percent.

Mikulski and other lawmakers, as well as groups like the American Legion and Disabled American Veterans, have since pressed for improvements. The Baltimore office has reduced its error rate to 23.5 percent and lowered its backlog of cases 125 days or more old to 77 percent.

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