Ongoing Hospital(s) Discussion

[Sasha]

Try housing 4 patients and their parents in a single room - house 2 people in a 10x10 cubicle with nothing for privacy but a curtain and a walk down the hallway for restroom facilities for 2 months, and you'll see that regardless of where you go, there will always be room for improvement. Foundations DO NOT pay for staff - ever. They exist to raise donations for capital expansions and patient amenities. They pay for the comfy chairs and TVs. You think you would like to hang out in a room for weeks/months at a time without even the privilege of watching TV, be my guest, but when it is a PT's only escape - don't deny it.

Close those 2 curtains - and live there for 2 months, and then tell me "extravagance" is unnecessary. BTW - that chair is also the parent bed.

Who said I was for denying TV? I am not against comfortable rooms. I am agaisnt rooms that go beyond comfort. I am not for no TV. I am against TVs bigger than the patient.

You can find a happy medium between slum and hotel room. It does not have to be one or the other.

 

[Sasha]

Also, hotel like facilities encourage nursing home patients to make up fake complaints so they can be taken to a much nicer facility for a day or two, which taxes the health care system. And don't pretend that doesn't happen because I have personally witnessed it on more than one occasion.

Pick up a dialysis patient who asks where you're taking them, tell them back to the nursing home "Oh... I'd hate to go there with chest pain".. their fifth hospital visit in two weeks!

 

[reaper]

That was an example of where a system as large as SF needs assistance from a private company since there seems to be a stigma about private ambulance services. Did you not read my example from the smaller hospitals and little services? We have been moving trucks around to maintain coverage in many parts of the state which includes the very rural and the cities.
Who is we? Have you been to the northern rural areas of FL lately? Yes, every county has ALS service, But some are covered by 1 or 2 trucks, in a county the size of Dade. The surrounding counties are the same and can not provide Mutual Aid for them.

I don't know where you are but if you PM me the names of some of your hospitals, I can probably get some of their transfer times from the QA person. We also had a discusssion about this on EMTcity and the ED doctors confirmed this was an issue. You have to deal with accepting facilities, insurances and finding the right team. You have to see that all of the EMTALA paperwork is done and you have to make sure the other facility has an ICU bed since they may no longer qualify for an ED to ED transfer. Some hospitals have had to hold patients for 3 days and by then it is generally too late. By the time we are given the okay to fly, we are essentially transporting a corpse that just happens to have a heartbeat.
I know how long the Pt's in our ED's wait for transfers. All Times are required to be on transfer paper work. We may have 1 out 30 that wait more then 3-4 hours.
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Many of these patients are anything but stable and we will do our best to get them to a facility of higher care without them dying in flight. Often the local little general does not have the means to properly stabilize. The patient may need dialysis in the form or CVVH. They may need nitric oxide or some form of higher ventilation. They may need a balloon pump. They may need a ventriculostomy. They may need a surgeon. And for neonates, while the little hospitals are friendly and give EMS providers lots of snacks, many of them suck when it comes to stabilizing a sick baby or child. While Neo and Pedi teams can be mobilized quicker than some of the adult teams, they may still have to drive if weather does not permit a flight.


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Does your area not have any STEMI or trauma protocols? Does every patient have to go to the closest facility and have the doctor say yes the patient meets trauma criteria or yes that chest pain with ST elevation is an MI and needs cath lab? Why would I think you might be trained with various vascular access devices if you are not allowed to make a decision about trauma? Of course if every patient has to go to the nearest facility, why would you need to know about some of the other devices?

Yes, we have STEMI, STROKE and Trauma protocols. I never once stated that those Pt's are taken to the closest facility. So you transport every SOB to a transplant center? Transport every transplant pt back to a transplant center, every time they call? No, I doubt they do. Not till it is found that they need to be transfered there!

 

[reaper]

I honestly don't know what more I can do. I consult. I am a faculty member at the college. I freelance when asked for an outside educational seminar. I attend as many state, national and local meetings as time allows I talk about education but there not a lot of people who are motivated to pursue higher education. We had a great thread here about some young person wanting a 4 year degree but again there will always be those that say it is a waste of time. Too often some will just go for a quick fix with a mill cert and a union card.

Unfortunely, I run into too many like 46young who will use every excuse not to attend an education class or I am up against a FD that has other training issues scheduled.

Try putting yourself in my position and understanding all the excuses I have heard over the years at the many legislative meetings between the cities, counties, the state and the unions.

I agree that you do a lot to push education. I agree that there will always be certain people that will be against it. All that can be done is keep pushing, keep stressing the higher level of education that is needed.

This will not happen by bad mouthing and putting down every medic out there. This will happen over time.

I stated before that I have seen changes for the better, in education and the way systems are ran, over the last 20 years. I would like the changes to happen faster, but they are happening. So encourage the changes and encourage those that need the education to receive it.

 

[VentMedic]

I know how long the Pt's in our ED's wait for transfers. All Times are required to be on transfer paper work. We may have 1 out 30 that wait more then 3-4 hours.

4 hours can be a long time for a STEMI, CVA or TBI.

You must be very close to major hospitals with specialty teams or have your own helicopter to have transfers done that fast. Most hospitals across the country need at least 3 hours just to get through the bare requirements for transfer.

This will not happen by bad mouthing and putting down every medic out there.

Every Paramedic? In many of my posts I have acknowledged Paramedics who have continued their education and the systems that go alittle about just the warm body with a patch mentality.

So you transport every SOB to a transplant center?

Now you are being just silly. People with asthma probably do not need a new set of lungs right away. To get on a transplant list one has many hurdles to jump just to qualify.

Transport every transplant pt back to a transplant center, every time they call? No, I doubt they do. Not till it is found that they need to be transfered there!

This is why we advise our patients NOT to wait until they need 911. Once they get stuck in a hospital that may just be down the street from where they need to go, they may not be able to easily transfer. But then again you are being silly or trying to make a joke out of something very serious.

 

[EMSLaw]

Yes, we have STEMI, STROKE and Trauma protocols. I never once stated that those Pt's are taken to the closest facility. So you transport every SOB to a transplant center? Transport every transplant pt back to a transplant center, every time they call? No, I doubt they do. Not till it is found that they need to be transfered there!

How many transplant patients do you have? We're not talking about every s/o/b patient, we're talking about a recent transplant patient, with s/o/b, who apparently was told by his doctor to return to the hospital.

Fortunately, I suppose, we weren't forced to make a decision in the case I had. But as I think about it more, I think that had the issue come up, we should have transported. A transplant center is the "nearest appropriate facility" in this case.

I understand Deborah Heart and Lung is planning to open an ER in the near future, which would have obviated the discussion. There would then have been a much closer appropriate facility.

 

[Jon]

I'm in suburban Philadelphia, a little less than an hour outside the city. There are a half-dozen hospitals in the city that do some form of transfer... heart, lung, liver, kidney, etc. Multiple facilities are sending patients HOME with LVADs.

Anyone on an LVAD gets a pretty much automatic ticket back to the facility that implanted it if they call 911 for anything other than something minor and isolated. In some cases, the stations and counties go so far as to add Aeromedical on standby automatically if EMS is dispatched to the residence where that patient lives.

Further - there have been a handful of patients with ongoing serious medical conditions that request transport into the city because they are followed by a specialty physician there.

While we "like" to transport to the closest hospital, there are more than half a dozen that are on a list of hospitals we can transport to... and sometimes we go to other facilities with good justification.

I understand where Vent is coming from. I am happy that I work in a system that allows us flexibility in our destinations, as long as we can justify it, and usually we'll have Medical Command sign off on it for good measure.


I have to concur with Vent, though... one of my former ALS supervisors at my work in Philadephia works for the City Fire Department. He couldn't understand why I was willing to bypass a hospital that was 1 block closer than my destination hosptial after a patient I was transferring for sepsis had a brief period of respiratory distress. If I'd diverted, I'd have not really gained any time, and the Pt. was seen in the other facility within the last month for stuff... her docs are there, etc. Both are hospitals with large staffs and lots of Med Students and Residents... I didn't feel Pt. would get any better care at the other.

I also pretty much said that I'm from the land where there is LOTS of distance between hospitals... and diverting actually MATTERS. He didn't seem to understand.



Also - Vent is right with the CCT ETA's. I've worked with several of the big Philly CCT projects... By the time the sending facility calls report to the floor and there is usally also a doc to doc talk, the crew gets a report too. Crew has to respond.. often takes about an hour to the facility, then figure 20-30+ minutes on the floor or in the ED to package patient, admin whatever other meds are needed, and get report, then roll out. Then another 30-60 minutes back tot he City. It can easily be 6 hours before the crew is at the patient's bedside... and if the facility waits 6 or 8 hours to decide they really need to ship the patient out... then 12 hours is totally possible.