An inside look at the logjams in E.V. hospitals

But first they’ve got to hold him still. It takes six people to restrain the fl ailing man long enough to wrap leather straps around each arm and leg, then bind him up like a dolphin in a fi shing net.

Once “netted and leathered,” he’s sedated, hooked up to a ventilator and a cardiac monitor and attached to intravenous lines.

Two hours later, he’s transferred to the intensive-care unit, his young family trailing quietly behind as hospital staff wheel their unconscious father upstairs. He may never awaken. If he does, nurses say there’s a fair chance he’ll be on kidney dialysis the rest of his life.

“This was not his fi rst attempt,” charge nurse Deb Howard says.

It’s just another heartbreak in a steady stream that flows in and out of this Mesa ER. But there’s no time to ponder.

Howard quickly turns her attention to another patient on “psych row,” a string of rooms in the medical center’s emergency room routinely filled with the mentally ill, drug addicts and alcoholics.

An angry woman insists on smoking a cigarette. She’s hugely drunk, with a blood-alcohol content almost three times the legal limit, and has come to the hospital because she wants to quit drinking. She’s shouting at the staff, using her IV pole to steady herself as she stumbles toward the door in her hospital gown, coat and hat.

“This is not detox. This is the emergency room,” Howard tells the woman firmly. “You’re not smoking.”

Down the hall, another woman is briefly handcuffed to her hospital bed. Mesa police arrested her for drunken driving and after finding a crack pipe in her car. A diabetic, she complained of lethargy and low blood sugar. Police brought her to the ER’s back door.

“We call it ‘arrest-o-genic shock,’ ” says Jane Rich, the night charge nurse who’s just taken over for Howard. “Sometimes I feel like we’re running a day care for naughty little children.”

Indeed, a week spent behind the scenes of Arizona’s busiest emergency department reveals a high-octane mix of severe physical ailments and injuries, substance abuse and mental illness, and a lot of people who would be better off staying home in bed.

It provides a glimpse of the dedicated doctors, nurses, therapists and aides who thrive on emergency medicine, candidly acknowledge its shortcomings and wouldn’t dream of doing anything else. Who stay sane with dark humor and inside jokes, and share everything from tator tots to the first whispers of pregnancy and divorce.

And it helps explain why, as the East Valley plunges into the winter flu season, patients can expect long waits in emergency departments Valleywide, even as hospitals, university researchers, doctors groups, ambulance companies and a gubernatorial task force search for ways to ease the pain of overflowing hospitals.

Because even if there’s a nursing shortage, a physician shortage and a hospital bed shortage, there’s surely no shortage of the sick, the injured and the worried.

“I think we’re in a much better position then we probably ever have been,” says Kevin Craven, director of emergency services for Banner Desert. “(But) you’re going to be there for five hours, on average.”

ACUTE CONDITIONS

Emergency room overcrowding is nationwide and its reasons multifaceted, but it’s particularly acute in the East Valley, where triple-digit population growth is taxing all corners of the health care industry.

Last Wednesday night at Banner Desert offers a prime example. The emergency department is fully staffed and there are hospital rooms available, but doctors and nurses simply can’t keep up with the volume of people pouring through the doors.

Medical monitors ping and beep from every corner, and the aide working the phones at the nurse’s station calls one person after another over the intercom. A doctor is holding, a bed is ready, a mop is needed.

Occasionally, the background chatter is broken by a piercing twotone horn; an ambulance is pulling up.

At one point, nine ambulances are lined up at the back door and the hospital alerts emergency crews to divert patients elsewhere. Still, they keep coming. An elderly woman is flown in from Showlow.

Patients are waiting more than 10 hours just to see a doctor. The ER’s 30 beds are full and patients are camped on hallway gurneys. A man has waited 20 hours with his catatonic daughter before a psychiatric unit agrees to accept her. An elderly woman with a heart condition still doesn’t have test results, though she was rushed back to a bed when she arrived 12 hours earlier. A mother is irate and threatening to sue everybody because her daughter has waited 12 hours with stomach pain.

Just as the staff seems to be making a dent in the 25 or so patients who have been triaged by a nurse but still await a physician, a blonde woman in her 30s is wheeled in from the waiting room with a flesh-eating disease that threatens to take her right arm, if not her life. A small army of nurses and technicians connects her to machines and frets over her vital signs. This case will keep one of four doctors tied up for several hours, piling his patient load onto the others.

“They’re coming in faster than we can handle them,” says Rich, an unflappable woman with a raspy voice and a fine sense of humor. “Now we know winter’s truly hit.”

Although it’s hard to tell on this night, additional East Valley hospitals beds have lightened the load somewhat.

The 88-bed Mercy Gilbert Medical Center, a new 120-bed tower at Banner Baywood Medical Center in east Mesa and the emergency-only Gilbert Hospital all opened this year. Banner Desert’s ER will handle a projected 85,000 patients in 2006, down from 94,000 last year.

Still, Arizona is below the national average of 2.8 beds per 1,000 people. Two more hospitals opening in the East Valley next year, Banner Gateway in Gilbert and Mountain Vista Medical Center in east Mesa, still won’t catch up with the area’s growing, aging population. And no one can afford to run a hospital year-round that’s built and staffed to handle the busiest day of the winter flu season.

That’s cold comfort to people in the waiting room of Banner Desert’s emergency department. On any given night, they are a miserable lot. They cough and sneeze and snooze in uncomfortable chairs. Some look like they’re about to vomit, and others already have — the unmistakable smell wafts across the room from the children’s waiting area. A boy with blood on his face screams and writhes in his mother’s arms. He’ll end up with stitches.

Earl and Pinky Wenngren came from their Ahwatukee Foothills home by ambulance on a recent evening. Earl, 77, an easy-going Chicago native, had been shocked back to life by his pacemaker-defibrillator en route, and he’s about to get a real hospital room.

“I’m very happy here,” he says. “They do a good job.”

His wife concurs: “We’ve never had a bad experience at this hospital.”

It’s Earl’s fourth visit in a year, thanks to his ailing heart. “It’s hell to get old, I’ll tell you that.”

NOT ENOUGH BEDS

Patients in the waiting room don’t see people like Earl and Pinky. They don’t know what’s coming in the back door, and are equally unaware of the administrative bottlenecks that keep them waiting. They may not realize that the young man sitting next to them, who came later but was seen first, has a congenital heart defect or stomach cancer. That the elderly woman’s blood pressure is dangerously high.

Nurses and doctors know, but federal law prevents them from sharing any medical information about other patients. They can’t turn patients away, even if they want to. They can’t ask someone why the heck they didn’t wait until tomorrow, or go to urgent care, or just stay home.

The shortage of hospital beds leads to the ER’s most insidious problem — so-called “administrative holds,” in which patients take up precious emergency beds as they wait for an in-patient room to open upstairs. That, in turn, keeps the sick and injured waiting longer for their turns in the emergency room.

Since one-fourth of Banner Desert’s emergency room patients are admitted to the 611-bed hospital, and half of hospital admissions come from the ER, the availability of in-patient rooms is critical to keeping things flowing smoothly in the emergency department.

Pediatric night charge nurse Cherry Creighton came on duty last week to find five of her 14 beds held children who had been admitted but were waiting for an in-patient room, including a newborn girl with a fever who’d been there more than six hours.

A few days earlier, Creighton had eased the same problem by borrowing rooms from the pediatric intensive care unit, but this night they were all full, too. Banner Desert has one of just three pediatric emergency departments in the state.

In addition to dramatically increasing the waits, “bed boarding,” as it’s also called, changes the dynamic for doctors, nurses and aides who feed on the frenetic pace and controlled chaos of a busy ER, but who may be relegated to keeping watch over stable patients for most of their 12-hour shift. It’s not what they signed up for, and, though triage ensures that the sickest children and adults are seen first, it pains them to know there are people waiting.

Patients also linger in emergency beds while nurses track down specialty doctors. National studies have found that the threat of career-ending lawsuits, uncompensated care and the on-call grind have forced brain, orthopedic, hand and plastic surgeons out of the ER. Gastrointestinal and ear, nose and throat physicians also are growing harder to find.

Doctors used to need hospital privileges to keep their practices afloat, and pulling shifts in the ER was part of the deal. The proliferation of specialty hospitals, however, has given many physicians the luxury to leave emergency medicine.

“Thank God there are still doctors here that, when you’re in a bind, they’ll take care of you. But those are the ones who get taken advantage of,” Rich says. “These are good people, and they’re being driven into the ground.”

Gov. Janet Napolitano infuriated health care workers this year when she vetoed a bill to make it harder for patients to sue their ER physicians, which hospital officials contend would have encouraged specialists to return to the emergency department. The governor created a task force to study the physician shortage, and its report is due this month, with tort reform among the list of draft recommendations.

Nurses also are in short supply. Banner Desert has a nurse vacancy rate of more than 30 percent, down from 55 percent last year. The hospital fills the gaps mostly with traveling nurses, who are under contract for 13 weeks and bounce among hospitals nationwide. Napolitano this year approved $20 million over five years to help state universities and community colleges turn out more nurses.

“People don’t have any common sense today,” says a frustrated nurse at the end of her shift. “The last place they want to go when they’re sick is the emergency room.”

It had been a hard day and she was venting in the parking lot. She’d been reprimanded that evening for being rude to a patient at the front desk, after juggling too many people who were in the ER because of their own stupidity, or who didn’t belong there at all.

Even so, she says, “I love it. You’ll have to carry me out of here.”

Nurses tell stories of being bitten, hit, kicked and spat at by patients. They mop up vomit, blood and feces. Routinely, people curse and berate them. Some refuse to work in the pediatric emergency room because they can’t stand seeing children suffer, and others because of the parents. The nurse vacancy rate there is 50 percent.

“Emergency room nurses are the most abused profession,” says Howard, a no-nonsense woman whose badge-holder says “Police line: Do not cross.”

“It’s not for the meek.”

DIFFICULT PATIENTS

Those who often wait longest in ER beds are the mentally ill and substance abusers, because it’s so hard to find a place to put them. Some have waited three days for a treatment bed. Banner Desert staff fear the problem will worsen when the adjacent 40-bed Banner Desert Behavioral Health Center closes this month. Hospital administrators say the 20-year-old behavioral health unit doesn’t fit their longrange plans for the Mesa campus, which include cancer and cardiovascular centers, the children’s hospital, neurosciences and the emergency and trauma center.

Even if, as administrators have promised, there’s enough room at Banner Scottsdale Behavioral Health to absorb the teens and adults who were treated at the Mesa campus, ambulances and families will continue to bring patients to the Banner Desert ER.

The psychiatric unit’s closure has left the staff disheartened and worried.

“We’re waiting for the tidal wave,” says Dr. Alan Walsh, the emergency department’s medical director. “The state is responsible. The state needs to step up.”

Arizona Department of Health Services director Susan Gerard says only Medicaid patients are the state’s responsibility. She’s waiting for hospitals to produce data that show how many behavioral health patients are treated in emergency departments and who’s paying their bills.

“We don’t have statutory authority to address it, nor do we have the funding to address it,” Gerard says. “I guess it’s a policy issue for the Legislature to address.”

Psychiatric patients not only wait longer in the emergency department, they can take an inordinate amount of staff time.

Like the drunken smoker, who ranted at two charge nurses, a doctor and several aides before checking herself out four hours later against medical advice.

Like the suicidal teen, who brooded in a pediatric bed for hours, hunched up and angry.

Like the boy with the dyed-black hair who’d been cutting on himself, who came in the same night.

Like the woman who scored an eight out of 10 on her blood test — positive for methamphetamine, opiates and depressants, among other things. (“And she wonders why she doesn’t feel well,” a nurse says.)

They wait for a therapist to interview them and decide where they should go. They wait for a doctor to prescribe treatment. Then, if they’re deemed a danger to themselves or others, they will wait hours upon hours, perhaps days, for a psychiatric bed. If they are a child or teen, they likely will wait longer.

And through it all, most have to be watched by a “sitter,” usually a nurse’s aide who could be doing myriad other things.

Along with the psychiatric unit, Banner Desert also is closing its outpatient behavioral health treatment program and laying off therapists who evaluated thousands of patients in the ER each year.

“This was one of the best (ER) setups for behavioral health I’ve ever seen,” Rich says, her eyes welling with tears. “Now, there’s nothing I can do for these people, and as a nurse that breaks my heart.”

On a recent morning, 11 people were occupying emergency room beds waiting for admission to a psychiatric facility.

“We can’t be a private care facility for psychiatric patients,” Howard says. “This kind of babysitting has to stop.”

It’s not that Howard, Rich, Walsh and the others are unsympathetic. It’s that they know the ER is not the best place for alcoholics, drug abusers and the mentally ill, and they’re concerned about the other patients who wait for care.

TREATING THE PROBLEM

Emergency room overcrowding is not new to the Valley, and state and federal groups have been studying the issue for years. But it took a frightening turn last winter, when a wicked flu surge brought a crush of patients that led Banner Baywood in east Mesa to close its emergency department for three hours on New Year’s Day.

In addition to drawing state and federal licensing violations, health care workers say Banner Baywood’s drastic move helped propel hospitals Valleywide into action. The state Department of Health Services organized a task force, and hospitals, ambulance companies and others involved in emergency care began regular meetings that appear to have generated frontline improvements.

New intake procedures at Banner Desert’s ER have shown promising results, though the system — initiated in October with a “doorto-doctor” goal of 30 minutes for 50 percent of patients — has yet to hit its mark or be truly tested by the onslaught of winter visitors and flu sufferers.

With grants from Banner Health and the federal government, Arizona State University industrial engineering professor Jeffrey Cochran and Banner executive Twila Burdick are helping redesign Banner emergency departments and their processes, and eventually will create an online “tool kit” available to all hospitals.

Other facilities are watching the Banner experiment.

“We are using these hospitals as living laboratories,” Cochran says of eight hospitals within the Banner system, including six in Arizona.

“The people at these hospitals deserve a lot of credit,” he says. “They’re changing the way they practice medicine.”

The southeast corner of Banner Desert’s emergency room has been transformed into a mini-ER, staffed by two nurses and a physician and equipped with diagnostic machines and bays for four patients. This gets people in front of a doctor sooner and saves precious emergency beds for those who really need them. About 25 percent of patients are treated and discharged from the waiting room having never seen a bed.

Children have their own triage office in their side of the waiting room. Doctors and nurses can begin treatments and order X-rays or other procedures while the children and their parents wait for a bed, or wait until they get results and can go home.

Banner Desert’s pediatric emergency department sees everything from drowning victims to constipated toddlers, and often their extended families. One mother brought her sick baby and his six siblings along.

Lindsay Hicks is a childlife specialist, and she helps children and their parents understand what’s happening to them, armed with a bag of toys and a photo album of doctors in scrubs and kids going under anesthesia.

“You don’t want to lie to a child,” Hicks says. “But we make sure that they know this is a safe place. This is a place where we make things better.”

Hicks’ intervention can reduce the time it takes to get an IV tube, an X-ray or other procedure completed by calming both the child and his parents. That’s good for the family and the staff, and frees a pediatric bed more quickly.

CUTTING WAIT TIMES

The new intake procedures have shaved about 30 minutes off the wait time to see a doctor, though at an average 80 minutes it’s still a way off from the hospital goal. It also has significantly reduced the number of people who leave without receiving treatment — from 8.4 percent in October 2005 to 2.2 percent this year.

Average wait time at Banner Desert in October was roughly five hours, from the time you walk in the door until you’re discharged or taken to an in-patient bed. That’s down from 5 1/2 hours a year earlier.

But anyone who’s been to an emergency room lately knows it often takes a lot longer.

And, depending on your ailment, it might be wiser to stay home in bed.

Triage nurses assess patients as they walk in the door, assigning them a level from 1 to 5, with 1 being the most severe and 5 reserved for folks whose conditions aren’t true emergencies. The level determines how quickly you’ll be seen and how often you must be monitored while you wait.

An increasing number of patients are being referred to the ER from their family doctor or from urgent care centers. Others say they can’t get in to see their physician for weeks, and are in too much pain or too worried to wait that long.

Still others — about 20 percent of Banner Desert’s emergency room patients — are uninsured. They have nowhere else to go.

This year, Banner Desert will absorb an estimated $46 million in uncompensated care, nearly double the $23.6 million in medical care the nonprofit hospital gave away in 2002.

Spend one evening in the ER and it becomes abundantly clear that there’s a need for basic first aid and health care education.

Along with the vomiting, feverish, bleeding children there are those whose worried parents waited hours in the emergency room to be told their child has the flu or a rash. The parents who wanted their daughter to be treated for nausea and vomiting, then fed her french fries while she waited.

Along with heart conditions, asthma and severe infections, adults may wait all night to be sent on their way with little more than advice: Go home, go to bed and drink lots of liquids.

“Parents want a prescription that’s gonna cure it. But there’s not a magic pill for everything,” says Nancy Smith, an on-call ER nurse who’s taking time off to care for her paramedic husband, diagnosed with cancer last May. “The ER waiting room is a petri dish full of, you name it.”

Though doctors and nurses are continually frustrated by people whose poor choices land them in the ER, federal law requires emergency departments to treat everyone who walks in the door.

It’s also worth noting that most of these patients are easy to fix and they’ve got insurance. A study published in August in the Annals of Emergency Medicine showed that the so-called “worried well” and those with sore throats, back aches and relatively minor conditions increase the wait time for people with true emergencies by an average of just 32 seconds.

And there’s a delicate balance hospitals and health care workers must tread between educating the public about when to stay home, when to call the doctor and when to seek emergency treatment. They don’t want nonemergencies clogging up emergency rooms, but they want to ensure people get the health care they need.

The men and women pulling 12-plus-hour shifts in the Banner Desert ER bear witness to the best and worst in human beings. Every day can be a matter of life and death, and though their collective cool often belies it, they are profoundly affected by the tragedies and triumphs they witness.

No matter how long they’ve been up to their elbows in the pain, agony and idiocy of the human condition, it doesn’t get any easier. Indeed, there are mornings when the night crew goes to “church,” gathering at a neighborhood bar after their shift ends at 6 a.m. so they can laugh out loud, commiserate, complain and cry with people who get it.

“Nobody can really understand us but us,” Rich says. “When you see enough dead kids, enough dead adults, enough dead babies, you don’t get hardened to it.”