[T]he emergency department at the University of Vermont Medical Center has seen a higher than usual surge of patients, particularly over the past three months, conditions that have prompted a formal complaint to Vermont regulators and a claim by a local ambulance chief of negligent patient care.
UVMMC officials see no single explanation such as the flu for the surge, which has been so intense that one day in the past two weeks the 45-bed emergency department had a record-breaking 106 patients admitted and waiting to be seen at one time. Overflow patients are routinely kept in hallways when the ED is over capacity. On a typical day, 175 patients cycle through the emergency department.
UVMMC’s chief medical officer, Dr. Isabelle Desjardins, said emergency department doctors and nurses follow a strict protocol to triage patients — determining who will be treated first based on the severity of injuries. She said even with the recent increase in volume that patient care had not been compromised.
Desjardins said the ED crunch was being felt regionally and that referral hospitals — like UVMMC and Dartmouth-Hitchcock Medical Center in Hanover, New Hampshire, that take patients from smaller area hospitals — are feeling the increase more acutely. A Dartmouth-Hitchcock spokesperson confirmed the large, regional hospital had also been seeing a higher than usual demand in the ER. (Hospitals have for years had challenges getting psychiatric patients into non-ER rooms, particularly after Tropical Storm Irene in 2011 damaged state facilities in Waterbury.)
The president of the UVMMC nurse’s union, Laurie Aunchman, said the emergency department overcrowding has been ongoing, was an issue in last year’s nurses’ strike and, while chronic, had been particularly heavy over the past three months.
The Chittenden County ambulance chief told VTDigger anonymously that a recent car accident victim his crew transported was not seen by a physician for almost four hours. The person was then was taken into an operating room with major internal injuries shortly after a doctor attended to her. The EMT said he would personally rather be transported to a different hospital.
“Bottom line: This person was inappropriately placed in the hallway bed and it almost resulted in their death. They were ignored because the hospital refuses to address the issues of overcrowding in the emergency department, despite running large surpluses. This is inexcusable. Even as a paramedic with many friends who are nurses and doctors at the UVMMC ED I would choose to be transported to a different hospital,” the ambulance official said.
Desjardins said she was unaware of the car accident case but regardless expressed confidence that proper procedures had been followed in that case as well as during the months-long higher traffic of patients.
“I am really aware of the (overcrowding) situation and curious about the root cause of it,” she said, adding that colleagues at the UVM College of Medicine were studying why the increase since December had occurred. ED overcrowding is a regional problem, she said, with patients older and apparently sicker than usual. There have also been falls on the ice and a typical flu season. She said the increase was not for any one reason but a combination of factors.
Patients in the ED “are sicker than they used to be,” Desjardins said, requiring additional admissions to an already full hospital.
Desjardins also said the flow of patients from the ED to regular hospital rooms has been slowed or blocked by a higher than usual number of double-bed rooms being used by only one person, either because of an infection or other issues that prevented two from sharing a room. Twice in the past two months, Desjardins said, there were as many as 60 beds in the approximately 400-bed hospital that went unused.
“We have had enormous amounts of fluctuations in the number of people we have to care for in our emergency department lately,” Desjardins said. “Part of the throughput challenge has been that we have some patients who are spending a long period of time in the emergency department waiting for in-patient beds. That is both for medical surgical beds and in-patient psychiatry treatment and that causes some traffic control, if you will, difficulties in the emergency department where sometimes we have to treat our patients and evaluate them on hospital beds that are not in individual rooms” but in the corridors.
“I wouldn’t necessarily call it a chronic problem,” Desjardins said. “Because It’s really a pattern we’ve started to see more or less in the past three months. But it reflects the needs of our population and a need to provide care differently,” including not having unused beds.
The hospital’s 138 new single rooms slated to be completed in June as part of an expansion should help the flow of patients and alleviate some of the backup in the emergency department, Desjardins said.
Aaron Smith, an official with the Centers for Medicare and Medicaid Services (CMS) in Boston, confirmed Vermont regulatory officials had received a complaint about conditions at the UVMMC emergency department and were “looking into it.” He referred further questions to Vermont regulators.
Suzanne Leavitt, the state survey agency director at Vermont’s Division of Licensing and Protection (DLP), said she could not confirm or deny a complaint had been filed, discuss the nature of any complaint or whether or when an investigation or inspection would be conducted.
A UVMMC spokesperson, Michael Carrese, said the hospital had not been notified by CMS, but Leavitt said inspections by a team of nurses were usually unannounced. She said the timing of investigations or inspections was done based on the severity of the complaint. She said hundreds of complaints about medical care are filed with her agency each year and can take weeks or months to investigate.
If a “deficiency” or non-compliance with state or federal regulations is found, the medical facility is required to fix the problem and the deficiency or non-compliance is made public on the division’s website, Leavitt said.
According to a review of the DLP website, there were four complaints investigated involving UVMMC in 2018 and a total of 25 investigations since 2010.
The local ambulance chief who contacted VTDigger described conditions in the UVMMC emergency department as being similar to “a developing country or war-torn region” and said that patients were not afforded enough privacy.
“This week I have witnessed patients hanging out of hallway beds, distraught and sick, in pain, while people walked by and gawked. I watched semi-sterile procedures be performed without even curtains to separate dirty ambulance stretchers from the patient as EMTs walked by to clean their equipment,” the ambulance head wrote.
Aunchman, the nurses union president who works in the Intensive Care Unit, said emergency room overcrowding was an ongoing problem but lately more constant.
“There’s not just a quick answer of we need more beds or more staff,” she said. “A lot of things contribute. We’re dedicated to our patients but it is a challenge when someone’s on a stretcher in the hallways. It’s not just unique to right now. It’s been happening for a while.”
Aunchman said recently that as many as nine ICU patients ready to go to a regular room couldn’t because there were no available free beds.
Dan Batsie, chief of emergency medical services at the Vermont Department of Health, said his agency had not received any complaints about patient care at UVMMC. All Vermont hospitals, he said, see high volumes at times in their emergency departments and have plans to cope with “surge capacity” for flu season or during disasters.
“ER’s get busy and you have crazy nights. It happens all the time,” Batsie said. “It’s not an uncommon thing for the census to go way up.”
Dartmouth-Hitchcock spokesperson Rick Adams Jr. said the emergency department had seen some surges of higher volume but was overall stable.
There were as many as 290 requests denied in a month for inpatient transfers from other hospitals, Adams said. Because of that, Adams said hospital trustees had given preliminary approval to renovate and expand the emergency department.
Adams said the complexity of patients’ needs in the ED was another pressure point “as well as the increasing number of behavioral health patients seeking our care, many of whom have prolonged ED stays due to a statewide shortage of behavioral health beds.”