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Are diverted ambulances the Achilles’ heel of the city’s health-care reform?

The annual visit of the Amusement of America carnival over Memorial Day weekend at RFK Stadium is a traditional rite of summer in the District. Unfortunately, the fair is as well-known for the fatalities and morbid injuries that often occur there as it is for its entertainment.

This year’s carnival proved no different. At around 10:50 p.m. on May 28, an argument flared between 22-year-old Freddie Aikens and a still-unidentified man in Parking Lot 6 of the stadium. During the argument, the man with whom Aikens was arguing pulled out a handgun and shot Aikens and another man. He then fled the scene and has yet to be apprehended.

The campus of D.C. General Hospital is a stone’s throw from RFK Stadium, but the hospital’s trauma center was operating under what is known as a “Level 3” designation—the lowest level of care—which bars ambulances carrying severely injured patients in need of surgery or hospitalization. So Aikens was taken instead to Howard University Hospital.

The four-mile ride from the scene of the shooting in Southeast to the hospital in Northwest takes approximately 15 minutes in non-rush-hour traffic. Aikens was pronounced dead at Howard University Hospital at 11:29 p.m.

It will take years to assess the long-term success or failure of the decision by Mayor Anthony A. Williams and the District’s financial control board to abolish the city’s Public Benefit Corp. (PBC), shut down most services at D.C. General, and replace the public health-care network with a private entity: the D.C. HealthCare Alliance Network. But the deaths of Aikens and others in the transition have become immediate rallying cries for the vociferous opponents of D.C. General’s closing.

Critics of the city’s health-care-reform plan also point to the death of 21-year-old John Thomas Ellis, who was shot on April 28 in the 3800 block of 9th Street SE at approximately 11:35 p.m. Ellis was transported to Howard University Hospital and pronounced dead at 12:48 a.m. They also argue that the death of 19-year-old William Eric Etheridge, a local star athlete who’d planned to attend college this fall, resulted from D.C. General’s phaseout. Etheridge was shot on May 5 at approximately 11:59 p.m. in the 300 block of Anacostia Road SE and then transported to Prince George’s Hospital Center, where he was pronounced dead at 12:53 a.m.

The Coalition to Save D.C. General Hospital argues that as many as 13 deaths have occurred since April that can be attributed to the impending shutdown of trauma services at D.C. General’s emergency room.

“In most major metropolitan areas, there is a health-care shortage—an existing crisis. Then, when the No. 1 trauma hospital is closed, you have a situation waiting to explode,” says coalition member Nina Ogden.

The five-year contract between the city and Alliance—worth nearly $90 million in the first year alone—is being implemented gradually. Inpatient services at D.C. General were transferred on Monday to Greater Southeast Community Hospital (which will serve as the flagship for the Alliance network), but Greater Southeast has yet to construct a trauma center equipped to handle victims of gun and knife violence, motor-vehicle accidents, and other such grave injuries.

Although the Statement of Work outlined in the final contract between the financial control board and Alliance set an August deadline for the transition of trauma services, there have been glitches on both ends of the deal. D.C. General permanently closed its doors to such emergencies in the third week of May (the emergency room was diverting severe trauma cases for weeks before that), and Greater Southeast’s trauma center will not be fully operational until this fall.

“Greater Southeast is gearing up to become a trauma center before October,” says Donna Lewis Johnson, head of marketing and public relations for Greater Southeast and Hadley Memorial Hospitals.

In the interim, there are five other trauma centers within the District, including Howard University Hospital, George Washington University Medical Center, Georgetown University Hospital, Washington Hospital Center MedStar Unit, and Children’s National Medical Center. None of these trauma centers are located in Southeast, however, so patients who are seriously injured there have to endure lengthy transits to emergency care.

The ability of area hospitals to absorb the influx of trauma patients during the transition is an open question. D.C. General accepted 6,046 ambulances between Jan. 1 and May 12 last year. During the same period in 2001, the hospital accepted only 3,991.

Even without a fully functioning trauma center, Greater Southeast this year

experienced a 13 percent increase in ambulance traffic from Jan. 1, 2001, to May 12 compared with the same period last year. Howard University Hospital experienced an 11 percent increase.

Johnson would not comment on an increase in ambulance traffic to other trauma centers during the transition, but she observes that “George Washington University Hospital, as an Alliance contractor, is providing trauma services” during the transition.

George Washington University Hospital, through a spokesperson, declined to comment on ambulance traffic diverted to its emergency room. Howard University’s public relations office also declined to comment.

Ambulance diversions are an easy hook on which to hang a larger protest against privatizing the city’s health care for the indigent. Perhaps too easy. Diversions of ambulances are nothing new in the District, or in any other major American city.

Hospitals, for a variety of reasons, often decide to divert some or all ambulance traffic for short periods of time. For a District hospital to receive temporary diversionary or closure status, a hospital administrator or other authorized party must call the city’s Emergency Medical Services (EMS) bureau supervisor, who then approves the request and grants diversion or closure status—most typically in two-hour increments.

Dr. Howard Freed, director of emergency medicine at D.C. General, argues that his hospital experienced ebbs and flows in diversion over the past few years.

“Ambulance diversion is a standard practice in D.C. and all other cities; it exists in all EMS systems,” says Freed. “Tracking of these diversionary hours has gone on for years, and in the past, D.C. General has had the most hours [of ambulance diversion].”

Freed argues that things at D.C. General did get better over time. “In 1997, services improved, and our number of hours on diversion began to drop,” he continues. “Last year was the first year that D.C. General was not the city hospital [in D.C.] with the most hours of diversion. In comparison to other major cities such as San Francisco, Denver, and New York City, our numbers looked good.”

The Williams administration disagreed with that assessment. A Health Services Reform Update released by the mayor’s office in March attempted to dismiss citizen concern over the closing of D.C. General’s trauma unit by noting that the hospital “failed its Level 1 trauma survey by the American College of Surgeons [ACS] in June 1999. Since then it has not been an ACS verified trauma center.”

The ACS assessment is a voluntary process that hospitals undergo every three years. Failing the survey does not bar an emergency room from providing trauma services, as D.C. General continued to do until late May.

Regardless of D.C. General’s rating, the transition plan called for the hospital’s trauma services to be left intact until the Greater Southeast center opened. But as the beleaguered hospital became increasingly embroiled in the political and financial struggle to keep its doors open, ambulance diversion rates skyrocketed to 50 percent through most of 2001 and then up to 60 percent in April.

“As D.C. General was dying, our hours of diversion increased once again,” says Freed. “Finally, as the PBC was abolished, one of the Health Department’s first moves was to restrict ambulances coming to D.C. General to Level 3—the lowest level of severity.”

Lack of staff appears to be the main factor in the drop in trauma care. Nurses who had known for months that they would be laid off on July 14—with the majority of the hospital’s other 1,640 employees—started cashing in years of “use or lose” sick and vacation time. The glut of vacation left the hospital understaffed and ill-equipped to handle severely injured patients—and led directly to the Level 3 classification.

“Level 3 patients are stable,” explains Freed. “If someone sprains or breaks an ankle, death isn’t knocking at their door, but they will need an ambulance to take them to the hospital.”

Dr. Larry Siegel, senior department director of medical affairs for the D.C. Department of Health, agrees that the Level 3 designation was the smartest move during the dismantling of D.C. General by the city. “We decided that trauma patients—the most critical patients—be taken to an emergency room where they can be best treated. The Level 3 designation exists so that EMS isn’t put in a position to make a decision that results in the improper transport of

a patient.”

Ambulances carrying less-than-stable patients are being rerouted to other hospitals, but patients with severe injuries who arrive at D.C. General on their own are evaluated by emergency-room doctors and transported after they have been stabilized.

Freed argues that patients with serious ailments are better served by being taken to a hospital equipped to handle their needs. “Most protocol directs ambulances to take patients to the nearest Level 1 trauma center,” he says. Freed argues that studies have found that patients had a better chance of survival “when [ambulances] drove past the closest full-service hospital and took patients to the appropriate trauma center.”

The awkward transition has placed the District in a position where it will test such theories this summer with the city’s trauma victims. CP