[Photo: The Washington County Hospital in Maryland is the only medical facility in its county. The hospital sometimes experiences two- to three-hour waits for ambulances at its back door. Photo courtesy of the Washington County Hospital.]
All it takes is a single major incident, or just a run of bad luck, for emergency responders in Baltimore to find themselves in a holding pattern.
“Even with 15 hospitals in the immediate area, it’s not hard at all for us to flood a single hospital,” said Capt. Jim Matz, an infection control officer in the Baltimore City Fire Department. “When that happens, our people end in a holding pattern, and with only 24 units to handle 180,000 calls a year, we can’t afford to get hung up.”
Fortunately for Matz and other first responders throughout Maryland, the state offers an easy-to-access, real-time system called CHATS, the County Hospital Alert Tracking System, which lets emergency departments give notice when they temporarily can’t accept ambulance-transported patients because of hospital overload.
Emergency room overcrowding can be a serious issue. Each year, half a million ambulances are diverted from full emergency rooms to hospitals farther afield, according to the Centers for Disease Control and Prevention. In Maryland, some hospitals’ emergency rooms diverted ambulances at least 15 percent of the time in 2008, according to a Washington Post analysis.
The CHATS solution covers 48 acute care hospitals statewide. There’s no cost to users, and the system is managed by the Maryland Institute for Emergency Medical Services Systems (MIEMSS). Online since 1993 and updated repeatedly since then, the system replaced a two-decades’-old method of phone calls and whiteboards.
Hospitals self-report their status to a Web-based application that’s available to emergency personnel through any browser. By putting up a color-coded alert, “the hospitals are asking ambulances: Can you go someplace else because we are kind of busy right now?” said MIEMSS Director of Field Operations John Donohue.
“Busy” can take multiple forms: Yellow indicates overly hectic conditions and a red alert means there are no critical care beds available. Ambulance personnel also can enter a “reroute” signal, letting other emergency responders know that ambulances are starting to pile up at the door. “It’s for when you know the ambulances are going to get stuck big time,” Donohue said.
Emergency department staff typically post an alert to CHATS as directed by the nurse or doctor in charge. However, whatever the alert code may be, critical patients still go to the closest facility.
Most recently, CHATS’ functionality was wrapped into the commercial software package HC Standard from vendor Global Emergency Resources. A dashboard application for tracking health-care operations, HC Standard brings enhanced scalability and reliability to CHATS’ original homegrown capabilities.
The application also incorporates the functionality of the state’s Facility Resource Emergency Database, a tool for communicating succinct information in the face of large-scale mass casualty incidents.
Before implementing HC Standard, “we were filling up their screens, we were giving them too much input,” Donohue said. “Now it’s all under one roof.”
At the 270-bed Washington County Hospital, CHATS has helped keep the switchboard clear, freeing up hands for work other than dialing.
“It used to be when we went on alert, we had to make a lot of phone calls to hospitals and to the 911 dispatch,” said Susie Burleson, trauma emergency medical services manager of the hospital. “You can have other calls coming in, you can take up multiple lines, all while you are busy trying to deal with all the craziness. CHATS takes away five or six phone calls. That is a big help.”
As with any emergency room, Washington County Hospital has seen its share of backlog. “We’ve gotten five ambulances in the back door with a two- or three-hour wait, with 30 people waiting,” Burleson said. “In the winter it might be the flu or in the summer it might be respiratory cases, but there is no rhyme or reason for the day or the time.”
As the only hospital in its county, Washington County doesn’t always have the luxury of redirecting incoming traffic. What CHATS can do that’s equally important is help hospital administrators allot their resources when an alert goes off in an adjacent county. “It gives us a chance to prepare for extra patients, to see how our bed situation is, to make sure we have all our supplies,” Burleson said. “If you know you’re going to get a couple of extra people, you want your staff to be prepared for that.”
First responders say the system gives them a clear look into traffic conditions at local emergency rooms, which helps guide their decisions.
Take for instance Prince George’s County Fire/Emergency Medical Services Department. With six hospitals in the county, it can be hard to know where to turn when conditions extend beyond the ordinary, said Paramedic Capt. Roland Berg. “If I have a mass casualty incident and need to determine where I am going to dispatch these patients, CHATS will give me real-time situational awareness to show me which hospitals I can send these people to,” he said.
The information is clear, concise and color-coded, which helps in making quick decisions. Perhaps most significant is the technology platform MIEMSS chose for the system: the Web. “Anywhere I can get an Internet connection, I can get this information,” Berg said. “I have sat on the scene, looked at my BlackBerry and brought up that Web page in real time to see what that hospital’s status is.”
Although CHATS can provide a snapshot, Berg said the system has limitations. In his experience, yellow and red alerts don’t always deliver the kind of granularity he needs when making fine-point decisions. In cases where more detail is needed, Berg said, it can help to augment the system’s data with more traditional in-person contacts.
“I can say to the charge nurse, ‘When do you expect to have a bed for these four units?’” he said. “Then I can make an assessment based on that information and based on looking at the patient loads, so that I can say, ‘Let’s go ahead and shut this hospital down completely; let’s put it on reroute.’”
As an infection control officer, Matz said he saw just what CHATS could do during last winter’s H1N1 outbreak. “You get somebody who gets the sniffles and they hear about swine flu and they run in to get checked,” he said. “A lot of those people will use an ER almost like a primary-care physician.”
The statewide system helps balance patient loads to prevent overwhelming one hospital. “If only 10 people hit one ER that’s already taxed to the limit, that can be all it takes to flood the ER,” he said. “When that happens, CHATS is a huge tool to help us balance the load around the 15 surrounding hospitals in our jurisdiction. It gets the right patient to the right hospital with the least amount of friction and the least amount of waiting time.”
Over time, CHATS has proven to be a powerful tool in more than just the daily routing of emergency room traffic. For planners at the state level, data from the system has helped shape big-picture decisions about the availability of health care.
Over the past five to eight years, the state has seen a big push to expand or renovate emergency room facilities, said Pam Barclay, director of the Center for Hospital Services in the Maryland Health Care Commission. “These tend to be large capital projects where hospitals are expanding or renovating major parts of their facilities and they are coming to the state for approval,” she said.
In making those decisions, Barclay’s office looks for any patterns of crowding that can be seen in CHATS’ data. “It’s not the only thing you look at, but it is an indicator,” she said. CHATS only reports on ambulances, and emergency room walk-ins can skew the figures, but Barclay added that CHATS tells you important data about the availability of emergency room resources.
CHATS’ long-term view is especially valuable to Barclay. “It gives you the ability to look at data over time,” she said. “For people who are doing planning and policy development, you never want to be looking at just one data point. CHATS can give you a picture of how things have changed and evolved.”
CHATS isn’t the only system of its kind in use today. Georgia relies on the off-the-shelf platform LiveProcess to report bed availability, keep tabs on patient surges and monitor supplies. New Jersey achieves situational awareness through its Hippocrates system, a high-level architecture for data collection, display and analysis.
New York state’s Health Emergency Response Data System provides real-time data on factors like inpatient bed capacity, available ventilators, isolation room capacity, staff resources and the availability of drugs and supplies.
Yet advocates of such systems say the prospect of emergency room resource reporting is by no means welcome in every case. “The politics against them have been fairly strong, because hospitals have not always been very open about how full they are,” said Ricardo Martinez, Division East president for the Schumacher Group, an emergency medicine practice management company, and a professor of emergency medicine at Emory University.
Too often, he said, hospitals will declare themselves overcrowded to keep beds open for scheduled surgeries. In case of emergencies, “many places will go on diversion, and you always are wondering whether everyone is doing their fair share,” he said.
A little more openness of the sort CHATS provides would serve both patients and emergency responders, Martinez said. “In health care, we are pretty good at competing, but we’re not that good at collaborating. That’s something that ought to change.”CAPTION:
The Washington County Hospital has experienced two-to three-hour waits for ambulances waiting at its back door.