The Implosion of Emergency Services in the Texas Gulf Coast

By Guy L. Clifton, M.D.
Neurosurgeon and Clinical Investigator, UT-Houston Medical School

The term "Golden Hour" is used by trauma surgeons to indicate that prompt care of seriously injured patients saves one-third to one-half from unnecessary death. Eighty percent of trauma is from motor vehicles and over half is alcohol-related with only seven percent from gunshot wounds. Texas has 21 major trauma centers (Level I or II) located in most of its major cities. (The only difference in Level I and II is that research is done in Level I centers.) These centers always have trauma surgeons in the hospital, specialists 15 minutes away, and operating rooms and radiology facilities ready for service 24 hours a day, seven days a week. Intensive care units are equipped and staffed to care for the most seriously ill patients. The Level I and II centers in each region of the state are backed up by Level III centers that have the capability to care for injuries that are not immediately life threatening. The trauma care system in Texas has consistently been able to provide rapid, specialized, life-saving care to anyone needing it at any time until recently. The stories of its failure are sobering.

Delmar Clyde was an active 72-year-old man who had retired to McAllen, Texas after a career in the computer industry. He began to lose consciousness on the morning of January 10, 2001. His wife called an ambulance, and he was taken to McAllen Regional Hospital where a CT scan showed a subdural hematoma, a blood clot between his skull and brain. Such a condition is an extreme emergency. Immediate surgery to remove the blood clot can be life saving. Because the McAllen hospital did not have the capability to perform such a surgery, doctors in the McAllen emergency room sought immediate transfer to a hospital with capability to care for Mr. Clyde. Doctors at the McAllen hospital however, called nine hospitals in the region but found none with an empty intensive care bed. As they call hospitals further and further away from McAllen, one empty intensive bed was found at Ben Taub Hospital in Houston. In desperation, the patient was flown approximately 300 miles from McAllen to Houston where he underwent surgery immediately upon arrival - twelve hours after he lost consciousness. By the time Mr. Clyde had surgery the clot had damaged his brain beyond recovery.

Unfortunately, this is not an isolated instance. A car struck a 21-year-old Katy, Texas man on Halloween night of 2001. He was immediately unconscious and was taken from the scene by ambulance to a small Katy hospital where he was found to have a severe brain injury, broken legs and injury to his chest. Normally patients with severe injuries are admitted to a local trauma center within one hour of injury. However, when Katy hospital personnel called both of Houston's Level I trauma centers, Memorial Hermann and Ben Taub Hospital, all intensive care beds were full. The young man was flown to the trauma center at Brackenridge Hospital in Austin, arriving more than three hours after injury, where he subsequently died.

In the winter of 2001 in Montgomery County, a car driven by a young mother swerved to avoid a head-on collision at night. The car struck a large pole. The mother and her two children, four and ten years old, were taken to Conroe Medical Center. The mother died of her injuries in the emergency room. The two children sustained brain injuries and fractures, requiring specialized care immediately - care not available in Conroe. After six hours of phone calls, two pediatric intensive care beds were found at the trauma center in Galveston. There were none in Houston. Fortunately, these two children recovered, but had their injuries been more severe, the delay could have been fatal.

The delay was fatal for two patients who sustained severe injuries and were taken to Cleveland Regional Medical Center in January. After six hours of attempts to find a Level I trauma center with an empty intensive care bed, both patients died in the emergency department of this small hospital. The nurse in attendance said, "I just had the feeling that the 18-year-old could have been saved."

Divert status is a signal sent out by hospitals when their emergency room is full or their hospital beds are full. Beginning in 1999, both Ben Taub and Memorial Hermann Hospitals experienced periods of insufficient capacity for patients who needed Level I care. The two most common reasons for divert status are no more beds in the emergency room in which to put a patient (one-quarter of divert signals), and full intensive care beds (three-quarters of the time). When both major trauma centers in Houston are on divert, City of Houston ambulances bring trauma patients to both, and the hospitals simply do their best to make room. In this circumstance, the trauma centers act as the hospital nearest the injury. However, trauma patients outside the city limits taken from the scene of injury to the emergency rooms of small hospitals to be stabilized must be delayed in admission when there is not room in the trauma centers. The consequences of divert status by the trauma centers have been quantified. Dr. Charles Begley of the University of Texas School of Public Health has shown that on days when Houston's two major trauma centers are on divert status for 8 hours or longer, the mortality rate of patients needing transfer is doubled. In 2001, Ben Taub Hospital and Memorial Hermann Hospital were on divert for at least 8 hours one-third of all days.

Save Our ER's was an organization founded to remedy these problems. A recent study in this region conducted by the Abaris Group and sponsored by Save Our ER's has shown that every hospital outside Houston has reported patients routinely endangered by delays in transfer. Not only trauma patients but also children with any emergency condition and patients with neurological emergencies were endangered due to transfer delays. Texas Department of Health standards call for transfer of emergency patients who need a higher level of care from small hospitals to larger hospitals within 2 hours of admission to the first hospital. In our region 70% of patients are transferred in over 3 hours with 10% requiring over 6 hours to transfer. Rural ambulance services throughout the region are failing due to lack of finances. Even if a bed can be found, in 14% of cases an ambulance may not be available for transport. Complicating the root cause of ICU bed and ambulance shortages was the finding that two-thirds of patients in our areas emergency rooms had complaints that were not urgent. Medicaid and uninsured patients flood our region's emergency rooms because they have no place else to go for care. The picture that emerges is of periodic failure of the emergency services system to provide appropriate care in the Texas Gulf Coast.

The causes of this implosion are uncomplicated. Significant reductions to hospitals in disproportionate share funds (Federal monies to hospitals that care for a disproportionate share of Medicaid and uninsured patient), the high percentage of Texas children who are uninsured, historically low hospital profit margins from care of Medicare and insured patients, and the high percentage of working adults between 18-64 years in Texas who are uninsured result in significant losses to trauma centers. These centers must take care of any injured patient at any time. When an emergency patient is admitted no one knows who is insured and who is not. The trauma centers, therefore, admit the same percentage of the uninsured (or more) present in the community. The uninsured problem is compounded by an unexpected increase in demand for intensive care services for all causes nationally and locally that have outstripped hospital bed capacity. That is, patients with other emergency medical problems are placing increased demands on available ICU beds in trauma centers as well as other hospitals.

A recent financial study by Bishop and Associates which was sponsored by Save Our ERs showed that the region's three Level I trauma centers (Memorial Hermann, Ben Taub and the University of Texas Medical Branch, Galveston) and its 8 Level III hospitals provided $39 million in care to uninsured trauma patients in 2000. The average loss on care of every trauma patient was over $2500 per admitted patient with losses on some patients exceeding $200,000. For this reason no new ICU beds for care of trauma patients have been added in the region for 10 years despite a 20% increase in population. Expansion of ICU beds or creation of new Level I and II trauma centers is impossible as long as hospitals lose more money for every trauma ICU bed they open and every trauma patient they admit.

Two steps must be taken to protect public health. First, sources of funding to permit hospitals to expand trauma services have to be found. Hospitals, doctors, and rehabilitation facilities in this region are providing $60 million/year in care to uninsured trauma patients with no reimbursement. Certainly, they cannot expand capacity without reimbursement. Second, a regional entity should be empowered to dispense the funds and coordinate the delivery of emergency services in the 13 counties of the region. A regional entity is necessary to ensure that trauma capacity is increased and meets community needs. A regional entity is needed to finance and monitor availability of ambulance services in rural counties where the voluntary system is imploding. The problem is not just with trauma care. Pediatric ICU capacity is deficient now. Hospitals are losing money from care of Medicare patients admitted to ICU beds. Elderly patients needing intensive care could face the same shortages that trauma and pediatric patients face now. In Houston, we woke up one morning and had lost 15 percent of the city's already insufficient trauma capacity as Ben Taub Hospital ran out of money and nurses to keep trauma beds open. This might have been prevented with ongoing monitoring of the situation by a regional entity that had the financial power to affect behaviors of hospitals and emergency medical service systems. The lack of regional emergency services infrastructure would leave us entirely unable to cope with a catastrophe such as 9/11.

The Houston/Galveston Area Council is composed of elected officials of Harris and every surrounding county and most municipalities. This established entity deals with issues requiring regional solutions such as transportation and air quality. It receives and distributes both State and Federal funds to regional governments. It has not, in the past, had a significant role in health care. This is the logical entity to solve the regional emergency services crisis. Both Harris County Commissioner's Court and the Board of the Houston/Galveston Area Council have supported the creation of an Emergency Services Council through the Houston/Galveston Area Council. This Council would accomplish the objective of ensuring that every patient needing emergency services in the region receives care in a timely manner.

These steps will be an appropriate start to solving our regional crisis. It will be up to the community to work together to find solutions for this public safety crisis.