Diverted into danger
Harried hospitals send ambulances elsewhere; one woman didn’t survive
MILWAUKEE – As she got ready to work the breakfast shift at the Medical College of Wisconsin cafeteria, Tiffany Tate didn’t feel well.
Tate, 37, was a fixture on the cafeteria’s “hot line,” where she worked behind a steaming grill. She knew the names of many workers and their kids, always sharing smiles and small talk.
She had a teenager and 8-month-old at home, so recent months had been an exhausting blitz for Tate. That morning, she told some of the other kitchen workers she had a headache and felt weak. She figured it was because of a new medication for her back pain.
Shortly after 8 a.m., as Tate and a group of workers came off a break, she felt worse. A coworker saw Tate leaning against a counter, supporting herself with one hand. The left side of Tate’s face drooped; she slurred her words.
A customer walked up. Both could see what was happening and said the same thing: “She’s having a stroke.”
At its most basic level, a stroke is an attack on the brain. A clot becomes lodged in an artery, choking off vital blood flow. Every minute blood flow is interrupted, it can cause irreversible damage to millions of brain cells.
Sending patients directly to top-level stroke centers – hospitals that can administer clot-bust-
“People can’t control when they have their stroke.”
Maria Raven, emergency room doctor
ing drugs or go in through arteries to physically remove clots – offers the best chance at survival. The ideal window for care is within the first three hours.
On that morning four years ago, Tate had a stroke on the grounds of the Milwaukee Regional Medical Center – 350 yards from Froedtert Hospital, the area’s most advanced, experienced stroke care center.
It would be a quick ambulance ride. If only the ambulance had taken her there.
It didn’t.
Little-known practice of diversion
Every day as thousands of ambulances zig-zag through city streets, along congested highways and rural roads, it’s easy to imagine they’re headed to the nearest hospital or to the emergency room best suited to care for the sick or injured person on board.
That’s not always so. Emergency departments in hospitals nationwide deploy a controversial tactic, turning would-be patients away. It’s called ambulance diversion. Hospital officials decide they are too busy and tell ambulances to go elsewhere.
In some cases, the crowding is due to a surge of patients. In others, the problem is a poor system for moving patients through the hospital, creating bottlenecks elsewhere that hamper the ER.
The ambulance carrying Tiffany Tate was sent to a hospital 3 miles away that offered only limited stroke care.
Federal law requires hospitals to treat patients who arrive in their emergency room and make sure they are stable before releasing or transferring them. That applies to everyone who walks in the door of any of the nation’s 5,500 hospitals.
If you’re in an ambulance that’s ordered not to come, the law is irrelevant.
Maria Raven, an emergency room doctor and professor at the University of California-San Francisco, said Tate should have been taken to Froedtert.
“To my mind, they shouldn’t be a Comprehensive Stroke Center if they can close,” Raven said. “Either you can be one or can’t be. People can’t control when they have their stroke.”
Milwaukee County officially ended diversion in 2016. The practice continues elsewhere.
A Milwaukee Journal Sentinel review of the 25 largest cities found 16 of them – including nine of the 10 largest – allow ambulance diversion of some kind, though rules governing when patients can be diverted vary widely.
They include cities such as New York, Phoenix, Chicago, Los Angeles and Knoxville, Tennessee.
No uniform set of rules governs how or when ambulance diversion is used.
No single agency tracks the practice or measures how frequently hospital doors are closed. No one tracks what happens to the patients who have their treatment delayed.
In some places where diversion is allowed, officials require hospitals to accept stroke patients even during periods of diversion.
Longtime practice
The practice emerged in the 1980s, when many hospitals found themselves so jammed that patients might lie on beds in emergency room hallways after initial treatment for hours, even days, before they could be discharged or admitted.
The problem was compounded by another common occurrence that continues at some hospitals.
Surgeons schedule operations and procedures earlier in the week, allowing for weekday healing time and discharge before the weekend when many hospitals have skeleton crews.
That meant intensive care units were often crowded through the middle of the week. Patients treated in the emergency room who needed to be admitted to the ICU would have no place to go.
ERs were forced to deal with an influx of psychiatric patients, the result of a federal court-ordered shift from institutional care to community placement.
In the years that followed, emergency rooms became the first stop for many kinds of care, often minor ailments – fever, dizziness, sprained ankles. Over the past 15 years, emergency room visits jumped 20 percent, to 137 million last year, from 114 million in 2003.
In urban areas, many hospitals have closed, putting extra pressure on the ones that remain.
A report in 2001 from the U.S. House Committee on Government Reform found diversions were so widespread they represented a threat to emergency medical readiness, including in the event of a terrorist attack.
“Diversion has been aggressively abused,” said Corey Slovis, chair of emergency medicine at Vanderbilt University and the medical director for the Nashville Fire Department.
Hospitals might turn away ambulances if equipment breaks down or if there is an unexpected problem, such as flooding or electricity being out.
The idea of diversion policies is to protect patients from long, dangerous waits at a crowded hospital. The key is to get the ambulance patient to a less crowded hospital that has the same capabilities.
The problem: When one hospital closes its doors, it sends extra ambulances on to the next hospital, which may have to close its doors. Sometimes hospitals close simply in anticipation of getting more patients.
“You really don’t want to be brought to a hospital that doesn’t think they can do the job properly,” said Lewis Nelson, a doctor and chair of emergency medicine at Rutgers Medical School in New Jersey.
A tragic sequence of events
It is less than four football fields from the cafeteria where Tate suffered her stroke to the emergency room at Froedtert. A skywalk connects them.
Had Tate been wheeled into the emergency room, doctors would have been required under federal law to care for her, even while ambulances were turned away. Instead, she was taken to Aurora West Allis Medical Center, about 3 miles away.
Aurora West Allis could not handle the case. It transferred Tate to Aurora St. Luke’s Medical Center. She arrived about three and a half hours after she first showed signs of stroke.
Using a catheter, doctors tried to reach the clot lodged in Tate’s neck through an artery in her leg, medical records show. The procedure didn’t work.
Tate’s family had gathered. Their biggest question: Why wasn’t she cared for at Froedtert?
“It didn’t make any sense to me,” her brother David said in an interview. “Damn, she was at Froedtert. She works there. She was right there.”
Several health experts had the same question. “To me, if someone is on the grounds of your hospital, they are yours,” Raven said. “It is really sad. There were so many failures.”
Michael Carome, a former top official in the U.S. Department of Health and Human Services who is medical director of Public Citizen, a public policy group, said the delay in getting Tate to a toplevel stroke center diminished her chances of survival.
“I would think there is a very high probability that the (delay) reasonably contributed to her adverse outcome given what we know about the golden window to quickly treat an ischemic stroke,” Carome said.
The experts said it is impossible to know whether Tate would have survived if she had gone straight to Froedtert.
But they were unified in this: She would have had a better chance.