Di­verted into dan­ger

Har­ried hos­pi­tals send am­bu­lances else­where; one woman didn’t sur­vive

USA TODAY US Edition - - FRONT PAGE - John Diedrich

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.


Alvin Blalock’s girl­friend Tif­fany Tate, mother of their son Alex, 5, had a stroke 350 yards from Froedtert Hos­pi­tal, a top-tier stroke cen­ter, but was taken to a hos­pi­tal that of­fered only lim­ited stroke care. She later died.

Maria Raven

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