Truth -- 87% of Palm Drive Emergency Room Visits Were Urgent Care

In a recent post, Dan Smith (aka Farmer Dan) stated that 85% of patients visiting the Palm Drive Emergency Room in 2013 actually required an emergency room rather than urgent care. The Foundation used exactly the same statistics in its public presentation last week in Sebastopol. According to both, Palm Drive ER visits were rated either "high acuity," requiring an emergency room, or "low acuity," requiring urgent care or less.

But this is simply wrong. Palm Drive Hospital didn't use a high/low acuity rating system--it used a 5-tier rating system, and only the top tier was used for "life threatening" cases that truly required an emergency room.

And in both 2012 and 2013, only 13% of visits were rated in this "life threatening" category.

The raw OSHPD data for 2013 is daunting (see link below for the full 2013 data set). Fortunately, Sonoma County has assembled a user-friendly summary for 2012. In 2012, just like 2013, the "life threatening" cases were about 13% of the total visits to the Palm Drive ER. Here's the link to the relevant page of that document (scroll down to the bottom of that page for ER statistics).

Let's be clear--I'm not minimizing the importance of those cases that truly require an emergency room. That's why I support reopening Palm Drive if it's fiscally responsible and sustainable. But we need to see the facts clearly, not distort the facts to support a particular viewpoint. If we can't reopen Palm Drive as an acute care hospital with an ER (a Herculean task, as everyone acknowledges ), then we need to understand our options to create the best health care services we can for all of West County.

The full OSHPD data set for 2013 can be found here (https://www.oshpd.ca.gov/hid/Product...ata_FINAL.xlsx) for the data lovers out there.

And here's a link to the full Sonoma County 2012 document.

"Fiscally responsible and sustainable"??? just get it done! 13% is more than enough. We're not talking about money here, we're talking about human lives. Ask the people who are anticipating their next stroke or heart attack, the people who won't be able to wait it out in an ambulance on their way to Santa Rosa. The people of Sebastopol are wealthy, and compassionate people. I think an ER is something they want and want to support. And from what I hear there's a lot of fiscal unresponsiveness wafting around down there. Maybe a larger financial oversight board is needed...

Jim,

What the data I provided showed was that the physicians rated the cases as emergent, not urgent based on their diagnosis. Emergent does not mean 'life threatening.' I did not claim that they were all 'life threatening,' which is obviously a much higher standard than the physician's rating of an emergency vs urgent. My data is not 'wrong', you are using a very different standard.

Let's take some examples: I dropped a farm trailer on my ankle (a real case.) The tissue above my ankle was badly traumatized and bleeding and I lost feeling in my foot. I could not tell if there were broken bones. I, and I am sure Dr. Betz, thought this was an emergency but neither one of us thought is was 'life threatening.'

I cut my leg with a chain saw (another real case). The wound was just above the knee and about 5 inches across. My leg was bleeding badly. Fortunately, the cut did not get into muscle or bone so simply sewing it up was enough, but I did not know this. Again, emergency, not life threatening.

My wife had an asthma attack and was have great difficulty breathing. Clearly, life threatening and needing immediate care in which minutes mattered. (another real case)

At the age of two, my daughter was stung repeatedly by bees. Knowing that she was asthmatic, we rushed her to Palm Drive. Was this an emergency? Likely. Was it 'life threatening?' Who knows.

At 12:01 on the night before the hospital closed, a family brought a gentleman to the ER. He had 98% occlusion of heart arteries and was experiencing chest pain. They had not called an ambulance because they did not think it life threatening though he likely was only a few minutes from death. Emergency and life threatening.

As you see, in the real world, people often do not know if they are experiencing a 'life threatening' condition. (Most of us are not trained ER doctors.) Let's take another real case: A 26 year old female is experiencing what feels like intense gastric distress. After a while, she starts to feel faint so she gets in her car and drives to Palm Drive. As it turns out, her 'urgent' case is the result of massive internal bleeding from a ruptured tubal pregnancy and by the time she reaches the ER, she is within minutes of dying. HAd she gone to an urgent care clinic, she would have died. She also would not have made it to Santa Rosa in her car! She sent Joan and I a very sweet card thanking us for keeping the hospital opened and saving her life, something I still treasure.

So your argument that only 15% of the visits to the ER are 'life threatening' does not hold any water (or with any of the doctors I know) for the obvious reason that most of the time we don't know if our condition is 'life threatening' until we get a full workup and diagnosis. We might think a stroke is a headache or a headache a stroke. We often think a heart attack is something else. As an example, one of my neighbors stayed home for 5 days after a heart attack thinking he was having gastric reflux. He is dead today.

But, just for the sake of argument, let's say that you think we really only have 15% of cases that are emergencies. So let's assume (for argument) that all of these people know that they are having a life threatening condition and all of the others know that they are not. Also, no ambulances are going to come. Let's say for argument that at least some of these cases are not life threatening. Now, only 80-85% of the cases are going to come to Jim's new urgent care center. (Actually, it will be more like 50% because many people will believe their condition is life threatening and go to an ER even though they could be seen in an urgent care.)

But Jim is going to run it 24/7 with a doctor on duty and nurses, X-ray and lab just like an emergency room? How do you make that work financially? The answer is you don't. That is why Memorial Hospital has said they will need $2.5 million from the district to put 24/7 urgent care in Sebastopol.

I appreciate you making your position clear on these matters. Through your commentary here, I think everyone is much clearer about your position. What I am also much clearer about is that you have not spoken with the physicians about any of this but are using your own judgements of the data to determine the efficacy of urgent care vs emergency room. My own approach is to ask the docs. They seem to understand the delivery of medicine much better than you or I.

Best Regards,

Farmer Dan

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Posted in reply to the post by Kai Daniel:

"Fiscally responsible and sustainable"??? just get it done! 13% is more than enough. We're not talking about money here, we're talking about human lives. Ask the people who are anticipating their next stroke or heart attack, the people who won't be able to wait it out in an ambulance on their way to Santa Rosa. The people of Sebastopol are wealthy, and compassionate people. I think an ER is something they want and want to support. And from what I hear there's a lot of fiscal unresponsiveness wafting around down there. Maybe a larger financial oversight board is needed...

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Palm Drive Hospital needs to be run as a successful business. It doesn't necessarily need to make a "profit", but it has to at least cover its expenses, and "profit", or income above expenses, allows for treatment of the uninsured (for which there may be no reimbursement), growth, additional services, upgrades, repairs and a host of other positive additions to its range of services.

Unfortunately, we are talking money here. Businesses do not run on angst. Palm Drive, for a variety of reasons, failed to cover, or even come close to covering, its expenses. That is why there is a "CLOSED" sign on the front door. Like any other business, if it can't be, at a minimum, self-sustaining, then it fails. Funds can come from a wide variety of sources, both governmental and private, to contribute to covering operating expenses, but if the total required isn't there, it doesn't work. It is simple business economics.

Fiscally responsible simply means generating revenues (of all types) in a logical/legal manner to equal or exceed expenses (of all types)- kind of like your personal checking account, or "living within your means." Financially sustainable simply means creating and working within a model that provides some assurance that the hospital, once opened, remains open, and does not create the situation where people find themselves on Wacco in 3-5 years discussing what can be done to reopen the hospital again. Do these two concerns seem irresponsible?

The emotionality of "just get it done!" doesn't pay the bills. There is no demanding or wishing Palm Drive back into operation. It will take a lot of things, but at/near the top of that list is money- significant amounts of it. If Palm Drive can't ultimately pay its own way, then a benefactor or group of them could keep it alive through subsidizing it. You are correct- the income demographics of Sebastopol are favorable towards local private support. It remains to be seen if it is forthcoming. That is why the highly-anticipated release of the financial documents that support the proposal from the Palm Drive Health Care Foundation is so important.

John,

Great points!

To run a 'fiscally responsible' business, we do not usually turn to people who have never run a large business. We turn to seasoned, experienced business professionals, people who have run large businesses with many employees and multi-millions in revenues. We use accountants, engineers, nursing instructors, physicians and others within the business, but we rely on experienced CEOs, corporate board chairs, and entrepreneurs to provide governance. We want not only savvy business leaders but subject matter leaders as well and we need a board that represents the interests of the stakeholders.

We don't usually expect that the guy who engineered the trusses in the Exchange Bank building should be on the board of Exchange Bank or that the Chief Nursing Officer of a hospital should be the CEO. (This was the case at Palm Drive in 2005 and 2006, which is likely why the hospital crashed in 2007.) They are great for what they do, but running a major business operation like a hospital is not their sweet spot.

We set out to find the best and brightest in the business community and put them together with the best and the brightest in the medical field and are on the path to having a great team of people like these:

•Merry Edwards, Founder, CEO, Merry Edwards Winery
•John Balletto, Founder, CEO, Balletto Vineyards
•Jane Hynes, Founder, CEO, Hynes & Company
•Paul Caracciolo, CIO, CTO, Stanford Hospital
•Ben Cushman, CEO, Supercuts
•Sue Rataj, CEO, BP Petrochemicals

•Dr. James Gude, MD, Professor UCSF

•Dr. David Murphy, Psychologist
•Dan Smith, CEO, Electronic Health Records International
•Beth Moise, CEO onPointSolutions
& Dr. Craig Campbell


We also need seasoned and skilled leadership on the management team. People like Ray Hino are hard to come by but we now have the benefit of his many years in healthcare management right here in West County. Ray is in Washington DC today as a board member of the National Hospital Association and will be back here on the job starting November 1.

I hope you will take time to make an appointment with him and give him your views on our community's health care needs. You can call the foundation at 823-8312 and ask Desiree for a time with Ray. I know he would welcome this.

Best Regards,

Dan Smith

Jim,

A brief followup to our discussion:

I met with a bunch of the local physicians tonight and was reminded of something they have said in the past, that they practice urgent care in their offices every day. What is meant by this is that they see critically ill patients on short notice in their offices. I know some of them leave time in their schedule in the afternoon to take patients who call in during the day. They all say they need an ER, a stat lab and imaging, not urgent care.

I also heard something new tonight and that was that recently Memorial Hospital has not been able to take admissions at times from their ER because all of their beds are full and that they have been having to ship patients from the ER to Petaluma Valley. This is a new development and different from the ER diverts that John Moise has reported, which show that in the last 90 days, one or more Santa Rosa hospitals has been unable to unload ambulances for over a half hour at least 199 times. (This is how a divert is defined by EMS.)

I am a little surprised by this because we are not in the middle of flu season, which is usually when all the beds are full in the county. I suppose the Sutter move and downsizing could be driving this.

Another message that was delivered tonight was that many of their patients are experiencing long, long waits in Santa Rosa emergency rooms. The word is to go to Petaluma or Healdsburg if you are not a Kaiser patient.

Best Regards,

Farmer Dan aka Dan Smith

I greatly appreciate Dan Smith's clarification of hospital data and financials. His analysis of causes for our hospital's past failures, and plans for how it can succeed in the future, makes sense to me. I find the entire City Council's apparent lack of enthusiasm and support for the foundation proposal puzzling and disappointing.
Treasure

As shown clearly by Palm Drive's own data, the majority of "emergent" cases could be handled at a properly equipped and staffed urgent care facility. In your original post "Palm Drive Truth or Friction," you listed the "urgent" vs. "emergent" statistics for 2013 and then made the following statement:

"The important conclusion to draw from this is that an urgent care would only be appropriate for a small number (1,111) of the patient visits that the Emergency Room had in 2013."

But that's a false comparison. The "urgent" vs. "emergent" categories are very broad and aren't intended to indicate which cases could be handled appropriately by an urgent care center vs. an emergency room. That's why OSHPD uses a much more comprehensive 5-tier system to rate the severity of cases. And I'm not doing the rating--that was done by our own ER personnel on duty at the time.

Consider this: in 2013, the Palm Drive ER received 6,463 visits that were not rated as life-threatening. Of all of those thousands of patients, only six were eventually admitted to the hospital--less than 0.1%. On the other hand, of the 965 life-threatening cases, more than half were admitted. Clearly, the majority of Palm Drive's ER cases could be handled at a properly equipped and staffed urgent care facility.

Just as clearly, though, an ER is preferable to an urgent care--all other things being equal. But there's the rub. To have an ER, we're also required by state law to run an acute care hospital with all of the attendant costs, requirements and regulations. I'm keeping an open mind on whether that can be done in a fiscally responsible and sustainable manner, and I'm still hoping to see comprehensive financial projections and to have my other questions answered. When I hear folks overselling their case, that just makes me more cautious, not less.

Jim,

Continuing to argue about your interpretations of the data is not useful.

I depend on what the physicians have to say when it comes to medicine and what the physicians are telling me is that we need an emergency room, not urgent care. I don't understand why anyone would think they understand the issues better than Dr. Powers, Dr. Pitzen, Dr. Davidson, Dr. Bernstein, Dr. Bernie, and all the others.

If you want to be a board member of a hospital, you will need to start listening to the doctors, not telling them what heath care they need to be performing.

Farmer Dan aka Dan Smith

And continuing to misstate my words and misrepresent my positions won't fool the voters, Dan. I agree that an emergency room is better than an urgent care center. But I'm not yet convinced that an ER and acute care hospital are feasible. My job is to seek the facts and use my best judgment, and I'll continue to do so for as long as I'm on the Palm Drive board.

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Posted in reply to the post by farmerdan:

Continuing to argue about your interpretations of the data is not useful....

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Posted in reply to the post by JimHorn:

And continuing to misstate my words and misrepresent my positions won't fool the voters, Dan....

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