Newest liability victims: West Virginia emergency patients

Hospitals nationwide are scrambling to find the subspecialists needed to keep emergency departments running 24/7.
By Tanya Albert, AMNews staff. Sept. 16, 2002.

A West Virginia hospital that struggled over the past year to keep its Level I trauma center adequately staffed has lost its fight.

The West Virginia Emergency Medical Services office in August downgraded the Charleston Area Medical Center to a Level III trauma center, down from a Level I center equipped to handle serious injuries 24 hours a day, seven days a week.

CAMC didn't have enough orthopedic surgeons to cover the hospital. Sky-high medical liability rates and physicians' inability to find affordable insurance helped lead to the shortage.

The hospital -- which also had been struggling to keep its neurosurgeons and plastic surgeons -- saw the number of orthopedic surgeons available for call shrink to five, less than half the number covering the emergency department two years ago.

"We already know that people will have poorer outcomes," said David Kappel, MD, state chair for West Virginia's committee on trauma for the American College of Surgeons.

An estimated 800 to 1,000 patients -- about 40% of the people who came into the emergency department every year -- are expected to go elsewhere, according to a CAMC spokesman.

40% of emergency patients will need to go to other hospitals.
But hospitals that can treat severe trauma patients are few and far between in West Virginia. The downgrade leaves just one Level I trauma center in the state -- about three hours north in Morgantown -- and only one Level II center in Huntington, about 45 minutes west of Charleston.

"This is a major, major blow to the patients of this state," said Ahmed D. Faheem, MD, past president of the West Virginia State Medical Assn.

"It's a serious problem," added William D. Ramsey, MD, medical director for the West Virginia Emergency Medical Services office.

In the past year, emergency departments across the country have had to divert patients because they didn't have the doctors they needed.

Trauma centers from Florida to Pennsylvania have been at risk of not being able to treat patients because a group of neurosurgeons, orthopedic surgeons or other high-risk group hasn't been able to find affordable insurance.

And as regulatory agencies in various states evaluate hospitals, there could be other downgrades in the future, said Seattle emergency physician Matthew Rice, MD, chair for the American College of Emergency Physicians' professional liability task force.

"Every day, emergency departments struggle to find physicians to take call," he said.

System already strained
The medical liability problems come at a time when emergency departments already were dealing with other pressures that have mounted over the past decade, said Dr. Rice, who also has a law degree and is a vice president for Team Health West, an emergency department management company.

Between 1997 and 2000, emergency departments saw a 14% increase in visits, up to 108 million in 2000 versus 94.9 million in 1997, according to the ACEP. During that same time, the number of hospital emergency departments decreased to 3,934 from 4,005.

Low managed care reimbursement rates, physicians less willing to open themselves up to high-risk cases that could lead to lawsuits and a desire to work fewer night and weekend hours also have steered physicians away from taking patients on call.

"But the true crisis right now is trying to sort through the medical liability insurance issue," Dr. Rice said. "It can only be resolved at the federal level."

Legislation that the American Medical Association supports has been introduced in the U.S. House of Representatives and Senate that is based on reforms enacted in California more than two decades ago. The bills include a $250,000 cap on noneconomic damages in medical malpractice cases and a limit on the number of years patients would have to file a lawsuit.

"Why should West Virginia patients or patients in any other state be put at increased risk all because lawmakers refuse to enact proven reforms?" asked AMA President-elect Donald J. Palmisano, MD. "It is an emergency situation when a city loses a Level I trauma center because of the medical liability crisis."

Improving conditions
In an ideal world, it would take about six months for the Charleston Area Medical Center to reopen its doors, but realistically it could take up to two years to recruit the physicians needed to keep the center staffed at Level I status.

"We're continuing our efforts to recruit physicians, but it's been an uphill battle," said Andy Wessels, CAMC spokesman. "We want to get the designation back, and we will do everything we can."

EDs nationwide dropped from 4,005 in 1997 to 3,934 in 2000.
West Virginia hospitals and physicians believe that state tort reform could go a long way toward solving the recruiting problem and other problems associated with medical liability insurance.

The WVSMA supports medical liability reforms on the state level, including a $250,000 cap on noneconomic damages, Dr. Faheem said. For the past two years, physicians have called on the Legislature for medical liability reforms, but they haven't gotten too far. With the downgrading of the Level I trauma center in the state capital, however, things could be different this time.

"I'm pretty sure it was a wake-up call," Dr. Faheem said. He noted that for the first time since West Virginia started experiencing problems, editorials in local newspapers have joined the call for the state Legislature to do something.

West Virginia lawmakers go back in session in January 2003.

"I hope everyone involved appreciates the seriousness of the situation," Dr. Ramsey said.