Hawaii gets a C- for emergency medical care

A national report card on emergency medical care in the U.S. gave Hawaii a C- grade saying the state suffers from a “severe gap” in hospital capacity that impedes response to everyday emergency care needs and potential disasters or mass-casualty events.

Hawaii’s C- grade, which is tied with West Virginia and ranks the state 24th in the nation, including the District of Columbia, is down from a C+ grade and a ranking of 16th in the nation the state received in 2009 on America’s Emergency Care Environment report card. Hawaii also received a C- in 2006, the first year the report was issued.

Hawaii was given an F for access to emergency room care; an F for disaster preparedness; a D+ for medical liability environment; a B- for quality and patient safety environment; and an A for public health and injury prevention, according to the report released Thursday by the advocacy group American College of Emergency Physicians.

Sen. Josh Green, D-West Hawaii, who heads the state Senate Committee on Health, said that while the state ranks among the top in the nation for prevention of injuries and protection of residents, the below-average grade is a reflection of the state’s physician shortage, primarily on the neighbor islands in the realm of trauma and neurosurgeons, as well as the geography of the state, which presents transportation issues since patients needing further care must be flown to other islands.

“We’re in a very unique situation,” he said, noting there is room for improvement in recruiting and retention of physicians and specialists, funding transportation, funding hospitals and reducing medical liability insurance costs.

“If we’re ever going to become a state that gets an A or B rating we would have to do all these things at once,” said Green, who is also an emergency room physician at Kohala Hospital. “And, still even with our geographic challenges, we may not have all (at the top) but we could transport people within an hour.”

Linda Rosen, who heads the state Department of Health’s Emergency Medical Services and Injury Prevention System Branch, said she was happy with the report’s findings, particularly the high grades for injury prevention and quality and patient safety environment.

She noted, however, that the report didn’t consider things such as Hawaii having a state-designated burn unit available because Straub Clinic and Hospital on Oahu doesn’t have enough admissions a year to qualify for national accreditation, already-in-place plans to increase capacity at hospitals for mass-casualty events or the availability of tents that can accommodate hundreds of additional beds.

“We can always do more. We are really happy with the positive parts, but we need to look at what we need to improve,” Rosen said.

Healthcare Association of Hawaii Director of Emergency Medical Services Toby Clairmont said the report “unfairly characterizes what we can do and what we can’t do.”

In particular, he said, the report’s finding that the state has the second lowest bed surge capacity in the state did not take into account the association’s work over the past decade to secure federal funding for tents to provide surge capacity and augment “brick and mortar hospitals.”

Clairmont said the association can provide up to 250 beds under a tent in the event of a disaster or mass-casualty event in the state. On Hawaii Island alone, the association has 40 beds pre-deployed and ready to go. The association can provide as many as 150 beds, however. It also has two 40-foot containers filled with supplies, including cots in addition to the hospital beds.

“We have the resources ready (on the ground), all we have to do is move people,” he said.

Nationally, the report gave the U.S. a grade of D+, down from a C- in 2009 and 2006. The D+ grade cited lack of access to emergency care, medical liability environment and disaster preparedness as reasons for the national grade to be lowered.

The current report gave no state an overall grade above B-; one state, Wyoming, was given an overall grade of F. The District of Columbia earned the best grade in the report with a B-, followed by Massachusetts (B-), Maine (B-), Nebraska (B-) and Colorado (C+). Ahead of Wyoming were Arkansas (D-), New Mexico (D), Montana (D) and Kentucky (D).

The report card, which grades states in five categories (access to emergency care, quality and patient safety environment, medical liability environment, public health and injury prevention, and disaster preparedness) based on 136 objective measures, provides a picture of how states measure up in supporting the ability for the nation’s emergency departments to provide care for patients.

“This report card points to the shortcomings and challenges in the emergency care environment, but it does not attempt to grade the care provided by dedicated emergency physicians and staff, nor does it underestimate the day-to-day commitment and concern that emergency physicians demonstrate in caring for millions on patients each year,” the report states.

Hawaii boasts a strong commitment to public health and injury prevention, according to the report, noting Hawaii’s A grade in that category ranks the state second in the nation behind only Massachusetts, which also received an A.

In ranking Hawaii second for public health and injury prevention, the report noted the state’s low rates of chronic disease and fatal falls, as well as the amount spent per person by the state to prevent injuries and improve public health. The report also noted Hawaii has some of the lowest rates of adult and child obesity.

“These … numbers are supported by the state’s fiscal commitment to injury prevention, with high per capita injury prevention funding ($961.64 for every 1,000 people) and funding sources specifically set aside for prevention of occupational injuries, childhood injuries, and injuries among older adults,” according to the report.

The state also has a good emergency medical services system focused on patient safety, the report found, giving Hawaii a B- in the quality and patient safety environment category and ranking it 16th in the nation. The grade is up from a D+ in 2009 and C+ in 2006.

“The state has adopted a uniform system for providing pre-arrival instructions and has implemented a statewide trauma registry” since the 2009 report card, according to the report. “Hawaii is ninth in the nation in terms of hospitals with computerized practitioner order entry … (and) provides funding for quality improvement within the EMS system and has a funded state EMS medical director, demonstrating a strong commitment to quality improvement and system oversight.”

Hawaii also ranks among the top five states for the proportion of adults and children with health insurance, the report noted, citing 95.9 percent of children and 91 percent of adults having health insurance.

However, Hawaii performed poorly in three categories: access to emergency care, disaster preparedness and medical liability environment.

The state garnered an F — down from a C in 2009 and C+ in 2006 — for its access to health care, according to the report, which said the dismal grade reflected a lack of “adequate” hospital capacity, “which can lead to dire outcomes.” In explaining the grade, the report noted the closure in 2011 of two hospitals on Oahu; state’s geography that keeps patients from accessing hospitals outside the islands; specialist shortages and low Medicaid reimbursement rates.

“Hawaii has one of the highest per capita rates of emergency physicians but few emergency departments (9.3 emergency departments per one million people),” according to the report. “Its hospitals are nearly at capacity, with the second highest hospital occupancy rate in the nation (77.1 per 100 staffed beds) and low numbers of staffed inpatient beds overall (231.9 per one million people), which equates to long waits in the (emergency) department.”

According to the report, the average waiting time from arrival to discharge in an emergency department in Hawaii was 330 minutes — 5.5 hours.

In the realm of disaster preparedness, the report gave also gave Hawaii an F, citing its lack of verified burn centers, few burn unit beds (just 2.2 per one million people), the fewest intensive care unit beds (117.8 per one million people) in the nation and the second lowest bed surge capacity (229.8 beds per one million people). Hawaii received a C+ for disaster preparedness in 2009.

The report stated that the infrastructure issues will “greatly hamper Hawaii’s ability to respond to a large-scale disaster or mass casualty event.”

The report recommended Hawaii increase the availability of medical facilities, intensive care unit beds, burn unit beds, emergency departments and inpatient beds.

Those actions “would go a long way toward improving the state’s access to emergency medical care and increase its ability to respond to large-scale disasters,” according to the report.

Medical liability is also hampering Hawaii from receiving a higher grade. The report gave the state a D+ grade, ranking it 30th in the nation, down from a C+ in 2009 and a position of 16th in the nation.

While Hawaii’s grade was aided by the relatively low number of malpractice awards payments (1.5 per 100,000 people) and average medical liability insurance premiums of $10,432 for primary care physicians and $44,860 for specialists, it was offset by few protections for the state’s health care workforce and the highest average medical malpractice award payments in the nation at $681,839.

The report suggested the state consider liability reforms such as reducing the medical liability cap on noneconomic damages to $250,000, requiring awards to be offset by collateral sources, and requiring periodic payments of malpractice awards. Such reforms could reduce the incidence of defensive medicine (providing extra medical treatments or tests solely out of concern to avoid litigation) thereby encouraging more specialists to provide on-call services to emergency patients.

“Additionally, Hawaii should implement expert witness rules requiring case certification; ensure that expert witnesses are of the same specialty as the defendant; and institute liability protections for care mandated by the Emergency Medical Treatment and Labor Act, which requires emergency care providers to perform life-saving procedures without a pre-existing patient relationship and little to no knowledge of a patients medical history,” the report reads.