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Medical Director of the Emergency Department's
View
As Medical
Director
of the ED, and an emergency physician at St. Luke's for 25
years, I
have concerns about some of the statements made about the
plans
for ambulatory care at the St. Luke's Campus.
We currently
receive close to 5000 patients by ambulance yearly,
about 9%
of all ambulance runs.
Paramedics would not bring the vast
majority
of these patients to a facility that did not have in-patient
services.
Closing
our inpatient services will place a major strain
on the
ambulance system, leading to longer transport times, longer
response
times, higher ambulance diversion rates, and disruption of
the
doctor/patient relationship.
The notion that
85% of our ED's patients could be handled by an
urgent
care center is ludicrous.
Our
department does have an urgent
care
area, staffed by a Physician Assistant 12 hours a day.
The
lower
acuity patients are already sent there, but 80% of our patients
are
triaged to the acute side.
We have
only 7 rooms, but 3 have 2
patients
each, separated by a curtain.
Despite
these 10 "beds", we
still
frequently have two or three additional sick patients on
guerneys
in the hallway, a dangerous situation of overcrowding linked
most
commonly to ambulance diversion from SF General (18% of the time).
It won't be
easy to staff such a stand-by emergency department,
either.
Our
emergency physicians can be expected to look for more
challenging positions, with sicker patients to treat.
The
doctors
who
might be appropriately trained for the urgent care/ambulatory
services
envisioned will have a rough time dealing with the sicker
walk-in
patients, without the back-up of a full hospital of
resources, including respiratory care and intensivists.
They
will
face a
major challenge in finding beds for these patients at crowded
facilities across town.
The issue is
money.
St.
Luke's has been losing about $30 million a
year.
Medi-Cal
pays us a lot less than the cost of care, and a third
of what
they pay the City for the same patients.
In our
ED, 50% of
patients
are on Medi-Cal, and 20% are uninsured.
The City
gets
funding
from the State for the uninsured, but does not reimburse us
for the
role we play in supporting the safety net.
The
unfunded
State
mandate of seismic upgrades is setting the time frame for this
crisis.
CPMC shouldn't
be blamed for behaving like a business that it is.
They and
Sutter Health kept us alive for the past 7 years and paid
off a
lot of debts from prior years. I don't think the problem will
be
solved until all the parties - CPMC, the City, the State, the
medical
staff and community, the Episcopal Church, and even SEIU, get
together
to find a solution.
The current
plan to close St. Luke's in 2009 will leave San Francisco
with one
over
crowded
hospital South of Market.
I don't
think that
this is
a smart plan for the future of acute health care in the City.
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