Special to the Cape Charles Mirror By Ervin E.Jones, MD. Published with permission from Citizens for a Better Eastern Shore
Shore Memorial Hospital, formerly Northampton-Accomack Memorial Hospital, and currently Riverside Shore Memorial, has been a part of Northampton County since the late 1920s and has been in its current location for 40 years. In September 2009, the Shore Memorial Board voted to affiliate with Riverside Health Services, Inc., Newport News, VA. A Certificate of Public Need (COPN) was issued in 2011 and the Hospital announced that it would be moving to Onley in Accomack County by 2015. As a part of the COPN application, Riverside Health Services provided assurance that it would continue to provide services such as an Urgent Care Center at or near the present site in Nassawadox. Expansion to 24-hour diagnostics, basic laboratory services, and other primary care services were cited by Riverside as longer-term goals. Riverside administration recently announced that the hospital as well as the cancer center will be relocated to Onley by the end of 2016. Although the building currently housing the cancer center will remain, no other facilities will remain in Nassawadox.
Impact on health services in Northampton County
Riverside Shore Memorial Hospital will be relocated 18 miles north of its current location. The nearest Emergency Department to the south is Sentara Independence in Virginia Beach. Ambulances traveling south will have to cross the 17-mile Chesapeake Bay Bridge-Tunnel, with potentially dangerous closure delays from accidents or weather. Not only will ambulance transport time to the nearest emergency department be longer, ambulance turnaround time will also be substantially increased It is estimated that the new minimum ambulance turnaround time for Northampton providers will be more than an hour. The transportation burden on Northampton County citizens will also be increased by the longer drive for health services. Pressure on EMS services will increase as the population becomes more dependent on EMS services for medical transportation. The loss of the hospital will deprive Northampton citizens of a local emergency room and other critical services, e.g., diagnostic imaging, laboratory testing, screening and other primary care services.
Emergency Medical Services (EMS) in Northampton
The Northampton County EMS system is made up of four separate agencies: the Northampton County Department of EMS (Machipongo) and three volunteer agencies – Community Fire Company, Exmore; Northampton Fire and Rescue, Nassawadox; and Cape Charles Rescue Service, Cape Charles. Each agency functions with its own articles of incorporation, licensure, leadership and financial management structure, by-laws and standard operating procedures. Each agency owns its buildings and emergency vehicles. Six ambulances comprise the County-wide EMS service fleet. In addition, four quick response vehicles (QRVs) are used to supplement the ambulance fleet as needed.
Personnel staffing for the agencies consists of a combination of paid and volunteer providers. An advanced-level career employee from the county EMS Department is generally embedded with the volunteer service 80% of the time. In addition, the QRVs, with advanced-level paramedics and duty supervisors, are generally available. Each EMS agency is required by Virginia Department of EMS to have an Operational Medical Director (OMD).
The current OMD for the County-wide EMS system is retiring and a replacement has not yet been hired. The responsibilities and authority of an OMD are broad and include provision of medical direction to providers, verification of qualifications, quality management and improvement, corrective action and interaction with state, regional and local authorities as needed.
Each of the three volunteer agencies has a designated call area. All calls go to the 911 Call Center in Accomac. The dispatcher then contacts the appropriate agency, and the nearest agency is expected to respond. The next nearest agency serves as backup. The responding agency is required by the Virginia Department of EMS to transport the patient to the nearest Emergency Department unless the patient signs a waiver refusing transport. The public must be aware of this transport requirement and its impact on EMS services.
EMS Requirements and Response Plan
Each EMS agency provides service within its primary service area on a 24-hour basis, and each locality ensures that EMS covers its entire area. The EMS response plan states that a unit will be on scene within 20 minutes of dispatch, 90% of the time, 24 hours a day.
The major challenge facing EMS is a lack of personnel to staff the ambulances. Some agencies cannot consistently guarantee volunteer staff and struggle to cover all shifts. This is of great concern, since EMS stations are primarily staffed by volunteers. Advanced-level career employees are often lost to other localities. A strong EMS training program is needed in Northampton County, and the volunteer EMS program needs to be rebuilt. In addition, Northampton County High School and especially the Eastern Shore Community College should be involved in training programs for careers in EMS. Garage and storage facilities are lacking for the Northampton County EMS service in Machipongo. The County EMS building is in need of renovation to reduce exposure of vehicles, reduce degradation of medical supplies due to overheating or freezing, improve vehicle readiness and to meet Occupational Safety and Health Administration (OSHA) regulations. Plans are under way to modify the existing building to meet the need. According to EMS leadership, at least one more ambulance will be required once the hospital moves because of increased travel distances and turnaround time. Funding for some of the agencies continues to be a major problem. In certain cases, billing revenue does not fully support the operations budget. Each agency employs its own billing vendor, which results in inconsistent billing from agency to agency. There is lack of coordination among the agencies with respect to equipment, billing, incentives for volunteers, and bulk purchases. Ambulances are not all equipped uniformly and as a result, not all personnel are familiar with all equipment on each ambulance. It will be necessary to improve coordination among the agencies to meet the challenges. Efforts to unify and streamline operations among the agencies are under way.
A Broader Perspective
A strong, well-equipped EMS service is clearly needed. However, EMS systems were never designed to comprise the entire healthcare delivery system for a locality. EMS cannot and should not function as “gate keeper” and principal provider for health services in the county. Instead, healthcare delivery and access must be viewed in the broader context of a well-balanced system of healthcare: emergency medical services, urgent care services, primary care and nursing home care. EMS services should be used for real emergencies and not routine transport for non-critical services. From a long-term perspective, it is unlikely that Northampton County can financially support a standalone Emergency Department. However, night and weekend medical services are needed. Twenty-four hour diagnostics, basic laboratory services, and primary care services are longer-term goals. All options to establish an urgent care center in Northampton County should be considered, including seeking and securing established medical service partners.
A Strategic Plan
In anticipation of the impending relocation of Riverside Shore Memorial Hospital, the Northampton County Board of Supervisors established an ad hoc Emergency Medical Services Committee to explore all options for provision of services. A consultant from the Virginia Rural Health Resource Center, Roanoke, VA, was retained to do an assessment and present options. The report provides numerous options for development of healthcare infrastructure in Northampton County.
The Committee chose to take a broader, multi-faceted approach and developed a seven-point strategic plan that would include other forms of healthcare delivery. The seven primary goals of the strategic plan are:
• Create a strong, well equipped, well-staffed EMS system to serve all residents of Northampton County
• Enhance, support and increase primary care resources in the county
• Provide urgent care service in Northampton County
• Create telecommunications infrastructure to support medical services
• Educate the public regarding health care resources and how to best use such resources
• Generate revenue to support medical services
• Develop a system for accountability and monitoring of health services in Northampton County
Although a strong, well-equipped, well-staffed EMS system is clearly necessary, both primary care resources and urgent care resources are also needed. Telecommunications resources are crucial in today’s healthcare environment as new approaches such as telemedicine, telehealth, in-home monitoring, long-distance care and wearables are all now a part of the evolving healthcare landscape. The public must be informed regarding the availability and the appropriate and efficient use of healthcare resources in order to provide the best care available to the people of the community. Finally, and perhaps most importantly, a system of accountability and monitoring of healthcare services in the County needs to be established.
The departure of Riverside Shore Memorial Hospital from Nassawadox will leave a serious deficit with respect to healthcare services in Northampton County. Not only will emergency medical services be challenged, other key healthcare services, such as imaging, laboratory diagnostics and screening, will be severely impacted. The availability of urgent care services will be lost. Solutions will require a concerted effort on the part of all of those with a stake in this matter. Creativity and innovation must be brought to bear. Numerous rural communities have faced similar problems over the past two decades. These communities have met these challenges through creative thinking, innovation and the realization that healthcare delivery, or the lack of it, is a community problem. Therefore, it is incumbent upon all of us to recognize this problem and seek solutions to it.
Dr. Jones, who lives in the Cape Charles area, retired from a long and distinguished career as a professor in the School of Medicine at Yale University. He is a current member of the ad-hoc Emergency Medical Services Committee of Northampton County.