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Berkshire Ambulance, Emergency Room Officials Oppose Question 1
Staff Reports, iBerkshires Staff
02:28AM / Thursday, November 01, 2018
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Heads of local ambulance services and emergency department officials gathered at County Ambulance on Wednesday to express the reasons for the opposition to Question 1. 
PITTSFIELD, Mass. — The phrase "holding the wall" hasn't really been used much in describing emergency medical services in Berkshire County. But, local EMS providers say that could be a real possibility if Question 1 is passed.
The term is used to describe the amount of time a patient is in an ambulance waiting to be ushered into the emergency department than is absolutely necessary. Ambulance companies don't want to be "holding the wall" but instead getting the rig back into service. 
Voters will decide next week whether to legally mandate specific ratios of registered nurses to patients. Ambulance providers and those who work in the emergency departments fear that the mandated ratios will bog down emergency rooms, causing delays in services.
"Being in my positions, I work with many communities that have volunteer or small ambulance services and are currently in crisis due to having to deal with the reality of dwindling volunteer EMT numbers. They struggle on a day-to-day basis to get ambulances out their doors to those 9- 1-1 calls in rural communities," said County Ambulance President Brian Andrews, who has been an officer in regional EMS organizations.
"Question 1 would add constraints to an already taxed system which would most likely push some of those struggling services right out the door and potentially leave communities with no coverage at all or rely on ambulances from distant communities. It is difficult to get people to be able to volunteer for these ambulance services and the passage of Question 1 could lead to ambulance calls that normally take an hour or two to do and add time and pressure to these volunteers."
Andrews, who made his remarks at a press conference at County Ambulance's headquarters on Dalton Avenue, said, "Sitting in the ambulance in a hospital driveway or standing in a hallway waiting to turn over patients until the staff ratio could be met would also cause stress to people who already see more trauma and suffering on a regular basis that most people will never see in a lifetime. Calls for help to 9-1-1 come in when patients need us, not when staffing allows."
Question 1 on Tuesday's election ballot is supported particularly by the Massachusetts Nurses Association, which says patients have been getting sicker and that staffing levels are unsafe. Nurses are currently in charge of too many patients at a time, the union claims. The local union nurses at Berkshire Medical Center reported more than 500 instances when they believe their patients were put at risk because of a shortage in nursing staff.
The association says mandating a patient-to-nurse ratio will ultimately lead to better health outcomes. For the cost, the nurses union says the hospitals can easily afford it if the money is reallocated toward patients through bedside nursing.
Berkshire Health Systems has strongly opposed the measure and on Wednesday other area organizations joined in opposition. Andrews was joined by four ambulance services in the county -- Northern Berkshire, Southern Berkshire, and Adams -- and three representatives from Berkshire Medical Center's emergency department. The group voiced concern that the mandate is too restrictive because emergency medicine "is not one where calls are scheduled and doesn't allow 100 percent predictability." 
Bill Hathaway, director of Southern Berkshire Volunteer Ambulance, laid out a scenario: at 2 a.m. there are only two nurses and six emergency room beds available. If an ambulance brings in two patients with critical chest pains, and then there is a car accident, there is nowhere for the those in the accident to go in order to comply with the mandates because each critical case can only have one nurse.
Hathaway knows that his team and those who work at Fairview Hospital in Great Barrington won't leave the victims in the back of an ambulance in that case. But, when they do take care of those car crash victims, the hospital will be slapped with a $25,000 fine.
"We are going to do what we need to do to take care of patients, that is what we are here for and that is what we do. So, OK, we get a $25,000 fine, that's what happens. It is the cost of doing business. But is it something we need to do? Are we actually helping our patients with these staffing ratios?" Hathaway said. 
Hathaway said a mandate "sounds good on paper but it really isn't." 
Andrews said if there are times in which ambulance drivers are forced to wait for the emergency room to free up a bed, then that often requires more paperwork to be filled out by the ambulance company, delaying even further progress to get back on the road and further discouraging volunteers from becoming EMTs.
If a patient isn't delivered to the emergency room within 30 minutes, the ambulance service is required to file a report with the state.
"Our industry is subjected to laws and regulations which Question 1 does not take into consideration and at this point, no changes are even being discussed to how we would do our job under mandates Question 1 proposes. We do not have the ability to divert to another hospital as that was forbidden here in Massachusetts some years ago and even if we did have it available in Berkshire County, we don't have hospitals around the corner," he said.
"I fear we may end up spending more time writing these delays up than we will be able to spend responding to 9-1-1 calls."
Andrews said the concern isn't just here in the Berkshires but that the Massachusetts Ambulance Association is also opposing the question.
Erryn Leinbaugh runs the satellite North Adams emergency services and he agrees with that notion. But taking those $25,000 fines adds up and he believes that the North Adams service may have to close.
John Meaney of the North Adams Ambulance Service is worried about that, too. He said in order for Berkshire Health Systems to pay those fines or increase staffing, services will have to cut. He fears that will come at the expense of North County. where just a handful of years ago North Adams Regional Hospital closed.
"We know if Question 1 were to pass all of the services Berkshire Medical Center worked hard to restore would be in jeopardy. We would be forced to make staffing changes that would negatively affect our services," Meaney said.
Meaney said it isn't hard to imagine plenty of times when there could be a finable instance. 
"Patients conditions in the emergency department change very quickly. This day in age, there is no way to predict a mass casualty incident, a natural disaster, or the number of overdoses that will occur on any given day in the county. If Question 1 were to pass and a critical incident was to happen while each nurse was at their legal ratio, patients will either sit in the waiting room or on the ambulance stretcher until the nurses became available to provide care," Meaney said.
Berkshire Medical Center has estimated a cost of $22.8 million annually to provide enough nurses throughout the hospital system to comply with the mandates. But, hospital brass says that may not avoid all instances of falling out of compliance. The hospital administrators have been pushing the need for flexibility in staffing because things can change so quickly. As more money is directed toward inpatient care, hospital officials fear that will come at the expense of outpatient programs, which in turn send more people to the hospital and puts a further strain on service.
Kerri Hallas is the director of Berkshire Medical Center's Emergency Department and she says the assignments of nurses shouldn't be driven by state mandate but by needs of the patient and the staff's skills and willingness. 
"For an emergency department, predicting the day is an impossible task. Accidents cannot be scheduled and emergencies cannot be planned. In the Emergency Department alone we will have to juggle four different patient ratios and make decisions not based on a nurse's ability or willingness to care for a patient but on mandated state laws," Hallas said.
Andrews added that ambulance companies and those working in the emergency room have long developed a system to provide the best care and the question threatens to unhinge that.
Those speaking in opposition on Wednesday also included Mike Gleason from Adams Ambulance and Michael Mchugh from the hospital's department of emergency medicine. The press conference was livestreamed and posted to Berkshire Medical Center's Facebook page. 
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