Should the Roseburg Veterans Affairs Medical Center reopen an intensive care unit? The Veterans Integrated Service Network leadership and administration at the Roseburg VA are strongly opposed. Local veterans service organizations disagree, stating that an ICU is necessary for Roseburg VA to be a full-service hospital. I believe there have been patients whose outcomes might have been better had an ICU been available.
During the time the Roseburg VA ICU was open, it was generally filled to capacity with a mix of patients truly meeting criteria for ICU care and those needing step-down care and more intensive nursing. Many patients were saved due to the excellent care of the ICU nurses and intensivist.
Do we need a high-level ICU capable of caring for those with major trauma, heart attacks, strokes or kidney failure? The answer most certainly is “no.” A busy, high-complexity ICU requires availability of medical and surgical subspecialists with interventional capability 24 hours a day. To build and maintain that infrastructure with a low need would not only be prohibitively expensive but would create difficulty maintaining skills.
Patients are not always predictable. Some who do worse than expected need the availability of more intensive nursing and monitoring than is commonly available on the medical/surgical floor. Typically, in addition to one-on-one nursing, they may need invasive monitoring, medications to support blood pressure and short term ventilators. These services were available when our low-complexity ICU was open. Can the staff of a low-volume, low-complexity ICU maintain enough experience to care safely for the patients needing these sorts of services? The VA maintains quality scoring systems for most surgical and medical care, and at the time the ICU was closed, our report card showed we had significantly lower morbidity and mortality compared to other VA ICUs.
The ICU was closed without any input from the clinical physicians who care for the sickest of the patients. VA central office has mandates for standard inpatient surgery that require VA facilities to maintain an ICU to provide a safety backup for these patients. Roseburg VA was given a special waiver, which to my knowledge was not given to any other VA hospital, that allowed simple inpatient surgery without an ICU. The complication rate for surgical patients remained low, as the surgeons carefully selected which patients could be safely treated at our facility. However, after a postoperative death, the surgical program was restricted to simple outpatient surgery, precisely because the guidelines to do low-level inpatient surgery required an ICU. So with over seven years of residency and decades of surgical experience, I (along with all of my colleagues) was restricted to intern-level cases. Even routine procedures like appendectomies and laparoscopic cholecystectomies were forbidden.
Associated with our downsizing and closure of the ICU, more patients have had to be transferred elsewhere. In emergencies, we have only been able to get them to our local community hospital about a third of the time. Many patients require long ambulance rides to Eugene or Portland. Portland VA itself has become so overloaded with consults that it frequently cannot take our patients. Delays of months to years are common for several elective procedures at VA facilities throughout Oregon.
Not only has Roseburg VA general surgery been reduced at least 30 percent, but complicated medical patients may be turned away. If there is a small chance that patients may require an ICU during their hospital stay, knowing that there would likely be substantial delays in getting them to an ICU at another facility, they may be referred elsewhere for their care. As Roseburg VA only accepts patients that are less sick, nursing and physician skills further deteriorate, creating a cycle of increasingly unsafe conditions for patients with more severe medical issues.
So how difficult would it be to reopen an ICU and bring back simple inpatient surgery? The old ICU still sits vacant and unused. In order to reopen, general surgeons, anesthetists, and operating room nursing staff would once again resume on-call shifts. Hiring skilled ICU nurses would be our biggest challenge, as an ICU requires 24/7 availability of trained registered nurses.
Some have blamed the supposed limitations of our town for the difficulty of recruiting top-notch medical personnel to our hospital. In fact, Roseburg is a beautiful and family-friendly community in which to live and work. Applicants have been impressed by the high quality of services offered. The main reason highly qualified applicants regularly turn us down is because they are unable to use all of their skills in a fully functioning hospital.
With all the current media attention to veterans issues, now would be a good time to talk to your politicians about what sort of VA hospital you would like to see in our community.
Dr. Philo Calhoun of Roseburg has been a general surgeon at the Roseburg Veterans Affairs Medical Center for 5½ years. He is also a commander in the U.S. Naval Reserves. He can be reached at firstname.lastname@example.org.