State tells Saint Alphonsus it has 1 year to gain back full trauma-center designation

The Idaho Statesman reported Dec. 7 that Saint Alphonsus Health System’s flagship hospital in Boise lost trauma-center certification from its national accrediting organization, the American College of Surgeons.

The health system wouldn’t say why, just that the surgeons college’s latest verification review made four findings that were “documentation/administrative in nature.”

Now, we know more about what led the college to revoke its stamp of approval for the Saint Alphonsus Regional Medical Center at 1055 N. Curtis Road, as the hospital works to get it back.

A survey for reverification is slated for spring 2024.

Chris Way, chairman of the Idaho Time Sensitive Emergency System Council, the state accrediting organization for trauma centers, said Saint Alphonsus has already corrected three of the four problems, with proof.

The four findings were related to the documentation of orthopedic-surgeon and neurosurgeon response times, as well as issues regarding alcohol screening and its process improvement and patient safety program, according to Way. The surgeons college, which confirmed the hospital’s status with the Statesman, would not comment or provide further details.

Surgeons’ arrival times not documented

Way said the findings regarding surgeon response times were due to a lack of documentation of when surgeons were arriving, not because they were late or failing to show up. He said the hospital has a new system in place now to record their arrivals.

“Although those surgeons were arriving, they could not prove it because they weren’t documenting it,” Way said Thursday.

The council’s standards manual for Level 2 trauma centers says orthopedic surgeons and neurosurgeons must be present in the emergency department within 30 minutes of a request, with an 80% achievement rate. To be certified, the hospitals must have orthopedic surgery and neurosurgery available at all times.

Trauma centers are also required to screen all admitted trauma patients for alcohol misuse and provide a brief intervention if appropriate, according to the manual.

They must have a program for performance improvement plans too. The program must have committees that meet regularly to address patient care and find ways to improve. Way said he could not adequately elaborate on why Saint Alphonsus’ hospital failed in this category.

Patient care remains same, hospital says

Saint Alphonsus still declines to disclose or comment on the findings. Letty Ramirez, a spokesperson for the health system, reaffirmed that the hospital hasn’t changed anything involving patient care.

”Our main concern is that the public feels safe,” Ramirez told the Statesman by phone. “We don’t want people to feel uncomfortable traveling or feel concerned that there’s a gap or something wrong. The processes are the same. Nothing has changed in terms of patient care.”

At a regular meeting Tuesday, the Idaho council reviewed the surgeons college’s latest survey and chose to uphold its own certification of Saint Alphonsus’ Boise hospital as a Level 2 trauma center, the most advanced designation in the state, with some stipulations.

Trauma center gets provisional status

“We gave them a provisional designation,” Way told the Statesman by phone. ”Part of the reason we made that decision was because there were no critical misses. And we did ask for regular documentation in the coming months to prove to us that those issues are resolved and that their new plan is indeed working.”

The provisional designation is good only for a year, meaning Saint Alphonsus will need to either gain back full designation from the council or re-designation from the surgeons college.

The 17-member council was created by the Idaho Legislature in 2014 to improve coordination and treatment of care of patients with blunt-trauma injuries, strokes and heart attacks. The council comprises doctors, emergency medical service workers, hospital administrators and a citizen.

It performs its own verification reviews to ensure hospitals are meeting its standards, which are “very similar” to the surgeons college’s standards, Way said, though state law allows it to skip on-site reviews when a hospital has been verified by a nationally recognized accrediting body like the American College of Surgeons. Trauma centers are verified with the state every three years, and an onsite survey is required for each verification process, according to the Idaho Department of Health and Welfare.

Way said the council did not think an on-site review at the Boise hospital was warranted for the provisional designation because each member received a copy of the findings and documentation from Saint Alphonsus that showed that the hospital had resolved most of the deficiencies and was working quickly to remedy the rest. In addition, a staff member of the state’s emergency system was present during the surgeons college’s on-site review, he said.

He could not recall exactly when that review was conducted, as it “takes months” for the surgeons college to finalize its reports, but estimated it was nearly a year ago.

“The council takes these things very seriously,” Way told the Statesman by phone. “We would never put a patient or patient care at risk, and we do not feel like there are any patients at risk as a result of this. Otherwise we would not have taken the action that we took.”

There are five trauma-center levels recognized by Health and Welfare. The higher levels, 1 and 2, treat more-complex patient traumas. The lower the level, the fewer the resources, and the greater the likelihood that some patients may need to be transferred to a higher-level center after receiving initial treatment.

There are no Level 1 trauma centers in Idaho. Those involve a partnership with a medical school.

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