In the past year, Rapid City Regional Hospital has delayed or diverted the admission of 65 ill or injured people because it lacked the beds or necessary staff to provide the medical care they needed at that time, according to a hospital official.

Although those 65 diversions are a tiny percentage of about 50,000 emergency department visits (and the nearly 18,000 hospital admissions) at Regional annually, Custer's Cindy Nobliski said it's a major inconvenience and a big expense if you happen to be one of them.

Nobliski broke her pelvis and fractured her skull in a horse-riding accident Dec. 10 at her home south of Custer. Tests performed at the Custer hospital showed she required neurological monitoring and possible neurosurgery as well as orthopedic care. Instead of being transferred by ground ambulance from her local hospital to nearby Rapid City Regional, she was flown to Sanford USD Medical Center in Sioux Falls when Regional told Nobliski's doctor that they didn't have an intensive care unit bed available for her.

"Yes, they said there was no room at the inn. That was kind of surprising to me," Nobliski said. "They said there was no room in the ICU and that they were full for neuro, too. I'm a little surprised by that."

Diverting patients is happening more often, according to John Culberson, a former Custer city council member who works with the Custer ambulance service.

Ruth Airheart, employee supervisor of Custer Ambulance Service, agrees.

"It seems to be happening more frequently as of late - more this last year than previous years," Airheart said.

The city of Custer allocates a city sales tax (three-quarters of 1 percent) for a hospital subsidy that is capped at $400,000 annually. A local nonprofit board - the Custer Community Health Systems Board - owns the hospital building and contracts with Regional Health to operate it, a clinic and a long-term care unit.

"I'm a strong, strong supporter of Rapid City Regional Health and Hospital, but I have some very serious concerns now," Culberson said. "This has happened with some regularity recently. Why would you even be affiliated with Rapid City Regional if patients from Custer can't be transferred to the 'mother' hospital in the system?"

Culberson said area ambulance crews have come to expect diversions during the annual Sturgis motorcycle rally. "OK, you can understand that. But if we're having it happen in the middle of December, what's going to happen next summer?"

Regional vice president Rita Haxton sympathizes with patients like Nobliski who get diverted to other hospitals.

"We're not talking about a huge problem, because it is just a fraction of a percent of all Rapid City Regional Hospital patients. It's very rare. But whenever it happens to you, it's a big issue," Haxton said.

Nobliski said her husband and her 87-year-old father, who was visiting at the time of the accident, were forced to make a late-night drive across the state and pay for hotel rooms in Sioux Falls.

Nobliski was discharged from Sanford Health on Dec. 13 and is recuperating at home. She is grateful for the excellent medical care she received and that the injuries she sustained - when her horse stumbled and lost its footing - were not more severe. She will use a walker for at least six more weeks while her fractured pelvis heals, and she is recovering nicely from minimal brain injuries caused when her head hit the ground: two subdural hematomas, or small brain bleeds, and closed fractures of her skull.

"I'm lucky, but I'd rather have been lucky on the other side of the state," she said. "The care at Sanford was absolutely wonderful. They have great folks there, but I would have preferred to be treated closer to home in Rapid City."

Nobliski has insurance, but whoever ends up paying her air ambulance bill will feel the pinch. Sanford charges a flat rate of $5,269 for a Level 1 medical flight, plus $17 per loaded mile, for a total cost of well over $10,000. The average cost of an ambulance transport by ground from Custer to Rapid City is between $700 and $1,000, Airheart estimated.

"It's a huge cost to the health care system, to the families, to everybody," Culberson said.

In the past 12 months, Sanford has logged 10 air ambulance flights that originated at a medical facility somewhere in western South Dakota, out of about 1,500 medical flights per year, according to Sanford spokesman Mark Johnston. Regional Health owns many of those facilities, but some might have come from Indian Health Service facilities, too.

The specific reasons for a delayed admission or a diversion to other hospitals vary from situation to situation, Haxton said, but it is always done to provide the best possible medical care for a patient. Only medically stable patients are diverted, and no one would be turned away from the emergency department if they were in a life-threatening situation, she said.

"We don't like to do it. It's turning away business for us," Haxton said. "But we do it because we put patient care and safety first."

Diversions happen for numerous reasons, she said, including the fact that the required physician specialist may not be available at Regional that day. That may mean that the right kind of doctor is not on staff or that a specialist is unavailable at that time.

Patients can also get routed to other Regional Health hospitals or sent out of the system if Regional has a shortage of available beds in the adult ICU or in other specialty units, Haxton said.

Regional has 25 beds in its adult ICU, and an average daily census for that unit of 18 to 19 patients. But if ICU is filled to capacity, or if the current patient population requires a higher than normal nurse-to-patient ratio, diversions are necessary.

In some instances, there may be empty beds, but not adequate nursing staff to man them. Culberson speculates that nursing shortages may be affecting Regional admissions.

Like many U.S. health care facilities, Regional Hospital faces a nursing shortage. At any given time, about 4 percent of Haxton's nursing positions at Regional are vacant, compared to 10 percent to 12 percent national nursing vacancy rates. Sanford's Johnston and Avera McKennan spokesman Daryl Thuringer said nursing vacancy rates at their Sioux Falls hospitals fluctuate between 1 percent and 1.5 percent.

Patient volume has grown about 6 percent in the past year at Regional, Haxton said, and balancing patient beds with nurses to staff them is an ongoing issue, but not the cause of most diversions.

"It varies for different reasons on different days, but most of the time it's because I don't physically have a bed," Haxton said.

Despite occasional specialty bed shortages, Haxton said another hospital is not needed in the Rapid City market and would not eliminate diversions. If anything, a second full-service hospital would contribute to more specialist shortages.

"I don't think we can support another hospital of our size," Haxton said. "I don't think we have the volume here to support another hospital."

Contact Mary Garrigan at 394-8424 or mary.garrigan@rapidcityjournal.com