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Critical Access Hospitals; an explanation

When a story about Box Butte General Hospital (BBGH) appears in the media, it often mentions BBGH is a Critical Access Hospital, or CAH. So what does that mean and what level of care can the people it serves expect?

A CAH designation is given to eligible rural hospitals by the Centers for Medicare and Medicaid Services (CMS). CAH legislation was passed by the U.S. Congress in 1997 to respond to what was then a crisis of rural hospital closures occurring across the United States. CAH was designed to keep access to health care viable in rural areas by reducing the financial vulnerability of rural hospitals. As of this year, there are 1,349 CAHs located throughout the United States, according to the National Rural Health Information Hub. Sixty-four of those operate in Nebraska. Box Butte General Hospital became a CAH on January 1, 2004.

To be eligible for the designation, hospitals must meet certain conditions:

  • Have 25 or fewer acute care inpatient beds
  • Be located more than 35 miles from another hospital
  • Maintain an annual average length of stay of 96 hours or less for acute care patients
  • Provide 24/7 emergency care services

Being designated a CAH doesn’t mean fewer services offered. As required by CMS, every three years BBGH conducts a Community Health Needs Assessment, using a focus group of civic leaders in partnership with the Rural Nebraska Healthcare Network and the Panhandle Public Health District. The plan makes sure BBGH offers services appropriate to meet the needs identified by the Assessment. The hospital also evaluates whether services provided are sustainable and financially viable.

So what level of care can the people BBGH serves expect? CEO Lori Mazanec said, “It is very important to understand our role as a Critical Access Hospital. Our goal as a CAH is to meet the health care needs of our area while also knowing what our limitations are. Once we’ve utilized all our resources to treat and stabilize a patient and it is determined that further resources are needed, it then becomes our responsibility to get them to a higher level of care facility so that their care is continued. That is a strength; knowing what we can do and when we need to refer on to someone else. It’s all about the patient receiving the best care possible. The patient’s best interests involving a treatment plan are always a top priority.”

One of the key contact points for knowing when a patient can be cared for at BBGH or should be referred is in the Emergency Department (ED). ED Nurse Manager Lori Fields, BSN, RN, “We do an Emergency Severity Index (ESI) evaluation on all patients. It is a triage process that our professionals train and undergo competencies for. Ultimately the ED provider determines whether the care is done here at BBGH or at a higher level of care facility.”

“Most of our ESI assessments indicate care can be done at BBGH, but there are cases that we refer on, such as trauma requiring surgery,” Fields said. “We don’t have a full time surgeon, so most patients needing that are stabilized and transported. We are fortunate to have visiting surgeons at BBGH quite often during the month, and when not in surgery they have been fantastic in coming to the ED for add-ons and assists.”

Other emergency cases often passed on to larger facilities are neurological in nature. “Stroke cases are the most common,” Fields said. “After evaluation, observation, and consults, we will have them transported if their provider deems that is the best course for the patient’s care.”

Residents may be surprised a trauma involving broken bones is another circumstance where the patient may be transferred. “Modern medicine just isn’t like it used to be back when a general practitioner often set and then cast broken arms or legs,” Fields continued. “It is all specialized now, which really IS better care for patients. Orthopedic specialists are the go-to physicians for the best care for broken bones. If our affiliated orthopedic specialists are on campus and available we will call them in. But if they aren’t we’ll transfer.”

It’s important to always be transported to the nearest ED when trauma or sudden illness occurs; obvious injuries like blunt and piercing wounds caused by accidents and sudden health emergencies such heart attacks and strokes are good examples. Broken bones should also be treated as soon as possible. “Take for example a broken ankle that’s absolutely turned the wrong way so that blood isn’t flowing right,” Fields said. “When that patient comes in we will do medical imaging of the trauma area and after that perform a reduction (setting and aligning the broken bone) so that blood flow is back to normal and arteries, veins, nerves, and tendons aren’t further damaged. We’ll then splint and make sure pain is under control before transport. This may not be as convenient as it was in the past, but again it all comes down to what is best for the patient. What’s best for the patient is to be diagnosed, treated, and stabilized as soon as possible, then transported when and if that is needed.”

BBGH Chief Nursing Officer Carolyn Jones likes to describe BBGH as, “a CAH that is a small large hospital, or a large small hospital. The number of services offered here is amazing. We often have visiting providers comment on how surprised they are about what we offer.” All the providers affiliated with BBGH know very well the level of care that can be provided at BBGH and when the care of the patient would be best served at a larger facility. “We’re a team here,” she said. “Our providers listen to our nurses and our nurses listen to our providers. On top of that, our providers, including our hospitalists, can consult with specialists when they feel the need to do so and they know when transfer is needed so that the patient receives the best care possible.”

BBGH is staffed with a medical team that is well trained and able to provide almost all the care required by area residents. “BBGH is small enough that I truly feel we are an extension of the families we serve,” Mazanec concluded. “We are very proud of the care we can deliver and are always striving to be the greatest place to receive care, to work, and to practice medicine.”

Box Butte General Hospital is an equal opportunity provider and employer.