SEPTEMBER 16, 1978 Yesup Memorial Library hospitals 34 Mt. Desert Bar Harbour, ME 04609 JOURNAL OF THE AMERICAN HOSPITAL ASSOCIATION MT DESERT ISLAND HOSPITAL A hospital for all seasons Jesup Memorial Library 34 Mt. Desert Bar Harbour, ME 04609 HEALTH CARE DELIVERY EMERGENCY A HOSPITAL FOR ALL SEASONS by Emily Friedman W hen hospital statistics are re- costs when census shoots up unex- ported on an annual basis, pectedly? when government requirements in- IN BRIEF Seasonal variations Virtually every hospital must clude minimum or maximum annual in occupancy, cash flow, staffing cope with these variations to one standards of care, or when planners patterns, and emergency depart- degree or another. Consider, how- analyze annual hospital occupancy ment activity are familiar to any ever, the case of Mount Desert Is- rates, hospital administrators can hospital, but institutions located land Hospital (MDIH) in Bar justifiably point to the unfairness in seasonal resort areas must Harbor, ME. Located on an island of it all. What about the Christmas cope with more extreme varia- off the northern coast and connect- holiday period, when inpatient cen- tions than do most hospitals. ed to the mainland only by a cause- sus drops markedly and emergency Mount Desert Island Hospital, way that is prey to the vagaries of department activity often increases? How can the slack times during the Bar Harbor, ME, has developed wind and weather, MDIH must deal with seasonal variations that would summer be averaged out in a fair several innovative means of han- give pause to the most determined manner? And what about overtime dling slack periods in wintertime compiler of annual statistics. In the and intense activity in the sum- winter months, the island is a quiet mer. Emily Friedman is field editor of Hos- and very cold place with a popula- pitals. (Please turn to page 104) SEPTEMBER 16, 1978, VOL. 52 101 HEALTH CARE DELIVERY tion of approximately 9,000 people. to the hospital in other ways. Un- periods. When financing becomes The hospital's 66 acute care beds like many hospitals for which sum- too precarious, employees are en- and 26 skilled nursing care beds mer is a slow period and winter is couraged to take unpaid holidays are generally 60 percent occupied. a time of much more intense activ- during the off-season. For non-nurs- Come spring, and some 21,000 more ity, MDIH faces its busiest period ing employees, the program is vol- people arrive to spend the summer in July and August. The increased untary, but employees understand swimming, fishing, soaking up sun summer revenues are the critical the necessity of having such an ar- -and using the services of Mount factor that allows the hospital to rangement and try to participate in Desert Island Hospital. The cause- provide extensive free care for the it. "The employees can see that way that sees but a trickle of traf- island population during slower helping to save dollars here and fic at the height of winter becomes periods when the weather is not so there helps them to keep their jobs," the site of a permanent traffic jam cordial. Many island residents work Lotreck explains. "If you're honest through which ambulances and ve- only during the summer in tourist- with employees, they are willing to hicles carrying critical supplies of related jobs. Even these jobs are go along with solutions that prevent blood and pharmaceuticals must hard to come by, however, because permanent reduction of services," maneuver, medical-surgical nurses a major fire devastated Bar Harbor Louise Dunn, R.N., director of find themselves delivering babies, in 1947 and resulted in a permanent nursing, adds. In order to encour- and the emergency department pa- decrease in the tourist trade. Thus, age this attitude, the hospital posts tient load nearly triples. Occupancy the island has poverty pockets and income and cost statements on bul- increases by 20 percent, and even a high rate of unemployment. Also, letin boards each month, which the number of trustees who attend 20.3 percent of the island's resi- helps to maintain employee cost con- hospital board meetings increases dents are older than 65, which is sciousness. by 25 percent. twice the state average for Maine. For nurses, mandatory unpaid How does the hospital manage? As a result, approximately 64 per- holidays are a condition of employ- Quite well, according to MDIH ad- cent of the hospital's revenues come ment. Upon joining the MDIH staff, ministrator Charles Lotreck. The from Medicare and Medicaid reim- each full-time nurse (as opposed to key is preparedness-always keep- bursement. the extra summer nursing staff ing the next season in mind, think- members) signs an agreement that ing in terms of the entire year, and A common cause mandates 12 unpaid days a year. trying never to be caught short by Nurses are encouraged to take even unexpected developments. It is an Surviving the hardships of sea- more days during slack periods, and effort that involves the entire staff sonal extremes is a job for everyone sometimes the timing of these un- of the hospital, not to mention who works at MDIH. One method paid holidays is dictated. In 1977, many inhabitants of the island and employed by the hospital is encour- for instance, each nurse was asked a large number of "summer people" aging autumn and winter vacations to take two unpaid days during the whose vacation homes are located and discouraging summer holidays. five weeks between Thanksgiving in or near Bar Harbor. "Discouraging" might, in fact, be and Christmas, when the hospital's too mild a word; for most em- occupancy and cash flow were both ployees, summer vacations don't ex- at a low ebb. The gifts of summer ist. The hospital recruits employees Recruiting staff under these con- The hospital was first founded in with this concept being fully under- ditions is difficult, but not as night- 1897 through the generosity of the stood at the time of employment, marish as might be expected. The island's summer residents, and sum- and scheduling has worked out well. hospital has 150 full-time equivalent mer tourists continue to play a maj- In addition to being a major resort positions and maintains a full year- or role in maintaining MDIH. More area in the summer, Maine is also round staff in most departments. than one-fourth of the members of a haven for cross-country skiers The 83 permanent nurses are aug- the governing board are "off-is- and hunters, and the autumn hunt- mented by 10 summer nurses who land" summer residents, as are at ing season is prime vacation time are generally recruited for the pe- least 10 members of the nursing for MDIH employees. So many deer riod between May and September. staff and several physicians who hunters work at MDIH, in fact, that Registered nurses and LPNs make have summer courtesy privileges. the period of November during up 60 percent of the hospital's staff. Fortunately, the island has long which deer hunting is restricted to The hospital has experienced some been a resort for wealthy eastern Maine residents is one of the peak difficulty in attracting LPNs to the families, and MDIH has earned vacation times; the hospital is area and thus is more dependent on their continuing support. sometimes forced to stagger vaca- RN nursing than are many hospi- Although philanthropy provides tions SO that staffing does not be- tals. MDIH does offer a program a major-and absolutely necessary come too depleted. that reimburses nurses for reloca- -component of MDIH's finances, But hospital holiday policies ex- tion expenses after the first six the summer population contributes tend far beyond selective vacation (Please turn to page 108) 104 HOSPITALS, J.A.H.A. HEALTH CARE DELIVERY months of employment. Student which helps." Also, medical-surgical extraordinarily busy maintaining nurses are also recruited to work nurses are cross-trained for OB- records for off-island visitors and at the hospital; under a new pro- GYN duty, and they switch off as shipping records to these patients' gram, nursing students from North- needed. regular physicians; the cost in- eastern University in Boston come Transportation of patients and volved in shipping the records is to MDIH on a three-month rotation. supplies is a constant headache. "a pretty major expense," accord- The hospital hopes that this pro- The traffic jam on the island and ing to Lotreck. Also, if a patient gram will provide summer nursing the causeway to the mainland seems is staying in the hospital for a staff in the future. In order to en- to be a permanent summer fixture, relatively long time, it is difficult sure that housing for summer and providing ambulance services for the MDIH staff to find inexpen- nurses is not a problem, MDIH into and out of the hospital is often sive housing for his family. Geared maintains a 16-bed dormitory for difficult. Normally, patients can be toward tourist incomes, the island them. One new factor that could be transported to mainland hospitals does not offer much low-priced ominous for MDIH is that two new for specialty care within an accept- lodging for transient visitors. nursing homes recently opened on able time period, although the ab- the island, and competition for sence of hospital staff members who Neither rain nor snow nurses has greatly increased. On accompany them can spread staff the positive the nursing homes thin at MDIH. Emergency patients The hospital's dedication to car- do refer patients needing acute who must be transported to Boston ing for its summer visitors pays care to the hospital. or Portland, ME, are carried by off, no matter how difficult the task Bar Harbor Airlines, a commercial is at times. The members of the Good staffing and carrier that works very closely with 36-person governing board who are the hospital. "The airline does an bad seafood summer residents "take a real pro- excellent job," Lotreck says. prietary interest in the hospital," During July and August, every- Lotreck notes, and the hospital, in thing from OB-GYN activity to the Keeping it going turn, works to keep them informed emergency department load in- all year. "If you keep them in- creases by a large amount. There is The cooperative nature of the formed, and they are educated about even a vast increase in the number work at MDIH also involves long- the hospital, their proprietary at- of gastroenteritis patients-a direct range planning by many different titude is very helpful." Lotreck result of summer visitors' some- staff members. The hospital's pur- knows of no friction between the times unsafe experiments in cook- chasing agent, for example, main- summer board members and those ing fresh seafood. The hospital's tains inventory by arranging for who live in the community year- response to this increased activity large stockpiles of supplies prior to round; the board promotes the hos- involves different deployment of the summer rush; in the winter, he pital's philosophy of providing the full-time staff. During this period, allows the stockpiles to drop down best care throughout the year, even the emergency department is staffed to normal levels. The dietary de- if some board members are not 16 hours a day by an RN and a full- partment must cope with the dif- present for a good part of that year. time receptionist. This arrange- ferent tastes of off-island tourists. After Labor Day, the tourists ment contrasts with the winter "Visitors like salads," Lotreck ex- depart, the hospital's cash flow schedule, when the ED supervisor plains, "but local residents don't slows, the deer-hunting employees handles most of the work and an seem to eat fruit or fresh vege- head for the hills, seafood poisoning RN is on call. The size of the medi- tables." The patient menus are ar- becomes an emergency department cal staff does not increase; the ranged accordingly. The mainte- rarity, and the island returns to a basic complement of 12 physicians nance department, which must keep beautiful, if chilly, peace. The hec- -two general surgeons, three in- the hospital in shape despite the tic summer has once again provided ternists, an obstetrician-gynecolo- severity of the winters, must also enough funding to carry MDIH gist, three family practitioners, a adjust its patterns to accommodate through to spring, even with the pediatrician, a psychiatrist, and a the high summer occupancy levels. marked increase in charity care that radiologist-remains the same. Painting of rooms, routine upkeep, will accompany the coming of win- "They just work a lot harder in the and the like must continue during ter. Even as the snow returns, the summer," Lotreck notes. Because a the summer season, and the main- staff of MDIH is hard at work large number of eye injuries occur tenance staff keeps busy finding planning, studying nurse recruit- during the resort season, MDIH is both time and opportunity to do SO. ment, examining inventory, and seeking to add an ophthalmologist to There are special jobs that are working on funding for this rare the staff. The main problem is one tied directly to the fact that so institution that continues to use of thin staffing in specialties. "The many patients live in other parts the fruits of summer to keep itself depth is not there," Dunn says. "We of the state or the country. The sound during the fiercest of win- do some specialty training of nurses, medical records department is kept ters. 108 HOSPITALS, J.A.H.A.