 ThinkTekAway. Civil engagement lives here. Welcome. This is your host Craig Thomas. On the show Much More on Medicine, assisted by our engineer Ray, and joined by Tammy Crore and Brian Sheplik from Oahua General Hospital. Welcome. Thank you. Thank you for having us. Thanks for coming. So today we're going to talk about our community hospital that serves Central Oahu in the North Shore, which, incidentally, is by far the largest geographic catchment area for a health facility on the island, and one of the larger ones in the state. Big Island has the largest geographic areas. Now it's not as populous as many of them, but from top of Pupukea, you have to decide where to draw your boundaries. Pupukea is certainly in the catchment area, and from the top of Pupukea to Oahua, it's about an hour. It can be longer when there's traffic at Laniakea. So this is an area that has some population centers. It has big military base. It extends down into Mililani, Mililani Malka. So it has some suburban areas. It's one of the fun things about working there. It's a variety. And I just for sort of closure started there in 1983. My very first shift out of residency started at 5 p.m. on a Tuesday at Oahua General Hospital. We all remember our first shift, especially since as I walked in, the doctor I was relieving was like, oh, the ambulance called. They'll be here in five minutes with a respiratory arrest. I'm like, you're not going anywhere. Things went fine. It's been over the years, a wonderful place to work. And still my favorite, actually. We staffed nine hospitals across the state, but Oahua is a sweet place. So I thought we might start with a little bit of the history and then we'll talk about sort of the how the hospital and the area grew and changed and we'll talk about some current roles. Okay. All right. Definitely. Well, I mean and you gave, I'm glad you started with the Ketchman area, but as you know Oahua was established back in I think I believe 1944 and came out of necessity out of World War II. The actual site where the hospital is now in Oahua used to be the old Oahua Elementary School, which is kind of interesting and the Oahua Hospital Association decided, well, we really need a hospital in this community because back then, I mean it was a little less populous, but we still served a wide area in the Oahua community as it was growing, as you know it became an agricultural hub and we were servicing the communities down in Wailua and Haliva and Minalani, although we didn't have Malka, Minalani Malka at the time, it was still serving old, what they call old Minalani at the time, so it was a wide area that necessitated actually the building of a hospital, a community hospital. Right. In fact when I started at Oahua, it was still an agricultural town, although I think the employment peak had passed. In fact in 1950, my understanding is Oahua was the third biggest community on Oahu. It had a skating rink, a couple theaters. When I was there, there were Dolm del Monte both and Wailua Sugar, so we're talking close to 20,000 acres in agriculture, so it's been a change. All that ended in the 90s and it's been a real change for the community. Not always an easy time for Oahua town. I'm glad you brought that up. I'm a little bit younger, but I'm originally from the big island. You mentioned the big island, yes. I've moved over here, so I've seen I've been here on Oahua since about 1990, living down in Wailua. I've primarily lived down in the north shore in the Wailua community and now I live in Milani, Malacca. You've seen the changes, you've seen the growth, you've seen some changes for the better, some for the worse. You've seen some other struggles that the hospital itself has had to adapt to and change along with. I know there was talk and everybody knows it's pretty widely known that back in 2015, 2016, there was a mention the hospital may shut down. There was a big push to keep the hospital open and I mean I'd be remiss if I did not mention our partners down at the legislature which is Senator Donovan Delacruz and at the time Representative Marcus Oshiro who made a big push to get some funding to keep the hospital doors open because realistically the hospital is a pillar of the Wailua community and to have it shut down not only for the healthcare reasons but really to be a hub for that Wailua community, it was important to stay open, keep the doors open there. Oh absolutely, I mean yes it is a hub for the community but it's also the area for acute diagnostics and emergent treatment for the whole catchment area. So we do owe the legislators our thanks and look forward to future joint endeavors just to put this more in context this is a story that played out across the nation both the farming community ARC but also the community hospital challenges in fact I didn't know you were a Hilo boy but I work in Hilo too and it used to be that you could drive from Hilo to Honika and never be out of sugar cane and that all ended about in 1995 and that's astonishing, that's what 40 miles so it's a big change for Hilo too big change and so across the nation pounds like this evolve and change and so do community hospitals and in fact the role of hospitals is changing it used to when I started somebody come in with chest pain and we say hmm looks like a heart attack take us a while for our test to work out here we didn't have very good test back then which didn't matter much because we had actually no treatment wait we didn't phrase it that way but in hindsight we weren't honestly doing very much and we'd put them in hospital and then it turned out to be a heart attack or not over the next few days and like I say the treatments weren't very effective all of that's changed and later in the program we're going to talk about the time sensitive issues around some specific diagnosis heart attack is definitely one of them that's true but before that I think we should talk a little bit about the hospital itself and the what's available there what's happened over the last few years and for that Tammy you're in the middle of it so after the help of the legislature we were able to partner with a mainland vendor who helped develop a turnaround plan and with all the local leadership still at the hospital and a successful turnaround plan I can say today that's exciting and you know this partnership thing well I'll be just out there my group does it too we in times past did everything we did our own HR we did our own IT which is why we don't do that anymore it turned out to be real expensive and you need specialists that you just can't have and the obvious way to solve that is to make a hybrid operation namely you keep local control local hands-on direction and you outsource to a larger entity things that are done remotely and it's huge it lets you take advantage of much bigger organization better purchasing power access to specialized folks like data analysts interface gurus those are the two things we needed a lot yes we did and it's I think it's a very successful model in fact it's almost the only way all local emergency groups like ours can compete against the large mainland networks and with this resource we can and they've helped numerous hospitals across the united states communities hospitals and actually I know that their specialty is community hospitals which is pretty different from tertiary centers and takes a special set of expertise so we've been able to join their purchasing group and saw approximately a million dollar savings in our supply costs so that helps significantly so that's big because what you're telling me is you're saving a million dollars a year and you have the same supplies so previously what another hospital might pay two dollars for we were paying ten dollars for because of our size so we made a big difference that's clearly a problem that needed to be solved tell me what else is going on they we have a recently renovated ED has 16 beds two trauma rooms we're doing a major IT infrastructure renovation I guess you can call it upgrading all of our systems which was in desperate need we've revamped our patient financial and accounting services with the help of the specialists from the vendor review productivity reviewing quality of care providing analytics performance analytics on your data it's the way of the world these days and the problem is it's easy to collect data it's much harder to actually evaluate it analyze it and implement what it's telling you I'd also like to thank you for the emergency department renovation I always loved working there but when we only had six beds and we were seeing on the order of 21,000 patients which means we were about a third to maybe a half the size we should have been and when the last window was in 1978 honestly it was tough it was much needed now they're all private rooms it's beautiful triage rooms the medicine is the same but the experience is much better much more comfortable for the patient it's much better tell me about some of your other services we have diagnostic imaging we utilize this quite a bit we do CT scanner state-of-the-art mammography machine ultrasound we also have cardiopulmonary department who performs pulmonary function tests for outpatients as well as inpatients stress test cardiac we have laboratory department we have rehab outpatient and inpatient rehab services our outpatient rehab services are growing currently we've opened up a new space for them to help the community so they don't have to travel to town once they're discharged from a hospital and they need continuing rehab so we're going to be offering that we have a 107 bed long-term care facility connected we have 5 bed ICU and 53 acute care beds total so one thing I've learned working as I said I work across the state and my sense is that the best care is appropriate care that can be delivered as closely as possible to home and a number of the things you just take by that so wherever you had your procedure if you need rehab in the end it's way better to have your rehab down the street if you have an acute event it's wherever you end up for say a thrombectomy for a stroke what you need is early initial diagnosis and stabilization you want that down the street to initiate a treatment yes so the spectrum of services you just provided demonstrate how many of these things can be done in the community and as we discussed before the community is big geographically big so down the street may still be a significant drive that additional 20-30 minutes is the difference for somebody the other thing that I think is worth emphasizing it's one of the few facilities with a skill nursing facility on campus and you mentioned it but you didn't really give it the focus I think it deserves I honestly think it's a great facility and it's a nice adjunct because some patients aren't ready to go home they can't live at home any longer so they provide skilled services whether it's skilled nursing care rehab short-term rehab long-term care and then also hospice services so they offer quite a variety of services and all those services clearly are better if families nearby yes we have patients request to go there so that their family is close by it decreases the burden on the family when they have to take time off of work and they can come visit much easier when they're close by one of the challenges with these groups of patients is keeping them still connected to their families and if you're at the island it just isn't going to happen there are folks in Wahiwa and the North Shore area they don't go to town so when they here they have to transfer to a larger facility in town they don't want to go because they're not used to it they're not familiar with it and you know we in medicine aren't as good as appreciating the importance of proximity is therapeutic and if you have someone who can help you navigate the health system your family or your neighbor working at the hospital since your neighbor probably does work at the hospital if you live in Central Oahu they are the largest employer we are the largest employer in Wahiwa 500 employees by far actually and I think your only contender in Central Oahu are you selling military? yeah so I'll be honest I didn't appreciate the importance of this when I first started medicine and I think a lot of people working at tertiary centers never learn it the focus wasn't there at that time no we were I trained at a tertiary center people come to us they're lost they're frustrated it's tough for them and so there's definitely a role for tertiary centers if a procedure is not done very often or it requires specific skills or equipment that you know is a high acuity low volume event clearly it should occur at a tertiary center and patients should end up there but many other things should not be done at tertiary centers the whole list you just put out there is in that category I know you also have a specialty clinic and so some of the specialists that not enough business to support daily practice do rotate to the hospital tell me a little about that we have some cardiologists neurologists geriatrician looking at a wound physician they all rent space so that the patients OB obstetrician gynecologist so that the patients in the area don't have to travel are there into town for their weekly, monthly, whatever clinic visits and then they can get their labs performed right there on site and they're imaging usually so it's been a good good experience for the patients in the area yes I'm familiar with the clinic and we actually get patients from there in the ED or we refer patients from the ED for follow up there so it works out pretty nicely yeah it does okay in a minute we're going to sorry go ahead in a minute we're going to talk about how community hospitals and medicine have evolved in the way that they have across the nation to be honest actually across the world or as I alluded to earlier when I started people came in we did what we could we put them in the hospital and incidentally it was staffed by community physicians and like the stay was long the bar to admission was low one of the reasons of course healthcare wasn't as expensive in those days so if you spent an extra few days no one cared very much and all that's changed and so now the patients come in even small hospitals like Wahiwa have tremendous amount of diagnostic capability immediately available and a lot of interventions and it's sort of changed everything right previously when I started at Wahiwa in 2001 the majority of the patients that came to the hospital were community physicians from their clinics their offices and as community physicians retired and reimbursements changed and it's the trend move towards hospital care in the inpatient setting so now the majority of the patients come in through the ED and then they're admitted and taken care of by a hospitalist who is in house 24-7 right and it's a big change it's a big change and medicine has evolved the complexity of the sort of evaluations and management strategies in your community doctors offices changed dramatically now they are calculating chance of a cardiac event based on your parameters in the next 10 years and entailing treatment to do that no one used to do that so they have a whole skill set which I know exists but I don't know about it on the other hand the flip side of that is that in the hospital it's also become more complex better and a number of other outcomes are possible but it's another skill set and so gradually and there are still a few who straddle both both camps which is impressive in my mind there's really nobody straddling the outpatient ED camp which honestly that's how it used to be in fact the beginning it was community hospital as community physician gets called to the ED oh your patients here and they'd come in and do something and then they got people like me and then 20 years after that as you said hospitalists and that's been an evolution for hospitals because it's required engaging different groups of physicians it's required a different relationship with specialists because they have the relationship with the community physician now they have it with the hospital based physician or the hospital themselves and it's a challenge for facilities of all sizes and I think particularly for smaller ones and I think it's important to mention that with the new management arm per se with the community hospital corporation they understand that they understand that the hospitals are evolving and they have their finger on the pulse so to have them come in and understand that and see it and like Tammy had mentioned I believe they're managing over 25 facilities across the nation that was a positive change for Oahuwa General it wasn't bad per se at Oahuwa General but there were some struggles there were some challenges and they were able to identify them and we're moving in a positive direction we really really are yes the ED yes the renovations but I think you had mentioned earlier the core group of people that we have there the nurses the doctors the level of care that you're going to get has always been great but now you have these new facilities and a new technology and things to go along with it the expansion from 7 beds in the yard to 16 I mean the two trauma rooms I mean if you look at the scars on my head I'm a patient I have gone to Oahuwa ER from my surfing accidents and I can tell you the care that I got was always great but now you're seeing the other side of it the technology the renovations to all the facilities even the acute care beds I mean we're getting new beds and it may seem small you may not see that from the outside but that's those are big changes and not only for the patients that come in but for the staff I mean it really improves morale and it really makes you want to come to work and do a good job and I think that's really important to mention because that goes a long way especially when it comes to providing health care for patients so that's important so a consequence of the changes we've been discussing in the old days essentially all hospitals most of the patients were admits from the community now at all hospitals the majority of admissions come through the emergency department and at small hospitals like Oahuwa it exceeds 90% I think it's damn close to 100% yeah it's pretty close to 95% and the reason for that is emergency departments have become the acute diagnostic stabilization and initial treatment centers of the whole medical community not just the hospital and so if you go to see your primary provider this is soon you can get in and they're working on that this is one of the focuses in health care is access to your primary provider another focus is something we should circle back to which is Oahuwa's participation in the blue zone because it's much better to stay healthy than try to get healthy again so let's circle back to that in a minute but if you get to your primary provider and it looks like you're potentially significantly ill you'll end up with me and in the old days that's not how it would have happened you would have either been directly admitted or they'd be like we'll schedule you for your oral closed histogram which we don't do anymore but it's how we used to diagnose skullbladder disease on Wednesday and take these two pills a day before that's kind of how it was done now let's go up to the ER, see Craig we'll get an ultrasound and if needed we'll call a surgeon so it's changed entirely and this is why you need a portal to the emergency department in every community every significant size community which this definitely is and our job then is to well it's really interesting in hospitals there's something called the ADT feed it's a technical term about kind of a data feed I never knew what ADT meant I talked about ADT feeds forever and you may know I will put you on the spot I do not so don't feel bad I talked about I set up ADT feeds for like 20 years we need them because they have the crucial demographic data about a patient so it's how you can get a test get demographic information you have to have it I never knew what it meant here's what it means admit, discharge transfer and I heard that and I said that's my life because honestly it is so in the world of the emergency department about 85% of people who come in to the ED they get evaluated and ultimately they go home but the other 15 that's where the real business lies I mean there's plenty of business you came, you got your head sewed up might have even been by me I think it actually was well I won't break any patient disclosure but I have I have sewed up a lot of people including some other members of legislative community in the central Oahu we will not mention names my kids have been sewn up there several times well I'll tell you a funny story years ago when a bunch of pineapples around I was riding my mountain bike and dodging security around the corner a little too fast lying on my butt and I'm like I shouldn't really go get this fixed up but I am no way going to my own emergency department to have them work on my butt so it just had to get better on its own never mind back to where we were the 85% of people go home and we may connect them with a special clinic or back to their primary care provider etc the other 15% get either admitted or transferred and we do the initial therapy and then we stabilize them we give them thrombolytics possibly for strokes we have a telemedicine consultation available we admit them and rule them in or out for heart attacks if they need a catheterization we send them directly we are going to have to have a brief summation about 30 seconds or so of where the future is so I'll start with you the future of Wahiwa what are your near term goals increase our ED visits increase the knowledge of the community so they know that we're there and they can come by instead of driving 30 more minutes to town for their treatment diagnostics I think that would all be good and I'm just going to echo those statements I'm part of that new plan two weeks into this job as a communications manager they saw that they needed the need for public relations communications and it's like Tommy said initially we really need to drive the traffic through the ER and it's huge if you live in Mill Honey Mocker even in Kahuku, Haliva the Wahiwa community I mean Whitmore you don't need to go to Polymomy there's nothing wrong with Polymomy but the ER at Wahiwa General is the level of care and I'm not going to say exactly how short the wait times are a lot shorter than some other places that you're going to have to sit in the hallway so by all means our ER is up and running and you're going to get a tremendous level of care there all boards certified well thank you both and thanks for joining us we'll look forward to chatting next week