ERs Increasingly Shutting Doors to Ambulances

Los Angeles County emergency rooms turned away paramedic ambulances 8% more often in 2005 than a year earlier, with some major hospitals closed more than half the time, according to data from the county Emergency Medical Services Agency.

Public hospitals such as County-USC and Harbor/UCLA medical centers closed to ambulances an average of about 20 hours a day while some private hospitals -- including Pasadena’s Huntington Hospital, Bellflower Medical Center and Lynwood’s St. Francis Medical Center -- closed for 12 hours or more.

Emergency room directors throughout the county say reasons for the overload include population growth, greater numbers of seriously ill or injured patients, increasing use of emergency departments for routine care, and recent hospital closures throughout the region.

The persistence of the problem has led the county to revise its diversion policy, further limiting the length of time in which hospitals can turn away ambulances. Those guidelines will be implemented in a couple of weeks, said Carol Meyer, director of the county Emergency Medical Services Agency.

Current policy allows hospitals to shut their emergency rooms to incoming ambulances for two-hour periods when hospital officials decide they are overwhelmed. The new policy would allow diversion for one hour at a time and require hospitals to stay open for at least 15 minutes before going back to diversion status, Meyer said.

Sending ambulances to nearby hospitals can create a domino effect, forcing other departments to close in succession as they too become overwhelmed.

Ambulances have to travel farther to find an emergency room, which can take them outside their primary coverage area and increase their turnaround time, said Dr. Marc Eckstein, medical director for the Los Angeles Fire Department.

Paramedics who choose to stay to monitor patients until a doctor is available can’t respond to the next emergency, Eckstein said. Paradoxically, when all hospitals in a designated area are closed for diversion, county policy demands that every one open up.

After dramatic increases in diversion hours in 2000 and 2001, the Emergency Medical Services Agency encouraged hospital officials to analyze more closely when and why they closed. The block of time allowed for diversion was halved from eight hours at a time to four in 2001, Meyer said, and from four to two in 2002.

This year’s changes were another attempt “to cut down on possible overuse of diversion,” Meyer said. The agency plans to create systemwide standards for when a hospital can divert ambulances, Meyer said. “Right now it’s sort of at the whim of each hospital.”

Some experts in emergency medicine say the latest changes are not enough, suggesting that diversion itself is not much of a solution to what is overwhelming hospitals.

“It’s window-dressing,” Eckstein said. “I don’t see how that’s going to help anything.” If a hospital diverts because it is truly busy, he said, being forced to stay open for that 15-minute period won’t alleviate anything.

Federal law requires that hospitals with emergency rooms screen and stabilize any patient who comes to them. If a hospital goes on diversion, the staff still is obligated to see whoever arrives at their doors.

Because emergency rooms prioritize patients, those who are severely ill are seen right away even if a facility is crowded.

In addition, an ambulance can override a diversion request if a patient is in great distress or at risk of harm.

“It’s a little bit of a Band-Aid,” Dr. Joel Geiderman of Cedars-Sinai Medical Center said of diversion.

Diversion is a symptom of bigger problems with the county healthcare system, Geiderman said, in which hospital capacity is relatively static despite increased demands for care.

Doctors and nurses say a swamped emergency department reflects strains throughout a hospital. Many facilities are unable to admit patients because of a shortage of nurses.

That was evident Monday at Huntington Hospital.

The emergency room had been on diversion since 8:50 a.m. All was relatively quiet by 5 p.m.; only a trickle of patients rolled through the sliding-glass doors from the ambulance bay. But because no beds were available, the nurse in charge kept the hospital closed to paramedic traffic.

In a small room, a computer screen flashed mostly red: 15 of the 18 area hospitals listed on the county’s ReddiNet system were on diversion. The only black letters belonged to County-USC, still open.

Nurse Jennifer Waldron said she sees a screen like that “more than half the time.”

On slow days, that much red is not a problem, Waldron said. But when one ambulance after another calls in and emergency rooms are closed, she said, “you start getting a little bit panicky at times.”

The pressure has only increased as patients stream in from areas that have lost hospitals. Nine medical centers and emergency departments have closed in the last four years.

When St. Luke Medical Center closed in 2002, Huntington almost immediately saw its usual 160 daily patients rise by about 50, said Connie Matthews, a hospital spokeswoman.

Recognizing the hospital-wide struggle with overcrowding, Meyer said, the Emergency Medical Agency will require medical centers to have a plan to speed up overall patient flow. Examples include having housekeeping staff clean beds faster or calling on physicians to write orders and release patients sooner.