Care Rationed at Overcrowded County-USC

Doctors at Los Angeles County-USC Medical Center are pleading for relief from overcrowding in the hospital’s emergency room that they say is forcing physicians to ration health care and has resulted in several patient deaths.

With unusual candor, both hospital administrators and county health officials acknowledge that intolerable conditions exist, yet solutions are beyond their control.

“The much-dreaded era of ‘rationing’ is upon us,” said Jerry L. Buckingham, the medical center’s executive director.

Across the nation, public hospitals report overwhelming numbers of emergency room patients and dwindling resources to meet their needs. The problem is particularly acute in Los Angeles County’s three major public teaching hospitals and especially glaring at County-USC, which operates the largest emergency department in the nation.

The chief of emergency medicine there, Dr. Gail V. Anderson, recently advised his superiors: “The public and elected officials should be made aware of this ‘Third World’ type of non-medical care that is permitted to exist in one of the largest public hospitals in the most advanced nation of the world.”

County-USC’s plight stands in stark contrast to its long and proud mission that is chiseled into the stonework of the medical center: “To provide hospital care for the acutely ill . . . without charge in order that no citizen of the county shall be deprived of health or life. . . .”

During the last four months, Dr. Edward L. Newton, a supervising physician in the medical center’s main emergency room, has repeatedly advised Anderson and others that patients needing urgent attention commonly linger in the emergency room 24 hours or more, waiting to be assigned a bed.

He said that several patients have died because operating rooms were full, and doctors have been forced to prematurely remove patients from ventilators.

“We are being required to ration health care, and at times to perform what amounts to passive euthanasia,” Newton wrote in a Sept. 16 letter. “This is not only morally outrageous but the situation seriously endangers the practitioners and patients involved.”

Dr. Sol Bernstein, medical director at County-USC, called the cases Newton cited “intolerable.” Dr. Jonathan Weisbuch, medical director for the Los Angeles County Department of Health Services, also acknowledged the validity of Newton’s concerns.

“The waiting times are egregious and the flow of patients through that place is overwhelming,” Weisbuch said. “Too many people are making demands on a system not funded or built for that.”

In response, county officials have formed an “action team” to explore short- and long-term solutions to crowding. The team’s first meeting is scheduled Tuesday. Among the possible solutions is a partnership with underused private hospitals. The principle stumbling block is finding money to finance such a program.

The situation at County-USC has its counterparts at urban public hospitals across the country. Health officials in California and nationally say shortfalls in state and federal funding for health care have made these hospitals unable to keep up with the demand for care.

Feeling the brunt of government budget cuts, officials in many states, including California, have moved to “tighten up on the number of available (public) hospital beds,” said Dennis Andrulis, president of the National Public Health and Hospital Institute in Washington.

According to Mary Pittman, executive director of the California Assn. of Public Hospitals, “The percentage of public hospital beds available to serve California is shrinking dramatically in the face of population growth.” A decade ago, the statewide ratio of public hospital beds was one for every 1,300 people. Now there is one for every 2,000.

In Los Angeles County, where population growth has been explosive, the total beds available at the six public hospitals actually declined from 3,345 in fiscal 1989 to 3,311 in 1990, according to state health statistics.

It is not only the poor who rely on these hospitals for care, but increasing numbers of newly unemployed Californians who have lost their health insurance along with their jobs.

Los Angeles has the highest rate of medically uninsured people in the nation. The county total is estimated at 2.7 million. These patients tend to be sicker than average, having postponed care until their problems become acute.

For them, the primary portal of entry to the hospital is the emergency room. And increasingly, these areas are logjammed.

At Martin Luther King Jr./ Drew Medical Center, patients have lingered on gurneys “for up to three days” awaiting a hospital bed, according to a September report by outside medical reviewers. And at Harbor-UCLA Medical Center, a study published this summer documented that many seriously ill patients were so discouraged by long waits that they simply left without being treated.

But nowhere is the crush of patients so overwhelming as at County-USC.

More than 500 patients a day seek care in the hospital’s main emergency room, which has 18 beds. The medical complex, made up of four hospitals, has a total of 1,398 beds--about 10% fewer than a decade ago.

As the linchpin in the county’s emergency care network, County-USC accepts patients from all over the county, not just the poor and uninsured. They include victims of violence, heart attacks, seizures, drug overdoses and dangerous infections.

The task for emergency room doctors is to stabilize patients and move them quickly into operating rooms, intensive care units or appropriate hospital wards for specialized treatment and tests.

But at County-USC, emergency physicians say these wards and units are too clogged to accept sick patients expeditiously. As a result, they back up on gurneys in the emergency room, receiving inadequate monitoring and treatment, according to Newton.

One patient waited 50 hours for a hospital bed, according to Newton, who since early November has been providing superiors with weekly reports on patients who have encountered “undue delays.”

Among the supporting evidence he and other emergency physicians have supplied is data showing a recent doubling in the number of patients with acute medical problems who waited for more than eight hours for an intensive care bed. The numbers increased from 250 patients during the month of February to 500 in July.

Hospital officials acknowledged that they do not have enough beds to speedily accommodate all the critically ill patients crowding the emergency room, despite the recent addition of two new intensive care units.

The emergency room is so jammed that doctors increasingly are closing the doors to paramedic ambulances, diverting the drivers to other hospitals. For example, during the month of March, County-USC’s emergency room was closed to ambulances for 236 hours, compared to only nine hours during the same month two years ago, Newton said in an interview.

Virginia Price Hastings, Los Angeles County’s chief of trauma hospital programs, said County-USC’s emergency room has been so swamped this fall that night-shift doctors have taken the unprecedented step of calling her at home to plead for a few hours respite from ambulances. She said doctors have called her three times since September, and in each case, she immediately gave relief by ordering private downtown hospitals, which had been closed due to crowding, to open their doors to accept more ambulances.

“They are used to making do over there (at County-USC). They don’t cry wolf easily,” she said. “So when they call me for help, I respond.”

Even when ambulances are turned away, the emergency room at County-USC cannot shut off its steady stream of walk-in patients who, by state law, must be treated and stabilized.

Newton cited several instances when the number of patients needing breathing assistance exceeded the number of ventilators. As a result, several patients who were determined to be clinically “brain dead” were summarily removed from the machines in violation of professional standards governing the termination of life support, Newton wrote.

The emergency department has “a real resource problem,” acknowledged Dr. Ronald L. Kaufman, the hospital’s associate chief of staff and director of medical quality control. But he took issue with what he called “sensationalized” allegations of “Third World” conditions.

“I don’t think it’s Third World medicine,” Kaufman said. “We don’t have flies. We don’t have cows walking through the place. It’s extremely sanitary.”

Moreover, Kaufman said, internal hospital studies show that despite all the problems, the emergency department continues to do an exceptionally good job of moving critically wounded or injured patients into the operating room within five to 10 minutes of arrival.

However, patients in serious but stable condition--those suffering, for example, from a knife wound to the abdomen--may encounter much longer waits, Kaufman acknowledged. He has set up a committee to try to come up with solutions to the emergency room backup, possibly squeezing greater efficiencies out of the main hospital in order to open up beds faster for waiting patients.

“It is not that anyone is trying to do harm to anyone else,” Kaufman said. “But we are overwhelmed with patients.”

Part of the problem is that many of the patients who flock to public emergency rooms have medical problems that are better treated--at lower cost--in clinics or doctors’ offices. Others are not sick at all, but represent the overflow of social service programs throughout the county.

Kaufman recalled one filthy and ragged young woman who showed up last month in County-USC’s emergency room, worried because her bones were becoming too prominent.

Her problem, Kaufman said, was hunger and homelessness--not treatable in the emergency room, but nonetheless heart wrenching to turn away.

Much of the burden on emergency room staff would be alleviated, Kaufman said, if clinics and social programs could promptly take referrals of patients not sick enough to be hospitalized. But most of the county’s 47 clinics and comprehensive health centers have waiting lists, as do out-patient clinics at the six public hospitals.

As for critically ill patients, health officials say a solution for them could come from Los Angeles County’s 111 private acute-care hospitals. Health officials point out that these private hospitals--with an average occupancy rate of only 50%--have the capacity to accommodate the overflow of acutely ill patients from the county hospitals.

But the private hospitals and their medical staffs will be reluctant to take indigent patients unless prompt payment and protection from malpractice liability is guaranteed, said David Langness, vice president of the Hospital Council of Southern California.

With another state budget deficit looming, and spending cuts for health and social services anticipated, “we do not see that there is enough money at the county level to even begin to put our finger in the dike,” Langness said.