ER Overcrowding Spreads Into Crisis Territory
Hospital emergency room overcrowding has become such an everyday problem in Los Angeles County that ambulances are routinely diverted to other facilities, resulting in delayed care for critically ill patients.
Ambulance diversions that used to be confined largely to busy inner-city hospitals or during the winter flu season have now “spread out all over the place,” said Virginia Hastings, director of Los Angeles County’s Emergency Medical Services Agency. “It’s a tremendous problem hospitals are having a difficult time solving.”
The diversions, which have been reported in cities around the country, are being blamed on an increase in patients, fewer hospitals beds and a worsening shortage of nurses.
A report released last week by a Washington-based health policy group found that “serious threats to patient care are emerging,” said Paul B. Ginsburg, president of the nonpartisan Center for Studying Health System Change.
Researchers visited emergency rooms in 12 urban areas, including Orange County, and found that the diversion problem is a symptom of a deeper crisis in the delivery of emergency care.
While no one has studied whether the practice is killing patients, regional emergency officials say the ER logjams would delay care in any case.
“What would the patient’s condition have been if they’d been taken to an overcrowded hospital? We would be equally concerned,” said Darlene Isbell, assistant director of the L.A. County emergency services agency.
The managed-care industry, which imposed restrictions that sought to discourage unnecessary--and often costly--emergency room visits, has not been that successful in reducing the reliance on ER care, Hastings said.
In response to consumer backlash and the passage of “prudent layperson” laws in more than 40 states, many HMOs loosened their policies--and have seen double-digit increases in ER use, according to the diversion study.
Moreover, many in the nation’s growing uninsured population continue to use ERs for routine, nonemergency medical problems. A 1986 federal law requires all hospitals that participate in Medicare to treat patients with emergencies, regardless of their ability to pay.
And even people with good insurance continue to seek treatment at ERs when their own doctors are unavailable, Hastings said, conceding that even though she is well-insured, she is reassured by the knowledge that an ER doctor would always be available to see her.
Hospital closures and mergers have slashed the number of inpatient beds, leading to ER backups, and a nationwide nursing shortage is exacerbating the crunch.
Also, fewer doctors are willing to be “on call” to hospitals--available on short notice to back up hospital staff when a patient requires specialist care, according to Dr. Loren Johnson, medical director of the emergency room at Sutter Davis hospital in Davis. “An increasing number of on-call specialists in the United States are not willing to take calls from hospital emergency departments because of inadequate reimbursement and increased patient volumes,” Johnson wrote in a recent article in the Annals of Emergency Medicine, a medical journal.
In Los Angeles County, hospital emergency departments were “on diversion” for more than 16,000 hours in March. That compares with 11,000 hours of diversion time during the same period a year earlier, according to Hastings.
And Hastings said the length of time that hospitals are requesting ambulances to be diverted from their ERs is growing longer. Diversions originally conceived to provide 30-minute respites for overloaded ERs to catch up have ballooned into eight- to 16-hour occurrences. In the first three months of this year, for example, 31% of the county’s 10,519 diversion requests from hospitals were for more than eight hours.
The agency requires hospitals to reassess diversions every eight hours, but a proposal to require reassessments every four hours faces a vote Wednesday by the commission that oversees the county’s emergency services, Isbell said. It’s expected to win approval.
Hastings noted that when the hospitals serving entire regions are on diversion simultaneously, they’re then forced to accept new ambulance arrivals. As the saying around the county goes: “If you’re all closed, you’re all open.”
In Los Angeles County, hospitals cannot turn away walk-in patients, nor can they divert ambulances staffed by emergency medical technicians. They can only divert ambulances staffed by paramedics, who have more medical training and can perform more life-saving procedures than emergency medical technicians. So diversions are sending on the most critical patients, those who have sought 911 assistance. The result, Hastings said, is “just moving the problem to the field.”
The burden then falls upon the 911 system and paramedics to find hospitals to accept the patients. That can tie up paramedics and ambulances for prolonged periods and force them outside their areas, further delaying services to others in need, said Dr. Robert G. Splawn, medical director of emergency services at California Hospital Medical Center in downtown Los Angeles.
L.A. County has taken several steps to blunt the impact of diversions. In the late ‘80s, it began enforcing a rule that prohibited diversions more than 10 minutes away. The county followed with a policy that prohibited diversions around seven hospitals.
That policy sought to ensure that all residents living near these hospitals would be accepted for emergency room treatment; ambulances carrying emergency patients from other communities would be directed elsewhere. The hospitals also agreed to make on-call specialists available to serve local emergency patients.
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For other busy county hospitals, however, diversions are a symptom of an unsolved crisis in emergency care, said Dr. Daniel Higgins, director of emergency services at St. Francis Medical Center in Lynwood, which sees 60,000 emergency patients a year.
“When everybody is diverting so much, something is wrong with the system,” Higgins said. “You’ve got multiple hospitals with several gurneys lining up trying to get care. You have patients languishing in emergency departments waiting to go upstairs for sometimes half a day, a day or a day and a half. There’s a domino effect that’s causing this. We have a 32-bed emergency department, but if we have 12 people waiting to go upstairs, we only have a 20-bed emergency department.”
