Study Cites Paramedic Response Delays
Paramedics for the city of Los Angeles are frequently unavailable to take urgent calls because of inordinate delays in dropping off patients at crowded emergency rooms, according to a study to be released today.
Analyzing data from Los Angeles Fire Department dispatchers, the study found that in one of eight trips to the ER between April 2001 and March 2002, paramedics couldn’t return to duty rapidly because they were stuck waiting for their patients to be admitted to ERs.
Paramedics are tied up at hospitals a median 27 minutes, about 12 minutes longer than the ideal turnaround time. Some crews waited an hour or more, and one wait stretched to seven hours.
“We can’t get our folks out of the ER,” said Dr. Marc Eckstein, who coauthored the study and is the medical director of the Los Angeles Fire Department and an emergency physician with the Keck School of Medicine at USC. “The study shows how it doesn’t take much to tip over the entire system.”
The report, which is to appear in the January edition of the Annals of Emergency Medicine, is the first to quantify a problem that paramedics here and elsewhere have been grumbling about for years.
The study found that delays were especially problematic at three hospitals in the city: Martin Luther King Jr./Drew Medical Center in Willowbrook and Good Samaritan Hospital and California Hospital Medical Center, both in downtown Los Angeles.
It is not clear precisely how much the delays at ERs affected the amount of time it took for paramedics to respond to other emergencies. But when a crew gets delayed, another must cover for it -- sometimes burning crucial minutes driving from another part of the city or county.
A crew could simply leave a patient at the hospital and leave, but for ethical reasons paramedics stay with patients to ensure they receive proper care, Eckstein said.
Eckstein said that the one saving grace has been an expansion since the late 1990s of the city’s ambulance fleet from 65 vehicles to 115, which has largely compensated for the delays. About 200 more paramedics were hired.
County officials say the problem extends beyond the city limits.
“We’d get to patients faster” without the delays, said Carol Gunter, the acting director of Emergency Medical Services for Los Angeles County. “There is no doubt that it’s affecting response times in the field. It’s nice to have an article that starts to measure this.”
The study, said Eckstein, is yet another sign of how an old problem -- the crowding of the region’s ERs -- is affecting public safety services.
In theory, said Eckstein, it should take paramedics about 15 minutes to drop a patient at the hospital and then return to service. That’s enough time to transfer the patient to ER doctors, complete paperwork and prepare an ambulance for another patient. But emergency rooms in Los Angeles County and many other metropolitan areas are suffering a crush of patients. In some instances, patients have spent days in the ER waiting to be admitted to hospitals that are short on beds.
Emergency rooms are overwhelmed for a variety of reasons, including a dramatic increase in the number of elderly people, the closure of county health clinics for budgetary reasons and a rising number of uninsured people who seek their primary health care in ERs.
“Look at a map and look at all the ERs in Los Angeles County and you’ll see there’s nothing around King-Drew except St. Francis” Medical Center in Lynwood, said Gunter. “There’s this big hole in the middle of the county, so it’s no wonder” the ER at King-Drew sees so many people.
Another example is Harbor-UCLA Medical Center near Torrance, which has seen about 65,000 people in its ER in recent years. About a third are not severely ill or injured and are sent to the hospital’s urgent care facility -- an increasingly popular tactic to reduce ER crowding.
Nonetheless, Harbor-UCLA still struggles to care for the remaining 45,000 patients, said Dr. Robert Hockberger, chairman of the hospital’s emergency medicine department.
“When I first came to Harbor in 1980, we were extremely busy all day long, but inevitably at 3 or 4 a.m. there would be time to sit back and do some teaching with the residents and sometimes even discuss our personal lives,” said Hockberger.
But since the late 1980s, “there’s not a moment to do those things or even time to go to the bathroom or get a cup of coffee,” he said.
At Good Samaritan, the story is similar. “We are serving 25,000 patients each year -- the ER was built for 9,000 to 10,000 patients a year,” said Andy Leeka, president and chief executive of the hospital. “Just in the last year our ER volume has grown by 15%.”
Good Samaritan serves an area in downtown that has a high rate of the poor and uninsured, said Leeka. He also said that the hospital’s ER lost $9 million to $10 million last year and therefore can’t be expanded to meet the crush of patients.
Leeka said that using triage nurses to assess patients and prioritize care has helped improve the situation, but he sees another problem on the horizon: A state law set to take effect Jan. 1 mandates hospitals to provide enough nurses to meet strict ratios. He believes that hospitals strapped for funds may be forced to lower the number of beds available in ERs or hospital wards to cover the cost of hiring more nurses. That, he said, will only exacerbate the backups in the emergency room.
Eckstein, the study’s author, agrees. “As a physician, I think the nurse-ratio law is well intended but ill-advised,” he said. “We don’t have enough nurses and there isn’t enough money to pay for it.”
