Emergency System Needs Transfusion
She wasn’t complaining. She wasn’t angry. She just wanted to know when an emergency doctor would see her. I glanced at her chart. To my shame, she had been waiting 17 hours for medical attention.
Meanwhile, more than 30 admitted patients clogged the emergency department at Los Angeles County-USC Medical Center. One, an older man, was near death. He had what I’ve seen called in the media “flesh-eating bacterial infection.” The staff had begun life-support measures and treatments and urgently requested a bed in the intensive-care unit. But there was no bed, so he remained in the emergency department. The patient died 24 hours later. Would ICU care have saved him? Gut instinct and 20 years of experience tell me he was beyond saving. But there is always the possibility that he might have benefited from our most intensive efforts.
The circumstances of these two patients stem from a confluence of forces that has been building for years and threatens to further stress County-USC’s emergency department. On the one hand, demand for medical care, especially in the uninsured population, continues to rise steadily. At the same time, public health budgets are shrinking -- and may shrink even more.
California’s economy is ailing, and the state has a $35-billion budget shortfall. One proposed saving is to toughen Medicaid eligibility. The county Board of Supervisors, faced with a $210-million shortfall, wants to end funding for 100 beds at County-USC. If either proposal becomes reality, demand for emergency services at the medical center will increase, further straining our capacity to provide safe, timely care to patients.
There are many reasons for the surge in emergency room visits. People, both insured and uninsured, are often unable to get timely medical attention anywhere else. For the area’s uninsured, ERs are often the only sources of medical care, as physicians, by law, must examine -- and, if needed, stabilize -- every patient who comes through the door, without regard for the patient’s ability to pay. Once it is determined that a medically indigent patient is sufficiently stable for transfer, he or she must then be sent either to a county or private hospital for care. Because many hospitals, especially those in the inner city, operate with narrow profit margins, absorbing the costs of more and more nonpaying patients will ultimately lead to bankruptcy. No other specialty has such an unfunded federal mandate.
Los Angeles has a huge population of uninsured residents, and the highest density of these patients is near County-USC. The center is the primary destination for indigent transfers from private hospitals who require highly specialized services, such as the treatment of burns.
County-USC is also the hub of L.A.’s 13-center trauma system. Some 30% of the area’s most severe cases are handled at County-USC. Trauma patients tend to be young and uninsured, and their care is expensive. A reduction in the center’s capacity to treat trauma cases would not only compromise care: It would also further burden the private sector with extremely expensive non-paying patients.
The emergency department at County-USC is among the largest and busiest in the nation, managing about 350 emergency cases a day. Because the center’s inpatient-bed capacity runs at nearly 100%, on any given day there are 20 to 40 patients admitted to the hospital who are unable to leave the emergency department. The wait for a bed can last as long as five days. Admitted patients forced to stay in the emergency department must endure an environment in which lights are never turned off, noise and bustle are incessant and personal hygiene in private is impossible -- not an environment designed to promote recovery from a heart attack, stroke or motor vehicle accident.
The situation is bound to worsen. Numerous hospitals in California have closed their emergency departments, and almost half the new ones don’t have ERs. Although passage of County Measure B assures that the doors of Harbor-UCLA and Olive View-UCLA medical centers will remain open, the county still plans to close Rancho Los Amigos National Rehabilitation Center and end funding for 100 beds at County-USC.
We can safely predict what will happen if the beds are lost. When nursing shortages at County-USC eliminated inpatient beds, there was a near-identical increase in the number of patients waiting in the emergency department for admission. Obviously, it will be impossible to accommodate an additional 100 admitted patients in a facility that has only 24 acute-care beds. Acutely ill patients will have to find another safe haven, most likely in private hospitals. We may well be returning to the time when ambulances carrying critically ill patients had to drive around looking for an open emergency department at which to land.
In the short term, it is imperative that the inpatient-bed capacity at County-USC be maintained, thereby allowing the other emergency departments in the county to keep their ERs open to ambulance traffic without being overwhelmed. Three public-interest law firms have sued to block the bed closures, but going to court, while important for the short run, won’t provide a long-term cure. Ultimately, we need to find a stable system of funding public health care. Here’s one idea: Because alcohol is involved in up to 60% of motor vehicle accidents and in medical cases such as gastric bleeding, liver failure, seizures, domestic violence, suicide attempts and pancreatitis, why not impose a tax on alcohol, earmarking the revenue for hospitals?
Forcing the sick to wait 17 hours for attention, or risking their lives because there are not enough inpatient beds, is not the solution.
