The flu vaccine shortage poses a new set of medical and financial challenges for Los Angeles County's struggling emergency-care network, which is reeling from the announced closures of eight emergency rooms in the last 18 months.
The flu season already is the busiest time of the year for emergency rooms, causing waits of several hours as flu patients jam hospitals along with more seriously ill people.
Some hospital administrators fear that a severe flu season will worsen both the crowding and the financial problems at emergency rooms, many of which lose money because they take in a large percentage of uninsured patients.
Hospitals are already taking steps to address the possible impact of the vaccine shortage by adding ER workers when the flu season hits in December and changing triage procedures to make sure that the most seriously ill patients get treated first.
The latest emergency room to close is at Suburban Medical Center in Paramount, where officials said Wednesday that they planned to convert the ER into an urgent care center that would no longer accept ambulance calls beginning early next year. Officials said the move was necessary to stem financial problems that threatened to close the entire 182-bed hospital.
That leaves Los Angeles County with 75 ERs to serve nearly 10 million residents. A decade ago, the county had 94 emergency rooms.
Health officials stressed that there was no indication that this flu season would be any worse than normal and said it was too early to tell whether the shortage of the flu vaccine would cause more people to get sick. Flu season, which typically peaks between December and March, is unpredictable; the illness can strike 5% to 20% of the population, depending on the strength of the flu strain.
The biggest concerns are being expressed by hospitals located near emergency rooms that are closing down. Frederick Carr, director of the emergency department at Little Company of Mary Hospital in Torrance, said he expected major complications because of the closure of nearby Robert F. Kennedy Medical Center in Hawthorne. He said the closure would send thousands more people to his hospital during the flu season.
"Emergency rooms in L.A. County are at a breaking point now," Carr said. "This is the slow season. People are already having long waits. Some are being seen in the hallways. There's no margin for error."
To prepare, he said, the hospital will have a separate admitting area for flu patients staffed by two nurses 24 hours a day. Some physician hours have also been increased four to eight hours a day.
Other hospital officials were more optimistic, but said it would require planning to avoid problems.
"I refuse to go in panic mode and say it's impossible," said Max Lebow, director of the emergency department at Centinela Hospital Medical Center in Inglewood, which will be forced to take in more patients when RFK closes Dec. 31. "It will be ... more difficult. We just have to be smarter and more efficient."
Lebow said his staff would focus heavily on quickly determining how severe each flu patient's case was so the more seriously ill could be transferred to free beds in other parts of the hospital.
Jonathan Fielding, director of the county's public health programs, said the flu's impact on emergency rooms would depend on whether officials could give the remaining flu shots to "high risk" patients such as senior citizens, young children and people with compromised immune systems. Fielding also hopes that people with minor respiratory problems will opt to see their personal physicians rather than go to emergency rooms, a move that would free up space for people with more serious maladies.
First and foremost, Fielding said, people needed to practice good hygiene by avoiding touching their nose and mouth, by washing their hands frequently and by staying home when they are sick.
"This is a problem we all have to work together on," Fielding said. "We're definitely a strained emergency system for this kind of problem."
The nation's supply of flu vaccine was cut in half after British regulators suspended the license of a pharmaceutical plant in Liverpool because of manufacturing problems and possible contamination. The plant, which makes the flu vaccine for Chiron Corp. of Emeryville, Calif., was expected to produce 46 million doses for the U.S. market.
The federal government has struck a deal with the other main manufacturer of the vaccine to distribute 22.4 million doses directly to hospitals, senior centers and other facilities so they can be given directly to "high risk" patients. But officials acknowledge that there probably won't be enough of the vaccine for all of Los Angeles County's more than 2 million people who fall into that category. At the same time, other people have been urged to forgo flu shots so people with the greatest need can get them.
The American College of Emergency Physicians -- representing 23,000 emergency medicine professionals -- called earlier this week for the federal government to hold a "crisis summit" to plan for the flu season.
But some question whether the vaccine shortage will significantly increase flu cases.
Jim Lott, a spokesman for the Hospital Assn. of Southern California, said vaccines in the past had not always been effective because they didn't combat the flu strain spreading in a particular year. But even in those years, the total number of flu cases had not dramatically risen, he said.
But Cathy Chidester, assistant director of the county's emergency services, believes that a bad flu season could jam emergency rooms, causing patients to wait longer.
"They will be able to serve everyone, but will they be able to serve everyone in a timely manner, is the question," she said.
A more complicated question is how a busy flu season would affect hospitals' finances. A recent report by the California Medical Assn. found that emergency rooms in Los Angeles County recorded $143 million in losses in the 2001-02 fiscal year, largely because of uninsured patients.
Emergency rooms generally treat more patients without insurance than other parts of a hospital. At Centinela Hospital, for example, Lebow said 20% to 25% of the ER patients didn't have insurance, meaning that the hospital had to pick up more of the costs.
And hospitals can't turn away patients seeking emergency services.
The more patients the ERs treat, officials said, the greater the losses.
"The system in Southern California is tremendously impacted by its uninsured population. They know they can receive emergency healthcare because it's a federal mandate," said Steve Shea, medical director of the emergency department at St. Mary's Medical Center in Long Beach.
"It's much more cost effective for them to come into an ER than go through a doctor and have to pay."