With the long-anticipated debut of the new Los Angeles County-USC Medical Center only months away, doctors and politicians are still sparring over scarce bed space, workers are trying to fix last-minute glitches, and contractors are struggling to incorporate new technologies.
The shimmering new facility was made necessary by the 1994 Northridge earthquake. It has been in the works for a decade, and was first expected to open by 2004, and then 2005 and then 2006.
Now the hospital is expected to be ready in October, but it looks like the rearranging and infighting may continue until the day the doors open.
The most pressing dispute, which pits adult patients against sick children, is emblematic of the struggle to open a county facility amid scarce resources and increasing demand. And the fight is all about bed space.
When doctors and patients move from the current Depression-era campus, the number of budgeted beds will drop from 671 to 600. It is unclear how many will be dedicated exclusively to children. Twenty-five beds are certain, but some people, including Supervisor Gloria Molina, are waging a fierce fight for 19 more, for a total of 44.
Without the additional beds, they say, the USC pediatric residency program would be at risk of shutting down and sick children from the Eastside would be forced into hours-long bus rides to other county medical facilities.
But health officials who want the beds to be open to adults say that the length of time emergency patients would have to wait for a bed elsewhere in the hospital would skyrocket if 19 additional beds were allotted to children only.
Ambulances throughout the Eastside struggle to find a hospital with space for patients, and the current County-USC campus is shut off to them a little more than half the time, so even the relatively small number of beds makes a difference.
The battle over beds is the continuation of a larger fight waged 10 years ago over how big the hospital should be.
"Supervisor Molina, when this decision was being made, argued for having at least the expansion capacity to go up to 750 beds," said Jim Lott, executive vice president of the Hospital Assn. of Southern California. "That wasn't paid attention to. Now we're squabbling over, do we hurt pediatrics or do we hurt overall services such as the ER. That's a decision we shouldn't have to make."
The debate over the 19 beds has never been publicly aired, although each of the five county supervisors has been briefed privately on the issue. County Chief Executive William T. Fujioka told The Times that his staff hoped to present a solution to the dilemma in the coming weeks.
The bed issue is only one example of eleventh-hour snags -- some of them substantial -- that will affect patient care at the new facility.
The most difficult problem, people on all sides of the issue said, is the product of a political and financial decision made in 1998 when Southern California's public and private hospitals were already struggling but had significantly more beds than they do today.
Since county supervisors decided on a 600-bed County-USC hospital, fifteen hospitals that receive emergency patients have closed in the county; only seven have opened or reopened.
Additionally, the county dropped plans in 2000 to open an 80-bed County-USC annex in Baldwin Park because of lack of money.
Now, although the new hospital is the largest construction project in Los Angeles County government history, nearly everyone's focus is on how small it is.
"Anybody can tell, you just can't make it work," said Molina, whose district includes the hospital. "It's a simple issue. Something is going to burst."
Ten years ago, Molina burnished a reputation for toughness and grit in her fight for a 750-bed hospital, finally pushing a plan to build a hospital with 750 beds but with the staffing for only 600. Her four colleagues voted for a firm 600-bed cap.
Anything more, they said, could bankrupt the entire county healthcare system.
The bitter fight left all sides feeling bruised, and many county officials seem especially chagrined to see it resurface.
The controversy seemed to divide officials into camps defined by ethnicity; virtually every elected Latino official in the area stridently lobbied the board to approve the larger 750-bed proposal and complained bitterly when they were denied. The rhetoric sometimes cut deep. Supervisor Zev Yaroslavsky, a chief proponent of the smaller hospital, complained privately that his opponents' criticisms were anti-Semitic, aides said.
Despite the hard feelings, Molina is pressing forward.
"Of course, the fight is back," she said.
Yaroslavsky declined to comment, but he has worked behind the scenes to maintain the 600-bed cap.
In an interview, Molina said her current bid for more beds begins with the pediatrics issue, believing that it will be the key to moving beyond the 600-bed cap. If the 19 additional beds at the facility are dedicated to children, it will keep the total number close to the current 51 pediatric beds. She believes that the county will eventually be forced to open more beds in nearby facilities because of a legal settlement with health advocates. The settlement requires wait times for County-USC emergency room patients who need a bed elsewhere in the hospital to be less than seven hours.
Simultaneously, Molina said, she is trying to keep open at least part of the old Women and Children's Hospital at the current campus. She said it can stay open until 2013 (seismic regulations call for it to be closed, eventually), and at least one supervisor -- Yvonne B. Burke -- has signaled her support for the idea to The Times. The other supervisors declined to comment.
The county Health Services Department, meanwhile, is resisting Molina's plans and has for years planned for the hospital to have 25 beds dedicated exclusively to children 13 and younger while providing 19 beds for patients between ages 14 and 21.
Those beds could be used for adults as needed, something pediatricians argue will happen every day in a hospital that is expected to operate at 93% capacity.
Meanwhile, workers are scrambling to fix other last-minute glitches.
In some cases, the hospital is struggling to incorporate changes in treatments or technologies that have occurred in the 10 years since the hospital was designed, said Carolyn Rhee, the replacement facility project director. Intensive care units typically lacked bathrooms because patients were presumed to be too sick to get out of bed. That thinking has changed, but not in time to install toilets. Patients will have to use a bedpan or a bedside commode.
Also in the last decade, emergency rooms have become more dependent on ultrasound imaging for everything from inserting central intravenous lines to diagnosing abdominal bleeding.
In this case, the hospital was able to add wall-mounted units, said Dr. Edward Newton, chairman of USC's Department of Emergency Medicine.
Other ER problems are more vexing. The triage area, where nurses meet patients who arrive by ambulance and determine who needs the most urgent treatment, is "very, very tiny," Newton said.
It was designed for patients to go directly from the ambulance gurney to an ER bed. But if all beds are taken -- as will probably be the case, especially with fewer beds in the rest of the hospital for patients who require admission -- there is no room for a backup, Newton said. Even the halls are smaller than the old hospital's.
The hospital also was designed to be completely paperless. The wrinkle is that the county has yet to make the transition to computerized records. Paper records will be kept in the basement of the old building until they can be scanned, Rhee said.
In reference to the glitches, Molina said, "Yeah, there are going to be all kinds of problems. Everybody knows that."