ERCrisis:Calif:Full emergency rooms send ambulances in circles
emsa.cahwnet.gov
By Jean P. Fisher
Bee Staff Writer
(Published April 17, 2000)
The emergency department phone rings for Sutter General Hospital charge nurse
Danny Shilin a little after 5 p.m. It's UC Davis Medical Center calling with what
has become all-too-familiar news: All four of central Sacramento's emergency
departments, including those at UC Davis and Sutter General, are full and closed
to ambulance traffic.
If no hospital opens up, Shilin is told, UC Davis, acting as the area's ER command
center, will switch the city's big hospitals to "round robin" mode. That means each
hospital will take turns receiving ambulances.
Shilin surveys his department.
One patient is on her way up to the intensive care unit. Another is on his way to
the morgue. With two emergency beds now free, Shilin can reopen Sutter
General.
Within seven minutes, an ambulance pulls up to Sutter's ER entrance, and
paramedics wheel in a patient on a gurney.
"Within 30 minutes, we'll get two or three more, and then I'll have to close again,"
Shilin says with a shake of the head.
Such was the state of emergency medicine in Sacramento on Wednesday.
Increasingly, it's becoming the rule rather than the exception in hospitals here and
across the nation.
Hospitals and emergency medicine practitioners say more people -- and sicker
people -- are flocking on foot or in their own cars to emergency rooms, clogging
the departments so that bed space is short when ambulances pull up outside.
Last year, more than 34,547 patients came through Sutter's emergency room with
its 15 treatment bays, up from 30,026 in 1994. The hospital projects that by 2002,
the number will have climbed to 40,000, by which time Sutter expects to have 28
treatment bays.
An increasing geriatric population that needs urgent care more frequently and the
overall population growth are contributing to the strain for all of the area's
emergency departments.
Emergency medicine practitioners say the principal sources of ER overload are
the rising number of people with no health insurance -- 7.3 million in California --
and the unknown number of insured people who turn to the ER to sidestep the
hurdles of managed care.
Nearly one in four patients seen in California emergency rooms is uninsured,
according to the California Chapter of the American College of Emergency
Physicians. The cost of treating those patients, who by law cannot be turned away,
is one reason about 20 California hospitals have closed emergency departments in
the past two years, chapter President Dr. Daniel Abbott said.
Managed-care refugees are harder to track. Much of the information regarding
their use of emergency services is anecdotal, but most in health care agree it is
widespread.
"I see probably 10 or 15 patients a day who apologize to me for being (in the
ER)," said Abbott, who practices in the emergency department of St. Jude
Medical Center in Fullerton. "They know they shouldn't really be there, but they
can't get in to see their doctor. They have minor things -- but nagging things -- that
they have to be seen for."
In a managed-care environment where many physicians see 40 or 50 patients a
day, doctors often don't have the flexibility to tend to patients who call with an
unscheduled urgent need, said Carol Robinson, UC Davis Health System's
associate director of hospitals and clinics.
"The health care system is broken," she said.
That's not to say physicians -- many in managed care -- aren't trying.
Many medical groups operate urgent-care clinics or contract with clinics that
provide short-term or after-hours care to their patients, said Norm Plotkin, a
spokesman for the California Medical Association. And most try to fit in patients
with urgent-care needs, though those patients may see a nurse practitioner or
physician's assistant rather than a doctor, he said.
"Unfortunately, the problem is so widespread that the system still gets overloaded,
and people do end up in the emergency room," he said.
That brings with it a whole host of problems, not the least of which is whether an
insured patient's health plan will pay.
"Obviously, the emergency room is the most expensive alternative," said Bobby
Pena, a spokesman for the California Association of Health Plans. "The plans and
the medical groups want to be sure that care is provided in the right setting."
Patients, however, have their own way of deciding what's right.
Later Wednesday night, when Sutter General closed its ER again, ambulances
started round robin delivery of patients to emergency departments at Sacramento's
four core hospitals: UC Davis Medical Center, Sutter General and Memorial
hospitals and Mercy General Hospital.
UC Davis, the area's designated trauma center, always keeps its doors open to
life-threatening emergencies.
Sacramento County's Emergency Medical Services Agency introduced the round
robin system in 1997 to help manage ambulance traffic during that year's flu
epidemic, which pushed hospitals past capacity.
But the system, which was devised for a crisis, is being used regularly. UC Davis
has declared round robin status 14 times in 1999 and 2000. That means all four
emergency rooms closed to ambulances carrying noncritical patients and said they
could not open, even though there was ambulance traffic. According to ER
personnel such as Sutter General's Shilin, the system comes close to round robin
status far more often.
Before 1999, the hospitals went for more than a year without resorting to round
robin mode.
In an effort to reduce the problem, Sutter General last year established a "fast
track" urgent care clinic in its emergency department to handle the steady flow of
less-serious problems into its ER.
Such clinics are becoming more common as hospitals step up to meet demand,
said Dr. Toni Mitchell, an Arlington, Va., emergency room physician and board
member of the American College of Emergency Physicians. More than half of
hospital emergency departments nationally have at least part-time fast-track clinic
services, she said.
In Sacramento, at least three area hospitals are expanding their emergency
departments to meet increased demand.
Last month, Sutter General broke ground on a $7.1 million emergency department
expansion that will more than double the size of its emergency department. The
expansion will add 13 treatment bays and more nurses and support personnel to
staff them.
Kaiser Permanente -- whose hospitals typically treat only Kaiser members except
in cases of critical need -- is expanding emergency services at Kaiser South
hospital to keep up with membership growth.
Mercy San Juan Hospital in Carmichael completed a major expansion last year
that included a much expanded emergency room and the addition of a level one
trauma center, designed to take the most serious cases.
Emergency services are still readily available when Sacramento needs them, said
Bruce Wagner, director of the county's EMS Agency.
"(Round robin) is not something that is happening all the time, it's just a tool they
use to help manage in a tight health care market," he said. "Everybody who needs
to be seen is seen. And for the most part, people are getting seen at the hospital
they want to go to." |
