By DOUGLAS E. BEEMAN
The Press Enterprise (California)
Long waits at Inland hospital emergency rooms are nothing new to ailing patients.
But now ambulance crews are waiting, too.
Ambulance crews have waited for as long as 5 1/2 hours to transfer patients to the care of Inland emergency-room staffs. Some patients, unable to secure an emergency-room bed, were treated on the ambulance gurney tucked in a hospital hallway, Inland health officials said.
The delays are the result of the region’s booming population growth, the slow pace of hospital expansions, and policy changes limiting how often ambulances are sent from hospital to hospital in search of an available emergency-room bed.
Delays became acute in December, when the region was hit hard with influenza and other respiratory ailments.
In Riverside County, ambulances waited a total of about 1,000 hours at hospital emergency rooms, said Michael Osur, who oversees Riverside County’s emergency medical services system. That was more than twice as much delay time as in any other month last year. Delays of an hour are not uncommon, said Bruce Barton, Riverside County ambulance operations chief for American Medical Response.
In the San Bernardino Valley region, AMR officials said, crews waited about 1,500 hours to hand off their patients. That’s like leaving two ambulances parked outside an emergency room for the entire month of December.
“It is taxing the system,” said Renee Colarossi, director of operations for AMR’s San Bernardino County office. “It does cause some delays, not only for us but for our first-responder fire agencies.”
Such delays can snag several ambulance crews at a time at a given hospital, preventing them from responding promptly to new emergency calls, officials say. So many ambulances were stranded recently at Victorville-area hospitals that San Bernardino County’s High Desert area was without a single available ambulance. AMR had to send backups from the San Bernardino Valley.
DISASTER AVOIDED SO FAR
Officials say they are not aware of any deaths resulting from the delays.
But, “the risk is there,” said Virginia Hastings, executive director of the Inland Counties Emergency Medical Services Agency, which oversees the emergency medical system in San Bernardino, Inyo and Mono counties.
Josh Lee, an AMR emergency medical technician, once had to stay with a patient for 4 1/2 hours. The emergency room at Arrowhead Regional Medical Center in Colton was jammed and his patient wasn’t as ill as others coming in for care.
A delay that long is rare, he said. More common are waits of 20 minutes or so before a patient is handed to hospital staff.
However long the wait, Lee continues monitoring his patient on a gurney in the hallway. Many hospitals will draw blood and begin other diagnostic tests while the patient waits for an emergency-room bed to open.
“It’s not like we just stand there on the wall and wait there. Patient care continues. It’s just not in the back of the ambulance,” he said.
REROUTING DIDN’T WORK
In the past, crowding led emergency rooms to divert incoming ambulances to other hospitals. Surrounding hospitals often got jammed, too. Several years ago, Inland emergency medical officials limited how often hospitals could divert ambulances.
One result: Fewer ambulances were diverted, but they were stuck longer at hospital emergency departments as they added to the congestion. Ambulance crews call the delays “wall time.”
“What we’ve done now is created another monster,” said Hastings, the emergency agency executive director.
Critically ill ambulance patients — such as people suffering heart attacks or with life-threatening injuries from an automobile collision — are quickly handed off to hospital staff, Osur said. The ambulance crew will provide the medical and other information they’ve gleaned to the nurse and sometimes to a physician and help move the patient onto an emergency room bed. Then the crew will write its report, clean the gurney and head back out to be ready for the next call, Osur said. Normally, such a hand-off should be completed within about 20 minutes, he said.
But ambulance patients who don’t have life-threatening ailments may have to wait just as walk-in patients with minor illnesses.
“The biggest percentage of our patients (brought in by ambulance) are urgent, but not critical. Those are the ones who end up waiting,” Osur said.
In most areas, ambulances are expected to respond to calls within 10 minutes, Osur said. But when ambulances get tied up at a hospital and a more distant backup crew must respond, a patient may have to wait longer for an ambulance. Most of the time, Osur said, the ambulance is only a few minutes late and fire crews are providing medical aid.
Hospital delays are now the biggest problem confronting the emergency medical system and “why we’re late to calls,” Osur said.
SOLUTIONS SOUGHT
In Rialto, the city staffs three ambulances, but often all three are stuck at hospitals out of town, said Joe Powell, the city’s emergency medical services coordinator. When that happens, AMR provides backup. That’s an imperfect solution.
“Usually when our ambulances are tied up, AMR’s ambulances are tied up,” he said.
So Rialto added paramedics to two of its fire engines in the past year to ensure the city could respond to medical aid calls, Powell said.
And a couple of times a month, Powell calls or visits emergency rooms to press hospital staff to take over the patients his crews have brought in. “It becomes more of a priority when I show up,” Powell said.
In December, federal officials in Atlanta warned hospitals in the southeastern United States that such delays could violate federal law and jeopardize their inclusion in the federal Medicare program for the elderly and disabled. Federal officials have not issued any similar letter to California hospitals, said Deborah Romero, a federal Medicare official.
Still, California emergency medical services officials have set up a statewide task force to look for solutions. One idea being discussed: Alternate clinics, such as urgent-care centers, where ambulances might take patients who need medical treatment but not the level of intensive care an emergency room provides.
Several Inland hospitals are building, or are planning to build, larger emergency rooms. Redlands Community Hospital, for example, will open 11 additional emergency beds this year. Hemet Valley Medical Center and Corona Regional Medical Center also will add emergency-room beds before the end of the year. And Riverside Community Hospital recently completed an expansion that made its emergency room, with 50 beds, the largest in Riverside County.
ER BOTTLENECK
But more emergency-room beds won’t solve the problem, health officials and hospital executives say.
“This is a hospital problem, not just an ED (emergency department) problem, not just an ambulance problem,” said Mickey Forrest, Inland vice president of the Hospital Association of Southern California.
Emergency rooms often are the entry point for patients who need to be moved somewhere else in the hospital. If no beds are available in the intensive-care unit or on a medical ward, the patient must wait in an emergency-room bed. That backs up other patients who walk in — or are rolled in on an ambulance gurney.
Hospital officials say they’re trying a variety of tactics — some small, others large — that might help.
Hemet Valley Medical Center, for example, keeps a spare ambulance gurney at the hospital. Waiting ambulance crews can leave the patient on their own gurney in the emergency room while they respond to a new call with the spare.
Riverside’s Parkview Community Hospital recently installed computers in the emergency room. Computer screens flag when a patient’s laboratory results or X-rays are taking too long so emergency-room staff can follow up.
“When you see the whole column turn red (on the computer screen), then you know something’s not being done,” said Al Nero, Parkview’s emergency room manager.
Many Inland hospitals have created so-called fast-track clinics near the emergency room to handle less severe ailments.
Even if hospitals added beds, shortages of nurses and other staff impair the hospitals’ ability to quickly absorb all the patients who come.
“If you don’t have the staff to staff a bed, then the bed is useless to you,” said Randy Bevilacqua, spokesman for St. Mary Medical Center in Apple Valley.