California residents got an ominous warning from the state's Emergency Medical Services Authority late last month when a draft report concluded that the state's emergency systems and hospitals don't have enough capacity to handle catastrophes.
The report was prompted by severe overcrowding in emergency rooms during last year's flu season. Starting in December, ERs in Los Angeles started to fill up and began diverting ambulances to other hospitals. The same problem spread to the rest of the state in January and February.
On Jan. 9, an interdisciplinary task force began assembling information on the scope and severity of overcrowding in the state's hospitals. This group launched a comprehensive review of the state's emergency capacity to prevent more problems.
The draft summary includes five pages of recommendations for hospitals, regulators and local emergency medical systems. The task force suggests that:
Hospitals report discrepancies between staffed beds and utilization.
Hospitals collect emergency department encounter data and forward them to the state.
The state Department of Health Services set up a surveillance system for influenza activity.
The summary also suggests ways to ease the shortage of nurses and specialty physicians that occurred during the last crisis. Among other actions, hospitals should encourage overtime, relax intensive-care-unit staffing ratios, restrict vacation requests and use unlicensed personnel for tasks that don't require licensed nurses.
The precipitating incident last winter, the draft report said, was the inability of the influenza vaccine to protect against an unexpected strain of the disease. This unusually tough flu virus took the healthcare community by surprise because their preparedness plans, based on recent years' experience, had been developed when influenza was unusually light in California.
Many patients had to be admitted, resulting in a sudden shortage of inpatient beds. In some cases beds were available, but hospital staff had been trimmed so much that patients could not be cared for. Repeated diversions of ambulances to greater and greater distances strained the entire emergency response system.
"This experience raises questions regarding the ability of the state's healthcare industry to effectively respond to similar situations and a major medical disaster," the draft summary states. "There exists little residual capacity" in the California healthcare system to respond to catastrophies with many casualties, it says. "The capacity to respond to events of even moderate impact is doubtful."
The issue of how well hospitals and paramedics can respond to public health emergencies has made headlines, especially in Northern California, because of the extreme consolidation of its hospital industry (July 20, p. 36). Public health leaders and political figures think the system is overstretched as it is; in a natural disaster, the system could collapse.
Michael Harris, a paramedic who directs the Alameda County Emergency Medical Service, said there's enough emergency room capacity in his county, for now. But this report is a useful call to action, he said.
"As ERs close, there's less capacity for disasters," he said.
Harris' group is working with the Hospital Council of Northern California to develop different reporting mechanisms for the flu season. Those mechanisms should apply to any disaster, he said.
Barbara Pletz, emergency management services administrator for San Mateo County, said she supports most of the recommendations in the report.
"What's happened whenever the hospitals fill up, they all want to divert ambulances. EMS people try to accommodate that," she said.
But hospitals must do more when the crunch hits, she said. When the beds start filling up, elective surgeries should be postponed. Patients coming to the emergency room as a convenience should be redirected to doctors' offices. Patients should be moved out of the emergency department as quickly as possible.
And, she added, hospitals need to report accurately how many "staffed" beds really have personnel to care for patients. This has caused repeated bottlenecks in California hospitals. Frequently there are not enough critical-care nurses on duty to allow patients to be moved from the ER into intensive care.
"They need to escalate and plan for these things ahead of time," Pletz said. If they will be short-staffed or anticipate a flu outbreak, maybe they should increase staffing, she said.
Of course that's not as easy as it sounds.
"As well as anybody wants to plan for these events, you're not going to get it right," said Jim Lott, executive vice president at the Healthcare Association of Southern California. "We couldn't forecast that the vaccines used to inoculate people were only going to be marginally effective. We couldn't plan for the time that the flu would hit its zenith, between Christmas and New Year's, when most personnel are off duty. The timing is everything."
Lott added that just because the hospital industry was represented on the task force doesn't mean it had much influence on he draft. The report unfairly blames the provider community and hospitals in particular for failing to manage the flu crisis, he said.
Lott also expressed frustration with public officials who want hospitals to downsize and eliminate beds yet expect capacity to reappear magically when there's a public health crisis.
"We're going to staff hospitals to meet the needs that are projected and paid for," Lott said. "Health plans and government payers don't pay us to staff empty wards. If we don't have the funding source to provide staff to wait for patients to show up, we're not going to do that. We're not going to stand by anywhere except trauma centers."
Meanwhile, Lott's association has prepared several contingency plans if there is a repeat flu epidemic this winter.
The plan includes flexible hospital staffing, transportation alternatives, expedited patient-discharge protocols, enhanced physician staffing and regional coordination in any emergency.
The Los Angeles County Department of Health Services has created a tracking system for marking the impact of the flu season on hospitals. Every eight hours hospitals will submit data through the Reddinet, a software system that links ambulances, emergency rooms and the emergency response headquarters.
That is the kind of response that Pletz said she hopes can help. But it's not necessarily the whole answer.
"Diverting ambulances is the end product of the problem," she argued. "The emergency medical directors have been dealing with the end product. We don't own this problem. The problem is really that inside the hospital there are not enough resources. They're the ones who need to solve it."
The final report is expected to be released in about two months, after a public comment period.