Emergency wards in Bay Area are overwhelmed
Kelly St. John, Chronicle Staff Writer
Monday, November 20, 2000
On a Friday afternoon, a dozen people wait outside San Francisco General Hospital's emergency department. Inside, the beds are full and four more patients on gurneys fill the halls. The hospital is turning away ambulances.
"It's kind of slow," said the nurse manager, David Fleming, in all seriousness. He assesses patients as they arrive.
Because of cutbacks at San Francisco General, as well as declining reimbursements from insurers and the government and growing numbers of uninsured people, hospitals throughout San Francisco are increasingly strained.
Earlier this month, 10 doctors and nurses wrote to The Chronicle warning that a growing shortage of critical-care beds could overwhelm San Francisco General during the winter flu season. The bed shortage has backed up San Francisco's emergency rooms, where the problems of an overstressed health care system are more visible than perhaps anywhere else.
Last year, the average San Francisco emergency room diverted ambulances 8 percent of the time because there was no room in the critical-care units for new patients. This year - after the closure of the emergency room at Mount Zion - that figure grew to 15 percent.
For one in every three hours during the month of September, paramedics were diverted from St. Francis Medical Center. At San Francisco General that month, it was almost one hour in two.
"Prior to 1996 or 1997, we went on diversion maybe two or three days a month for a few hours each day," said Dr. Alan Gelb, chief of San Francisco General's emergency department. "Now, in a month we might have one day when we don't go on diversion."
In October, San Francisco General diverted ambulances 35 percent of the time. In September, 48 percent. "The numbers speak for themselves," Gelb said.
Not Even a Busy Day
On this typical Friday it's not yet flu season or even a busy holiday. Still, St. Francis is also turning away all ambulances, and three other San Francisco hospitals are diverting critical-care patients, such as people with chest pains.
"It's a disaster waiting to happen, and it is happening," said Dr. Marc Snyder, director of St. Luke's Hospital emergency department.
Most patients who come to emergency rooms walk in on their own. But ambulances usually carry people who need the emergency room most - people with chest pains that may indicate heart attacks, or people having trouble breathing.
So when hospitals' emergency rooms are so crowded that they turn away ambulances, emergency room physicians warn, it is a clear symptom of a health care crisis.
Same Situation Elsewhere
And it is not only San Francisco's emergency rooms that are feeling the strain. Nursing shortages, an increase in the number of uninsured people who rely on emergency rooms for primary health care, and closures and cutbacks at emergency departments are affecting hospitals throughout the Bay Area and the state.
In 1990, California had 415 hospitals with emergency departments. By 1998, that number had dropped to 382, according to the Office of Statewide Health Planning and Development.
"I wouldn't hesitate to say there are increasing periods of time that hospitals are at peak saturation and beyond," said Art Lathrop, emergency medical services director for Contra Costa County.
In Contra Costa, four emergency rooms have closed since 1996. Still, ambulance diversions are rare. That is not because emergency rooms aren't full,
but because the county's emergency medical services department strongly discourages hospitals from declaring diversions. In a county where hospitals are farther apart, diversion means as much as 20 more minutes to get to a hospital, and that is more dangerous.
Whole City on Divert Status
Even in San Francisco, where hospitals are closer together, ambulance diversion is called off if four or more of the city's hospitals go on "total diversion." Then paramedics are free to take ambulances to the nearest hospital regardless of how busy it is.
That prevents paramedics from being forced to circle around, "shopping hospitals" for care, something that happened regularly in the late 1980s and early 1990s, said Dr. John Brown, San Francisco's emergency services director.
In an era of malpractice lawsuits, nurses and physicians are hesitant to talk specifically about how overcrowding is harming patients. "Theoretically, when it is so busy, patients will get a lower standard of care," said Dr. Preston Maxim, an attending physician at San Francisco General.
Privately, a physician at another San Francisco emergency room described a cardiac patient whose ambulance had been diverted from the hospital where he was usually treated. The hospital had no interpreter to help the man, who spoke Chinese. Nor did it have his medical records.
The doctor called the other hospital to ask for the records. During the hour-and-a-half wait, the patient had a seizure, stopped breathing and died.
"Was he going to die if I admitted him? Maybe," he said. "But I won't know."
S.F.'s Only Trauma Unit
But at San Francisco General, whether it is on diversion or not, patients in the most serious medical trouble are never turned away, because the hospital runs the city's only trauma center.
On this Friday afternoon under diversion, San Francisco General's emergency room receives a succession of trauma cases. One woman's severed ulnar artery literally pumps blood out of her left arm. A 12-year-old boy howls in pain after a car accident. Doctors whisk a man who fell on his head off for immediate neurosurgery.
Because the sickest patients are treated first, each new case delays care for someone else. At St. Luke's Hospital, about 3 percent of people who come to the emergency room give up and leave without care, Snyder said. That's a problem because they often come back later when their health conditions are even worse.
At San Francisco General, Robert Mills waited on a gurney in the hallway for the results of X-rays. Now immobilized in a neck brace, the 35-year-old man was installing a glass window when he fell two stories. He arrived here in an ambulance at 9:30 a.m.
Cleared of life-threatening injuries but writhing in pain from two spinal fractures, Mills was waiting for a bed in the trauma unit to become available so he could be admitted. With the growing shortage of critical-care beds, waits like his have gotten longer.
Two years ago, San Francisco General reduced the capacity of its emergency room from 40 to 31 beds because patients were being placed less than one yard apart, in violation of federal requirements, Gelb said.
At 5:45 p.m., nurse Amy Kohler told Mills he would be taken upstairs. "Finally," he said.
Ways to Ease Crowding
Perhaps the best solution to emergency room overcrowding is to give people who do not really need the emergency room a better place to go for health care,
said Dr. Mitchell Katz, director of San Francisco's Department of Public Health. Insure the uninsured, he said, and expand urgent care at clinics into evenings and weekends.
For example, San Francisco General opened a wound care center this summer to take patients who would otherwise pass through their emergency wards.
Other emergency room workers want the city to establish an intermediate care facility - or medically supervised "drunk tank" - to serve the dozens of intoxicated people brought to emergency rooms every day. Nurses say they often admit several drunk people a day, sometimes seeing the same person several times in 24 hours.
A decade ago, these patients might have been arrested by San Francisco police and forced to sober up behind bars. But to prevent deaths among people in custody, police take them to emergency rooms.
"It is not uncommon for chronic alcoholics to have underlying medical problems," said Inspector Sherman Ackerson. "We won't detox someone in a holding cell unless we're relatively certain the person is in good shape."
An intoxicated person spends an average of six hours in an emergency room bed, versus two hours for other patients, said Katz. Still, Katz said, the city is not convinced an intermediate care facility would save money, since many of the patients would have to be checked out at the emergency room first anyway.
Clear Up Backlog
At San Francisco General, staff members use the few hours they are working under ambulance diversion to catch up on their backlog of patients. At 5:45 p. m., the staff alerts paramedics through the computer system connecting the county's hospitals. It can take all ambulances.
"We're off divert, let the bombing begin," said a nurse rushing down the hall.
The hallways fill up. A man with a stab wound in his abdomen. Another puncture wound. Intoxication. An elderly woman complaining in Spanish about her splitting headache.
At 7 p.m., the hospital notifies paramedics to take nontrauma cases elsewhere. Fleming ends his shift.
"It's going to be like this all night," he said.
E-mail Kelly St. John at email@example.com.