Crisis looms on ER crowding
Hospitals vow to make changes as more ambulances are turned away.
By Lisa Rapaport Bee Staff Writer
Publication Date 2/8/2002
The number of hours Sacramento County emergency rooms are closed to all but critical
ambulance traffic has climbed more than 600 percent over the past three years.
Patients who call 911 will be just about guaranteed a ride past their local hospital to a
facility across town by the end of 2003 if no changes are made to the county's ambulance
diversion program, a new study predicts.
In 2001, the county's emergency rooms were closed to ambulances a total of 22,290
hours, up from 10,235 hours the year before and only 3,272 hours in 1999, according to a
study released this week by the Hospital Council of Northern and Central California.
Aware that they are turning away too many ambulances, local hospitals have pledged to
radically change the way they run their emergency departments.
"If we don't act now to cut the diversion hours by half, we could have a major crisis on
our hands," said Robert David, regional vice president for the council, which
commissioned the study on behalf of Sacramento's health care systems.
That's because diversion creates as many problems as it solves, said Mike Williams,
president of the Abaris Group, which did the study.
Ambulance patients regularly end up at hospitals where their insurance is not accepted,
and where they are treated by unfamiliar doctors who don't have access to their medical
Diversion has become so routine that more and more patients who call 911 are refusing
ambulance transport when they find out the rig isn't headed to the hospital of their choice.
It didn't start out this way.
Originally, Sacramento's ambulance diversion program, like others around the country,
was designed as a stopgap measure to occasionally relieve pressure on overcrowded
emergency rooms. It was supposed to help hospitals cope with a bad flu season or a
catastrophic freeway pile-up.
The county's diversion program was set up to let individual emergency departments
reroute ambulances when they already have patients facing long waits. There was one
catch: once five hospitals closed to ambulance traffic, they all had to reopen in a round-
By 2000, even with the diversion program, hospitals that had reduced staff and inpatient
capacity found themselves with backlogged emergency rooms and not enough beds,
nurses or on-call specialists to undo the gridlock.
"The reality is we have had all of these staffing and capacity problems as our community
is growing and access to physician care is less adequate than it once was," said William J.
Hunt, chief operating officer for Catholic Healthcare West's greater Sacramento service
area, which includes Mercy General Hospital, Methodist Hospital and Mercy San Juan
While the population has grown, per capita use of Sacramento emergency rooms has
dropped over the last decade, the study found.
Most hospitals around the region already have expanded their emergency departments
and more beds are planned, despite limited funds. But simply adding beds isn't the
answer, study author Williams said.
In the coming months, hospital administrators, county officials, doctors, nurses and
others in the local health care community will meet to hammer out new ground rules for
the ambulance diversion program. All have agreed to replace the county's current
protocol, which leaves ample room for interpretation, with rules that spell out criteria that
administrators must meet before deciding to divert ambulance patients.
Hospitals also have committed to slash their ambulance diversion hours in half by the end
of this year, a herculean task.
There's no battle plan yet, but administrators expect to draw on practices that have helped
them control overcrowding in the past.
Mercy hospitals, for example, do bedside admissions, taking ER patients straight to an
exam room instead of making them wait to check in, be examined by a nurse, and
eventually be shown to a bed to wait for a doctor.
"It doesn't work all the time, but we do it as frequently as we can to move people in and
out the door faster," said Mercy's Hunt.
UC Davis Medical Center, meanwhile, has seen its hospitalist program help relieve
pressure on its trauma and emergency departments. Hospitalists are physicians who
coordinate admissions, lab tests, exams and discharges, a practice that improves
efficiency so beds become available faster for emergency room patients who need
The medical center also relies on a home health program to bring routine care to people
with chronic conditions.
"This is one of the things that helps us monitor patients and treat them before they need to
come to the emergency room," said Bob Chason, chief operating officer of UC Davis
health system and director of hospital and clinics for the medical center.
Kaiser has long offered a 24-hour phone line that patients can call to decide if they need a
doctor's appointment or a trip to the emergency room. The HMO also links each plan
member with a primary care physician.
For patients with ailments, such as chest pain, that don't appear to be an emergency but
could easily become one, Sutter General Hospital set aside monitoring beds in its
emergency department. These beds let doctors wait for test results and watch patients for
several hours to see if a critical situation emerges that warrants a hospital admission.
"It can take hours just to get a lab test back, then hours more if you have to admit then
discharge a patient who didn't really need a hospital bed," said Larry Maas, chief
operating officer for Sutter Medical Center, which includes Sutter Memorial and Sutter
Sutter and many other local hospitals also set up fast-track units in their emergency
departments to speed treatment of patients who come in for minor ailments. The quicker
non-urgent patients get in and out, the more beds are available when ambulances arrive.
All of these practices, as well as others aimed at reducing the time it takes to treat and
transfer patients, could soon be part of a countywide protocol for improving access to
emergency care, said David, of the Hospital Council. "At this point we're taking a hard
look at what we've done right and what we can do differently as a community to fix the
Diversion hours rising
On average, Sacramento County hospitals receive 175 ambulances each day, a 22 percent
increase since 1997. Total annual emergency room visits, including walk-ins and
ambulances, have climbed 29 percent to 340,804 during the same five-year period.
Here are number of hours that overcrowded Sacramento County emergency rooms close
to all but critical ambulance traffic:
Total diversion hours
Source: Hospital Council of Northern and Central California
Hospitals reduce ER traffic jams
New capital-area rules tackle the crowding that could send ambulances miles out of
By Lisa Rapaport Bee Staff Writer
Publication Date 7/8/2002
Ambulance traffic congestion has eased at Sacramento-area emergency rooms following
months of work to control overcrowding at local hospitals.
At the start of the year, many feared a full-blown public health crisis as more and more
patients who called 911 were being driven past their jam-packed local hospital to a
facility across town, often to be treated by unfamiliar doctors without access to their
But hospitals finally bucked the trend in May, halving the number of hours they were
closed to ambulances compared with the same month the previous year.
"This took incredible effort for stakeholders with competing interests to sit down and
work toward a common goal. If we maintain these results, people from all over are going
to look to copy what has been accomplished in Sacramento," said Robert David, vice
president for the Hospital Council of Northern and Central California.
Originally, Sacramento's ambulance diversion program, like others around the country,
was designed as a stopgap measure to help hospitals cope with unplanned events, such as
a bad flu season or a catastrophic freeway pileup.
The idea was simple: Hospitals could turn away ambulances when patients faced long
waits for care. If five hospitals tried to close at once, they were all forced to reopen and
accept ambulances in a round-robin rotation.
But here, as elsewhere, hospitals that had reduced staff and inpatient capacity found
themselves with backlogged emergency rooms and not enough beds, nurses or on-call
specialists to undo the gridlock.
"People used to seize on diversion as a fix for occasional capacity problems, but now
hundreds of communities around the country are trying to figure out how to solve the
problems with diversion," said Mike Williams, president of the Abaris Group, an EMS
consulting firm hired by area hospitals to help them reduce diversion hours.
Over the past few months, hospital administrators, county officials, doctors, nurses and
others in the local health care community met to develop new ground rules for ambulance
Hospitals agreed in February to try each month to reduce by half the number of hours
they closed to ambulance traffic.
May was the first month that area hospitals reached their target. And they did it despite a
threatened nurses strike at UC Davis Medical Center in Sacramento that forced a cutback
in emergency services at that facility.
The reduction in ambulance diversion hours was most pronounced at Mercy General
Hospital in Sacramento, one of three facilities in midtown that, combined, traditionally
account for the lion's share of ER closures.
Mercy General diverted ambulance traffic from its ER only 44 hours in May, an 89
percent drop from the 407 hours the facility reported in May 2001, according to figures
released this week by the Hospital Council.
Like its counterparts all over town, Mercy reduced diversion hours by looking beyond its
emergency department for ways to improve efficiency throughout the hospital.
"Rather than having the ICU say the ER will just have to hold patients because there
aren't enough housekeepers to clean ICU beds for patients admitted from the ER, an ER
supervisor might go up there and clean the beds. That has happened, and that's the kind of
teamwork we're talking about," said Page West, emergency department manager for
At Sutter Medical Center, which includes Sutter Memorial and Sutter General,
loudspeaker announcements alerting the entire hospital to ER crowding problems have
helped the facilities cut diversion hours, said Linda Bjorklund, nursing director for the
ER at Sutter Memorial.
"It lets everybody know we need assistance like labs and x-rays speeding up orders for
the ER or doctors on rounds prioritizing patients waiting in the ER," said Bjorklund.
UC Davis Medical Center focused on reducing patient wait times in the ER by opening
up a new unit to treat patients awaiting a bed elsewhere in the hospital.
"Ordinarily, if we couldn't put a patient in a bed, we'd divert them - we avoided putting
them into the ER pile - essentially freeing up more ER space. Now, we can put those
patients in the access unit to wait for a bed upstairs," said Carol Robinson, senior
associate director of hospital and clinics at the medical center.
Kaiser, meanwhile, has focused its efforts on linking each HMO member to a primary
care doctor, building new medical offices in Folsom and Elk Grove, and expanding
urgent care units within its hospitals to more quickly treat ER patients with less urgent
"We have consistently kept our ambulance diversion hours low. With our unique
integrated model, the strong partnership between our medical group and hospitals has
helped us control diversion through efforts in our emergency rooms and our outpatient
clinics," said Kaiser spokeswoman Cinde Breedlove.
For area hospitals, the next challenge will be sustaining and building on their recent
successes in controlling ER crowding.
One way they hope to do that is by installing Web-based software - which cost EMS
stakeholders a combined $100,000 - that will soon help hospitals better track patient
capacity at neighboring facilities.
"We've done very well, but we still have some obstacles," said David, of the Hospital
Council. "All of our hospitals are full, and one of the hardest choke points to overcome is
the number of patients who need admission and sit in the ER when no hospital beds are