Treating an Emergency Care Crisis

SAN RAMON, Calif. —  There is a hole in Ruby McCan’s heart that will never heal, because her beloved 7-year-old grandson died of an infection after waiting for hours in a crowded Walnut Creek emergency room.

“My favorite picture of Gregory is from his preschool graduation,” McCan said mournfully, “because it was the only graduation he ever had.”

In the fast-growing Bay Area, hit by a spate of emergency-room shutdowns and downsizings in recent years, health officials and lawmakers say stories like Gregory’s have become far too common.

An emergency-care network that many expect to be there in their time of greatest need has eroded to the point of danger, they say--and government, which is supposed to provide oversight, is powerless to stop the deterioration.

So in a revolutionary gambit rife with implications for emergency services around the state--perhaps the nation--Assemblywoman Dion Aroner (D-Berkeley) is pushing legislation to grant California counties the power to prevent private hospitals from shutting emergency rooms. The bill recently cleared the Assembly and has moved to the Senate, where it could face significant opposition from the hospital lobby.

Though they admit there is a problem, hospital chains vehemently oppose government’s forcing them to stay in the ER business, saying it would hamstring their ability to compete in a cutthroat health-care marketplace.

The reasons behind the emergency department closures--the growing number of Californians without health insurance (more than 7 million) and federal requirements that hospitals treat all emergency-room visitors--require more than knee-jerk solutions, hospital officials say.

“You are applying a Band-Aid to an open wound,” said Jim Lott of the Healthcare Assn. of Southern California, which represents 225 hospitals. “You have mandated that hospitals treat all comers, and now you are trying to stop the hospitals from closing facilities they cannot afford to keep open any more.”

Supporters of government intervention, who include the powerful California Nurses Assn., concede the problems causing the ER shutdowns are much greater than the legislation would remedy. But they say the public interest must be protected while bigger answers are sought, because highly profitable hospital chains seem to have only their bottom lines in mind.

“This is not Macy’s,” Aroner said. “This is people’s health we are talking about.”

Although Aroner’s bill was requested by Contra Costa County, where public officials are seething over a continuing series of private hospital closures, its effect would be just as great in Los Angeles County.

A report issued by the National Health Foundation in 1997 predicted that Los Angeles County, which has seen a 20% decrease in emergency departments over the last two decades, will face a “serious undersupply of emergency room capacity” in all regions except the Westside by 2005. For a 10-day span during last December’s flu outbreak, officials said, three-fourths of area hospitals were so full that they were attempting to send ambulances elsewhere.

“We can’t allow these emergency rooms to close willy-nilly, like they are now,” said Assemblyman Martin Gallegos (D-Baldwin Park), chairman of the Assembly Health Committee. “There are dangerous consequences to these closures. As always, the impact is always stronger on the low-income and minority communities.”

The problem is hardly unique to California. Nationwide, the number of emergency departments has fallen from about 5,000 to 4,600 over the last decade. ER visits, meanwhile, have risen from 89 million in 1992 to more than 100 million in 1998, according to the National Center for Health Statistics.

Managed health-care plans were expected to reduce 911 calls and emergency visits by providing affordable preventive services before people became extremely ill. Instead, ER traffic has increased.

Frustrated by managed-care restrictions, more and more patients procrastinate and turn up sick in emergency rooms. And Americans without health insurance, estimated to number 44 million, are flocking to ERs in more severe stages of illness.

As a result, hospital chains are increasingly deciding that emergency departments, which have always been financial losers, are too expensive to keep open. That is leading to greater workloads and bed shortages at the hospitals that continue to operate them, as well as longer waits and ambulance transport times for victims.

Unless the problem is solved in the near future, the public may no longer be able to rely on emergency departments for “quality and timely emergency care,” two doctors at UC Davis Medical Center concluded in the January issue of the Annals of Emergency Medicine.

Some, like Ruby McCan, have already lost faith.

A state investigation into the 1998 death of her grandson at Kaiser Permanente’s Walnut Creek Medical Center revealed a systemic breakdown. ER doctors failed to diagnose the spinal meningitis that ailed him. A pediatrician did not examine him for hours, a violation of the hospital’s rules. And he was not admitted to the pediatric ward right away because adults filled the beds.

“I thought it was a childhood thing--nothing serious,” recalled McCan, who runs a day-care center at her San Ramon home. “Finally, the nurse--she took us in this room and asked us if we wanted a priest.”

Nancy Casazza, one of the nurses who was working at the hospital that night, has never forgotten the experience, because she knows the strain the staff had been under. Tormented by Gregory’s death, she considered leaving the profession until a counselor dissuaded her.

“It’s one of those things that changed my life,” Casazza said, weeping. “It’s a loss of life, and a loss of trust in the system.”

In response to the state investigation, Kaiser Walnut Creek agreed to have doctors available more quickly for consultations in the emergency room and to no longer fill the pediatric ward with adult patients. But hospital officials defended the care Gregory received, saying emergency personnel did the best they could to diagnose a deadly and fast-moving condition. Overcrowding, they say, played no part.

No one, it appears, questions that there is a crisis in emergency services. But many question whether Aroner’s bill, AB 421, would solve it. The legislation would prohibit approval by the state Department of Health Services of the downgrading or closing of an urban emergency department if a county or its emergency agency has concluded it is not in the community’s interest. Rural hospitals would be exempt.

The move to stop downsizings is meant to prevent emergency rooms from becoming bare-bones “standby” facilities. The standbys, which were initially meant to serve sparsely populated areas, often have minimal medical staffs, yet are easily confused by the public with full-service ERs.

In one highly publicized case three years ago, Willa Hives, the 39-year-old daughter of a Berkeley City Council member, died in an ambulance after spending hours in a standby emergency room in Richmond, where she had driven after feeling chest pains. Hospital officials later disclosed to investigators that it took 90 minutes just to find another hospital that had an intensive-care bed for her. .

But the bill does nothing to ensure that physicians remain on the job after a hospital has announced its intention of reducing or shutting down services, which even some sympathizers consider a serious shortcoming. After learning that a hospital chain no longer seeks to maintain a facility, nurses and doctors often polish their resumes and quickly find other work.

And perhaps most critically, the bill does not yet address the financial impact on the private sector--the issue that is likely to determine whether it leaves the Legislature is signed by Gov. Gray Davis, according to other lawmakers.

Aroner has promised her Assembly colleagues that she will add a financial carrot to her bill to make it more palatable to hospitals. But the ideas being discussed--subsidizing hospitals that can prove they are in financial straits or increasing reimbursement rates for ER doctors--could prove extremely expensive, experts said.

“We can’t do this on fairy dust,” said Dr. Brian Johnston, an emergency physician in East Los Angeles who heads the Los Angeles County Medical Assn. board. “If there are dollars to cover the costs, this could work. But if people cannot receive compensation, the hospitals and the doctors can’t be expected to provide services.”

Whatever the case, health officials predict that the ER problem--and the debate in Sacramento--will not go away.

“The public does not react well to waiting six or seven hours in an ER. Paramedics are not reacting well to being diverted,” said Virginia Price Hastings, Los Angeles County’s director of emergency medical services. “If the industry does not come to the table on these issues, the next legislation could be even stronger.”