BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 911
A
AUTHOR: Lieu
B
AMENDED: July 2, 2009
HEARING DATE: July 15, 2009
9
CONSULTANT:
1
Tadeo/
1
SUBJECT
Emergency rooms: overcrowding
SUMMARY
Requires, until January 1, 2014, every licensed general
acute care hospital to assess the condition of its
emergency department, using an overcrowding score, every
four hours, and to develop and implement capacity protocols
based on an overcrowding scale. Requires the capacity
protocols to be filed with the Office of Statewide Health
Planning and Development.
CHANGES TO EXISTING LAW
Existing law:
Provides for the licensing and regulation of health
facilities, including general acute care hospitals, acute
psychiatric hospitals, and special hospitals by the
Department of Public Health (DPH).
Establishes the Office of Statewide Health Planning and
Development (OSHPD) to analyze California's health care
infrastructure, provide information about health care
outcomes, assure the safety of buildings used in providing
health care, insure loans to encourage the development of
health care facilities, and facilitate development of
Continued---
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sustained capacity for communities to address local health
care issues.
This bill:
Requires every licensed general acute care hospital with an
emergency department to calculate and record an
overcrowding score every four hours to assess the condition
of the emergency department, with exemptions as specified.
Defines an overcrowding score as a score calculated to
measure emergency department and hospital overcrowding,
with an equation, as specified, using the following
variables:
Number of patients within the emergency department;
Total number of beds staffed in the emergency
department, not to exceed the number of licensed beds;
Total number of admissions waiting in the emergency
department, including patients awaiting transfer;
Total number of acute inpatient hospital beds
routinely in use by the hospital, excluding beds in
the newborn nursery, neonatal intensive care unit, and
obstetrics:
Total number of patients in the emergency
department admitted to the intensive care unit;
The longest admit time, in hours, including,
transfers; and,
The wait time for the last patient waiting the
longest in the waiting room, in hours.
Defines overcrowding scale to mean a range of scores that
are divided into the following categories: not busy; busy;
extremely busy; overcrowded; severely overcrowded; and,
dangerously overcrowded.
Requires every licensed general acute care hospital with an
emergency department to determine the range of overcrowding
scores that constitute each category of the overcrowding
scale for its emergency department.
Requires by January 1, 2011, every licensed general acute
care hospital to develop and implement, in consultation
with its emergency department staff, a full capacity
protocol for each of the categories of the overcrowding
scale that addresses the following factors, where
applicable:
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Notification of hospital administrators, nursing
staff, medical staff, and ancillary services of
category changes on the overcrowding scale;
Bed utilization;
Diversion;
Elective admissions;
Transfers;
Triage;
Responsibilities of inpatient medical staff and
specialty service operations for rounds, discharges,
coordination with the emergency department, and
emergency consults for emergency department patients;
Hospital unit operations;
Nursing services;
Supplies;
Calling in additional medical staff; and,
Space utilization, including alternate care sites.
Requires every licensed general acute care hospital to file
its full-capacity protocols with OSHPD, and annually report
any revisions to its protocols.
Allows licensed general acute care hospitals with emergency
departments that do not have an overcrowding score over 60
for the pervious 30 days to calculate and record an
overcrowding score every eight hours instead of four.
Requires a licensed general acute care hospital that is
calculating an overcrowding score every eight hours instead
of four that scores over 60 to again calculate and record
an overcrowding score every four hours.
Repeals its provisions on January 1, 2014.
FISCAL IMPACT
Unknown. According to the Assembly Appropriations
Committee analysis of a previous version of AB 911, annual
General Fund costs and $1 million to the University of
California and county-operated medical centers to comply
with the National Emergency Department Over Crowding Scale
(NEDOCS) reporting every three hours. (Amendments now
require the reporting every four hours, and deletes the use
of the NEDOCS score in favor of a different, although
similar, overcrowding score tool).
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Additionally, the Assembly Appropriations Committee
analysis of a previous version of AB 911 also reports
one-time fee-supported special fund costs of $170,000 to
DPH to establish regulations and maintain oversight of
requirements of this bill during the licensure and
certification processes.
BACKGROUND AND DISCUSSION
According to the author, California emergency departments
are dangerously overcrowded and have reached a crisis
level, ranking last in the nation in the number of
emergency rooms available to its residents. The author
states that California provides only six emergency rooms
for every one million persons. The author argues that the
common misconception surrounding emergency department
overcrowding links congestion with non-urgent patients and
the uninsured, when the real reason for this congestion is
that hospitals keep patients who need hospitalization in
the emergency room until a hospital bed becomes available,
a practice known as boarding a patient.
The author states that there are reported cases in which
patients have been boarded in hallways or waiting rooms for
up to 24 hours before they are admitted into the inpatient
unit of the hospital. The author further states that, the
use of an overcrowding score known as the NEDOCS score,
similar to the overcrowding score proposed in AB 911, and
a subsequent full capacity protocol plan, at LAC/USC
Medical Center have significantly reduced wait times and
patient boarding. The author contends that this approach
would work on a statewide level, and that AB 911 does not
require the same full capacity protocol plan for all
hospitals; instead, each facility would come up with a plan
that works for that particular hospital.
A 2003 U.S. General Accounting Office analysis of emergency
department overcrowding (GAO report), reported that
overcrowding is a problem that has reached historic levels
and can be attributed to a number of factors. The report
found that the single most common variable linked to
emergency room overcrowding was the growing problem of
boarding patients who were already screened and stabilized
by emergency staff, until inpatient beds were available.
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The GAO report maintains that when emergency departments
saturate because of patients waiting for beds and nurses to
become available on inpatient units, emergency waiting
rooms become overcrowded, wait times increase, and there is
a greater risk for poor health outcomes. According to the
GAO report, this leads to temporary closure of crowded
emergency departments to inbound ambulance traffic, a
process known as diversion, which increases travel time as
ambulance drivers seek other hospitals to which they can
transport their patients.
According to a 2007 Institute of Medicine report,
"Hospital-Based Emergency Care: At the Breaking Point"
(IOM report), despite the lifesaving feats performed every
day by emergency departments and ambulance services, the
nation's emergency medical system as a whole is
overburdened, underfunded, and highly fragmented. As a
result, according to the IOM report, ambulances are turned
away from emergency departments once every minute on
average, and patients in many areas may wait hours or even
days for a hospital bed. Moreover, the IOM report
maintains, the system is ill prepared to handle surges from
disasters such as hurricanes, terrorist attacks, or disease
outbreaks.
According to information posted on the American Academy of
Emergency Medicine website, the Joint Commission issued an
important guideline on emergency department overcrowding,
in 2004. The website states that the Joint Commission
guidelines recognize the link between overcrowding and
quality. While the guidelines do not call for hospitals to
have explicit policies to alleviate overcrowding, they do
call for hospitals to have a plan for surge capacity in
place, and to provide a level of service to boarded
patients comparable to that which they would receive in an
inpatient unit.
The IOM report called for the strengthening of The Joint
Commission standards that address emergency department
overcrowding, boarding, and diversion.
Overcrowding score
The overcrowding score calculation in AB 911 is a mechanism
that was developed by a stakeholder group consisting of the
California Chapter of the American College of Emergency
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Physicians, the California Emergency Nurses Association,
and the California Hospital Association, based on the
National Emergency Department Over Crowding Scale (NEDOCS)
score. The overcrowding score is designed to measure
emergency department and hospital overcrowding. The
following variables are used in the calculation of an
overcrowding score:
Number of patients within the emergency department;
Total number of beds staffed in the emergency
department, not to exceed the number of licensed beds;
Total number of admissions waiting in the emergency
department, including patients awaiting transfer;
Total number of acute inpatient hospital beds
routinely in use by the hospital, excluding beds in
the newborn nursery, neonatal intensive care unit, and
obstetrics;
Total number of patients in the emergency
department admitted to the intensive care unit;
The longest admit time, in hours, including,
transfers; and,
The wait time for the last patient waiting the
longest in the waiting room, in hours.
Under the scoring system, each level (not busy, busy,
overcrowded, dangerously overcrowded, severely overcrowded)
corresponds to and necessitates an institutional response
with respect to systems, space, and supplies.
LAC/USC results
LAC/USC uses the NEDOCS score, similar to the one required
by AB 911, and has developed corresponding full-capacity
protocols. According the LAC/USC Surge Plan, the
application of these protocols have freed up treatment
areas and staff for the evaluation and treatment of new
emergency patients, have increased emergency department
capability and resulted in: decreased patient boarding
time; decreased emergency department and inpatient loss of
services; improved patient safety; improved patient
satisfaction; improved morale; and improved resident and
student training in both the emergency department and
inpatient services.
LAC/USC reports that this approach works because it
mandates accountability; delegates responsibility; defines
procedures and protocols, offering uniformity and
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standardization; and creates hospital awareness of
overcrowding and response thresholds. The LAC/USC
protocols, as a part of its standardized procedure, call
for conducting a NEDOCS assessment every two hours.
Crowding comparisons in the LAC/USC Surge Plan illustrate
very little change in the "not busy" and "busy" categories;
a rise in the "overcrowded" and "extremely busy" categories
and a dramatic decrease in the "severely overcrowded" and
"dangerously overcrowded" categories. LAC/USC reported the
following measures for 2007 and 2008:
Extremely busy category at 1.2 percent in August,
2007, and at 27.8 percent in August, 2008;
Overcrowded category at 29.3 percent in August,
2007 and at 62 percent in August, 2008;
Severely overcrowded category at 31.7 percent in
August, 2007 and at 9.6 percent in August, 2008;
Dangerously overcrowded category at 37.8 percent in
August, 2007 and at 0.3 percent in August, 2008.
Prior bills
AB 2207 (Lieu, 2008) would have required hospitals to
assess the condition of an emergency room via the NEDOCS
score every three hours and would have authorized hospitals
to use hallways, conference rooms, and waiting rooms as
temporary patient areas pursuant to hospital full capacity
protocols. This bill was held in the Assembly
Appropriations Committee.
Arguments in support
The American College of Emergency Physicians, State Chapter
of California, sponsor of AB 911 states that, in hospitals
that have utilized the approach that this bill proposes,
the scoring and assessing of emergency departments as well
as the development of a plan to best utilize hospital space
and personnel at each level of crowding, has resulted in
reduced overcrowding, decreased wait times, and improved
patient care.
The California Medical Association (CMA) states that AB 911
would establish plans for times when hospitals reach
capacity, which is essential to providing consistent and
quality emergency care. CMA further states that AB 911
would also provide a way to increase knowledge of the
overcrowding problems caused by hospital closures and
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consolidations.
Arguments in opposition
In reference to a previous version of AB 911, DPH states
that there is no evidence that using a NEDOCS score is
effective and would work for California. DPH further
states that it has only been used in one hospital in Los
Angeles, and will not necessarily help or prevent emergency
room overcrowding. DPH contends that overcrowding
assessment in emergency rooms is already done and that
there is insufficient evidence to show that AB 911 would
have any impact on improving emergency room overcrowding.
Concerns
The California Hospital Association has requested an
amendment to allow small volume emergency departments to
perform the overcrowding score on a daily basis only,
unless their census is one standard deviation above their
average daily census, at which time they would have to go
back to performing the overcrowding score every four hours.
COMMENTS
1)The author may wish to amend AB 911 to change the
performance requirements for overcrowding scores
conducted at small volume hospitals.
PRIOR ACTIONS
Assembly Floor: 45-31
Assembly Appropriations:12-5
Assembly Health: 11-3
POSITIONS
Support: California Chapter of the American College of
Emergency Physicians
(sponsor)
California Academy of Physician Assistants
California Medical Association
California Professional Firefighters
Oppose: Department of Public Health (previous version of
the bill)
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