BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 491
AUTHOR: Ma
AMENDED: August 24, 2012
HEARING DATE: August 29, 2012
CONSULTANT: Marchand
SUBJECT : Health facilities.
SUMMARY : Deletes a requirement that cardiac catheterization
laboratory services be located in a hospital, as long as the
laboratory space is connected to the general acute care hospital
by an enclosed all-weather passageway, performs no more than 25
percent of its procedures on hospital inpatients, and meets
other specified requirements.
Existing law:
1.Licenses and regulates general acute care hospitals by the
Department of Public Health (DPH).
2.Permits a general acute care hospital to be approved to offer
special services, in addition to the basic services offered
under their license, including cardiac surgery and cardiac
catheterization laboratory services.
3.Requires a cardiac catheterization laboratory service to be
located in a general acute care hospital that is either
licensed to perform cardiovascular procedures requiring
extracorporeal coronary artery bypass, or have a licensed
intensive care service and coronary care service and maintain
a written agreement for the transfer of patients to a general
acute care hospital that is licensed for cardiac surgery.
4.Prohibits, except as specified, cardiac catheterizations from
being performed outside of a general acute care hospital or a
multispecialty clinic, as defined.
5.Establishes the Alfred E. Alquist Hospital Facilities Seismic
Safety Act of 1983 (Seismic Safety Act), which establishes
requirements for health care facilities under the jurisdiction
of the Office of Statewide Health Planning and Development
(OSHPD).
6.Exempts from the definition of "hospital building," for
Continued---
AB 491 | Page 2
purposes of the Seismic Safety Act, any building where
outpatient clinical services of licensed health facility are
provided. Specifies that if any one or more outpatient
clinical services in the building provides services to
inpatients, the building shall not be included as a "hospital
building" if those services provided to inpatients represent
no more than 25 percent of the total outpatient services
provided at the building.
7.Permits DPH to license a freestanding cardiac catheterization
laboratory that was part of a Health Care Pilot Project
testing the feasibility of performing diagnostic
catheterization procedures in a freestanding laboratory.
Subjects these freestanding cardiac catheterization
laboratories to the DPH regulations governing cardiac
catheterization laboratories operating in hospitals without
facilities for cardiac surgery.
This bill:
1.Deletes the requirement that a cardiac catheterization
laboratory service be located in a general acute care
hospital.
2.Permits cardiac catheterization laboratory services, beginning
on March 1, 2013, to be expanded by a general acute care
hospital to include cardiac catheterization space that is in
conformance with applicable building code standards, including
those promulgated by OSHPD, as long as all of the following
occur:
a. The expanded laboratory space is located in
the building so that the space is connected by an
enclosed all-weather passageway that is accessible by
staff and patients who are accompanied by staff;
b. The service performs no more than 25 percent
of its procedures on hospital inpatients; and,
c. The service complies with all policies and
procedures approved by hospital medical staff, and all
standards and regulations prescribed by DPH, including
applicable nurse-to-patient ratios, and with all
standards and regulations prescribed by OSHPD.
3.Requires emergency regulations permitting a general acute care
hospital to operate a cardiac catheterization laboratory
service to be adopted by DPH and OSHPD by February 28, 2013.
4.Requires cardiac catheterization laboratory services to be
AB 491 | Page
3
reviewed by OSHPD for compliance with the OSHPD 3 requirements
of the most recent version of the California Building
Standards Code.
FISCAL EFFECT : Unknown.
PRIOR VOTES : Prior votes not relevant.
COMMENTS :
1.Author's statement. With the passage of the Affordable Care
Act, California will see an increase in patients seeking
access and care in a health system with limited resources and
already at capacity. There is also a national trend toward
wellness and early intervention by treating problems before
they require hospitalization. This is good not only for
patients but also for managing the overall cost of healthcare.
In order to provide increased services to these newly covered
patients, plus those seeking earlier intervention, California
hospitals will need to utilize all resources available in
order to treat patients in a timely manner.
Cardiac services are in great demand and hospitals can better
serve some of these patients in an outpatient setting. Under
current law, DPH has no authority to allow cardiac
catheterization services to be performed in an outpatient
setting. This bill seeks to resolve this dilemma by amending
the law to allow qualified hospitals to perform cardiac
catheterization services in an outpatient setting. This bill
will allow no more than 25 percent of cardiac catheterization
laboratory inpatient services to be performed in an
appropriately equipped and staffed outpatient setting. Should
an emergency arise that requires cardiac surgery service
support, the bill requires the outpatient cardiac
catheterization space be located in a building connected by an
enclosed all weather passageway to a general acute care
hospital. The cardiac catheterization physician will determine
which patients will be treated in the outpatient cardiac
catheterization laboratory setting based on the type of
procedure and condition of the patient. In order to improve
access to health care for patients requiring cardiac
catheterization services at the earliest possible time.
2.Coronary catheterization? According to the National Heart
Lung and Blood Institute, cardiac catheterization is a medical
procedure used to diagnose and treat some heart conditions. A
AB 491 | Page 4
long, thin, flexible tube called a catheter is put into a
blood vessel in the arm, groin (upper thigh), or neck and
threaded to the heart. Through the catheter, doctors can do
diagnostic tests and treatments on the heart. A special type
of dye can be put in the catheter to facilitate x-ray pictures
of the heart and coronary arteries, called a coronary
angiography. Physicians can also treat cardiac heart disease
during catheterization using a procedure called angioplasty,
where a catheter with a balloon at its tip is threaded to the
blocked coronary artery. Once in place, the balloon is
inflated, pushing the plaque against the artery wall to create
a wider path for blood to flow to the heart. Sometimes a small
mesh tube, called a stent, is placed in the artery during
angioplasty to support the inner artery wall.
3.Related legislation. SB 276 (Corbett), pending in Assembly
Rules Committee, requires DPH to promulgate regulations
regarding the type of medical procedures that can be performed
in the cardiac catheterization laboratory of a hospital that
also has on-site cardiac surgery services, and permits
hospitals to perform certain specified procedures until such
regulations are adopted.
4.Support. This bill is sponsored by the California Hospital
Association (CHA), which states that with the passage of the
Affordable Care Act, California will see an increase in
patients seeking access and care in a health system that is
already challenged with limited resources and capacity.
According to CHA, in order to provide increased services to
these newly covered patients, California hospitals will need
to utilize all resources available in order to treat patients
in a timely efficient manner. CHA states that OSHPD currently
allows up to 25 percent of procedures on inpatients to be
performed in an outpatient setting, and that this legislation
is necessary to conform DPH authority that currently restricts
inpatient cardiac catheterization services to an acute care
setting. According to CHA, this bill would allow no more than
25 percent of cardiac catheterization laboratory inpatient
services to be performed in an appropriately equipped and
staff outpatient setting. CHA notes that should an emergency
arise that requires cardiac surgery service support, this bill
requires the outpatient cardiac catheterization space to be
located in a building connected by an enclosed all-weather
patient passageway to a general acute care hospital.
Cedars-Sinai Medical Center (Cedars) states in support that it
AB 491 | Page
5
is constructing a new 800,000 square foot building on the
campus called the Advanced Health Science Pavilion (AHSP).
Cedars states that the AHSP will primarily house outpatient
services and advanced clinical research activities. According
to Cedars, one full floor will be devoted to outpatient
surgery, including surgery and interventional radiology
suites, and two cardiac catheterization laboratories. Cedars
states that the AHSP is immediately adjacent to the
seismically compliant main hospital building and will be
connected to the hospital at the fifth floor surgery level by
a fully approved and enclosed OSHPD Level 1 bridge. Cedars
states that it is one of the largest cardiac care providers in
California, providing 5,000 cardiac catheterization procedures
per year, and that these new facilities will allow it to serve
patients in a more convenient and accessible way.
5.Opposition. The California Nurses Association (CNA) opposes
this bill, stating that it is an end-of-session "gut and
amend" that would completely alter the settings in which
cardiovascular procedures are performed in California and
would significantly and negatively impact patient care in
California. CNA states that this bill would take
catheterization laboratories into an outpatient clinic-like
setting where hospital inpatients would have cardiac
catheterization procedures performed in buildings that skirt
seismic requirements by being licensed under clinic building
standards rather than standards and regulations for hospitals.
CNA also opposes the use of the emergency regulations, which
are required to be adopted by February of 2013, to implement
this change in the provision of cardiac catheterization
services. Rapidly implementing regulations would deny DPH the
immediate benefit of public input into a significant change in
the manner in which care is provided to consumers. If these
proposed changes have any merit, they need to be considered
during the regular full session to allow the public and
Legislature more time to consider this major change in the
provision of high risk health care services.
This bill is also opposed by the United Nurses Associations of
California/Union of Health Care Professionals (UNAC/UHCP),
stating that it is their view that conducting cardiac
catheterization procedures on an outpatient basis, even on the
campus of a hospital, is unsafe. UNAC/UHCP states that if
something goes wrong during the procedure, the patient will
need care within seconds or minutes, minutes that do not allow
AB 491 | Page 6
a patient to be transported from an outpatient facility to an
inpatient facility. The hospital campuses where such
procedures might be conducted are generally very large
physical plants where a patient could be literally a block or
more from the inpatient facility.
6.Drafting errors.
a. Incorrect nurse staffing ratio reference. The
provision of this bill requiring the cardiac
catheterization laboratory service to comply with
applicable nurse-to-patient ratios incorrectly cites the
nurse staffing ratios for long-term care facilities,
rather than for hospitals. The author is proposing
amendments to correct this statutory cross-reference.
Specifically, the amendments would do the following: On
page 4, line 23, strike "1276.5" and insert "1276.4".
b. A catheterization laboratory licensed to perform
cardiac surgery? The provision of this bill deleting the
requirement that a catheterization laboratory be located
in a general acute care hospital also changed other
wording in a way that requires the cardiac
catheterization laboratory itself to either be licensed
to perform cardiac surgery or have a licensed intensive
care unit and a written transfer agreement to another
hospital with cardiac surgery services. The statute
should continue to require the hospital to either be
licensed to perform cardiac surgery or have a written
agreement for transfer to another hospital, not the
laboratory. The author may wish to consider an amendment
to address this error.
SUPPORT AND OPPOSITION :
Support: California Hospital Association (sponsor)
Association of California Healthcare Districts
Cedars-Sinai Medical Center
Scripps Health
Oppose: California Nurses Association
United Nurses Associations of California/Union of Health Care
Professionals
-- END --
AB 491 | Page
7