BILL ANALYSIS Ó
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 336
S
AUTHOR: Lieu and De León
B
AMENDED: March 21, 2011
HEARING DATE: March 23, 2011
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CONSULTANT:
3
Tadeo/jl/mn
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SUBJECT
Emergency room crowding
SUMMARY
Requires, until January 1, 2016, every licensed general
acute care hospital to assess the condition of its
emergency department (ED), using a crowding score, every
four or eight hours, and to develop and implement capacity
protocols for overcrowding. Requires every licensed
general acute care hospital that operates an ED to develop
and implement full capacity protocols, and requires these
protocols to be filed with the Office of Statewide Health
Planning and Development (OSHPD).
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).
Defines a general acute care hospital as a health facility
having a duly constituted governing body with overall
administrative and professional responsibility and an
organized medical staff that provides 24-hour inpatient
care, including medical, nursing, surgical, anesthesia,
laboratory, radiology, pharmacy and dietary services.
Continued---
STAFF ANALYSIS OF SENATE BILL 336 (Lieu and De León) Page
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Permits hospitals to provide emergency medical services,
under specified circumstances.
Establishes 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
sustained capacity for communities to address local health
care issues.
This bill:
Requires, until January 1, 2016, every licensed general
acute care hospital with an ED to assess overcrowding every
four or eight hours, as well as develop and implement
full-capacity protocols that address staffing, procedures,
and operations when an ED is overcrowded.
Defines "crowding score" as the score calculated to measure
ED and hospital overcrowding, with an equation, as
specified, using the following variables:
Total number of patients within the ED;
Total number of staffed beds in the ED, not to
exceed the number of licensed beds;
Total number of admissions waiting in the ED,
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 ED admitted to the
intensive care-critical 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 "crowding scale" as the range of crowding scores
that are divided into six categories, of which level one
represents the lowest level of crowding and level six
represents the highest.
Requires every licensed general acute care hospital that
operates an ED to determine a range of crowding scores that
STAFF ANALYSIS OF SENATE BILL 336 (Lieu and De León) Page
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constitutes each category of the crowding scale for its ED.
Requires every licensed general acute care hospital that
operates an ED to assess the condition of its ED by
calculating and recording a crowding score a minimum of
every four hours, or, if after calculating and recording a
crowding score less than level four for the previous thirty
days, to calculate and record a crowding score a minimum of
every eight hours. In this case, if the hospital records a
score of level four or higher at some point, it must resume
calculating and recording a crowding score every four
hours.
Provides that every licensed general acute care hospital
that has an ED and a census of less than 14,000 visits
annually to calculate and record the crowding score once
daily between 4:00 p.m. and 8:00 p.m.
Requires, by January 1, 2013, every licensed general acute
care hospital that operates an ED, to develop and
implement, in consultation with its ED staff, a
full-capacity protocol for each of the categories of the
crowding scale that addresses all of the following factors:
Notification of hospital administrators, nursing
staff, medical staff, and ancillary services of
category changes on the scale;
Hospital operations, including bed utilization,
transfers, elective admissions, discharges, supplies,
and additional staffing;
Emergency department operations, including
diversion, triage, and alternative care sites; and,
Planned response of the organized medical staff for
rounds, discharges, coordination with the ED and
emergency consults for ED patients.
Requires every licensed general acute care hospital that
operates an ED to file its full-capacity protocols with the
Office of Statewide Health Planning and Development
(OSHPD), and annually report any revisions to its
protocols.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
However, based on previous fiscal analyses of AB 2153
(Lieu, 2010), a bill identical to SB 336, the fiscal impact
STAFF ANALYSIS OF SENATE BILL 336 (Lieu and De León) Page
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of this bill is unknown. According to the Senate
Appropriations Committee analysis of AB 2153, to the extent
the bill results in an ED serving patients more efficiently
and thus cause a net increase in the number of patients
seen in a day, there could be increased costs to the state
in the form of claims for reimbursement for services
rendered to Medi-Cal, Healthy Families, and other
publicly-funded health care program beneficiaries. However,
there could be savings to publicly-funded health care
programs to the extent ED efficiencies reduce wait time,
decrease the length of inpatient hospitalizations, and
correlate with improved health outcomes. Additionally, any
costs to DPH to add additional criteria to its licensing
inspections, or to OSHPD to collect and store full-capacity
protocols, would be minor and absorbable. Costs to
hospitals to develop and calculate crowding scores, to
create a full-capacity protocol, and to train staff could
be minor and absorbable. The Assembly Appropriations
Committee analysis of AB 2153 states that it would likely
create minor costs to hospitals to periodically calculate
the overcrowding score and to implement the full capacity
protocol; but that the bill generally describes current
practices and policies for hospital emergency services.
Many busy EDs must assess capacity and patient flow
frequently to determine whether they should go on
diversion, for example, during which ambulances are
redirected to other hospitals.
BACKGROUND AND DISCUSSION
According to the author, California EDs 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
ED 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
STAFF ANALYSIS OF SENATE BILL 336 (Lieu and De León) Page
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use of an overcrowding score known as the National
Emergency Department Overcrowding Score score, similar to
the crowding score proposed in this bill, and a subsequent
full-capacity protocol plan at Los Angeles
County/University of Southern California Medical Center
have significantly reduced wait times and patient boarding.
The author contends that this approach would work on a
statewide level and that SB 336 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.
The crowding score proposed in SB 336 was developed by the
American College of Emergency Physicians, State Chapter of
California (CAL/ACEP), the sponsor of the bill, the
California Hospital Association (CHA), and the California
Emergency Nurses Association. According to CHA, the three
organizations hosted an online forum in April 2010 to
educate hospitals about the use of this innovative tool and
to seek their participation in a three-month pilot to
evaluate its efficacy. CHA planned to evaluate the results
of the pilot to identify if the tool could assist hospitals
in objectively determining the amount of ED crowding and
assist in the development of full-capacity protocols.
According to CHA, it was unable to evaluate the pilot and
is currently working with a researcher to collect data from
at least fifteen hospitals, which reflect the variety of
size, region and geographic location of hospitals in
California, to evaluate which variables/conditions
correlate with crowding. This researcher will be analyzing
and publishing the data sometime in the future.
A 2003 U.S. General Accounting Office analysis of ED
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. The GAO report
maintains that when EDs 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 EDs to
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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 EDs 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. The
IOM report called for the strengthening of the Joint
Commission standards that address emergency department
overcrowding, boarding, and diversion.
Information posted on the American Academy of Emergency
Medicine website states that the Joint Commission issued an
important guideline on ED 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.
Prior legislation
AB 2153 (Lieu) of 2010 contained provisions identical to
those contained in this bill. This bill died on the Senate
Floor inactive file.
AB 911 (Lieu) of 2009 contained provisions identical to
those contained in this bill. This bill was vetoed by
Governor Schwarzenegger. In his veto address the Governor
stated that, although he supports the intent behind the
bill, it is not necessary and he does not believe it would
provide any significant improvement to the underlying
problem. The Governor further encouraged hospitals to use
the crowding score outlined in the bill and work to develop
full-capacity protocols that best address their individual
STAFF ANALYSIS OF SENATE BILL 336 (Lieu and De León) Page
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hospital needs.
AB 2207 (Lieu) of 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, California
State Chapter (CAL/ACEP), sponsor of this bill, states that
SB 336 provides an opportunity to relieve ED overcrowding
that is simple, has a proven, successful track record, and
doesn't require additional funding from the state or
hospitals. CAL/ACEP notes that LA County/USC hospital,
with the largest ED in the state, implemented this approach
at no additional cost and experienced a dramatic reduction
in ED overcrowding.
Arguments in opposition
The San Bernardino County Board of Supervisors (SBCBS)
states that there is no evidence that using a scoring tool
is effective and would work for California. The SBCBS
notes that overcrowding assessments in EDs are already
conducted and that there is insufficient evidence to show
that using a scoring tool would have any impact on
improving ED overcrowding. According to SBCBS, Arrowhead
Regional Medical Center, San Bernardino County's public
hospital, already employs an effective system to avoid ED
overcrowding, and feels the mandated tool in this bill
would impose an unnecessary and unfunded state mandate.
The Association of California Healthcare Districts argues
that the solution to easing demands on existing EDs does
not lie in adding an administrative burden to an already
overtaxed system, but rather in addressing the reasons for
non-emergent use, or emergent use that could have been
avoided by early intervention.
POSITIONS
Support: The American College of Emergency
Physicians, California State Chapter
(sponsor)
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Oppose: Association of California Healthcare Districts
San Bernardino County
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