BILL ANALYSIS Ó
SB 336
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Date of Hearing: June 14, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 336 (Lieu and De León) - As Amended: May 16, 2011
SENATE VOTE : 38-0
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). Specifically, this bill :
1)Defines "crowding score" as the score calculated to measure ED
and hospital overcrowding, with an equation, as specified,
using the following variables:
a) Total number of patients within the ED;
b) Total number of staffed beds in the ED, not to exceed
the number of licensed beds;
c) Total number of admissions waiting in the ED, including
patients awaiting transfer;
d) 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;
e) Total number of patients in the ED admitted to the
intensive care-critical care unit;
f) The longest admit time, in hours, including transfers;
and,
g) The wait time for the last patient waiting the longest
in the waiting room, in hours.
2)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.
3)Requires every licensed general acute care hospital that
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operates an ED to determine a range of crowding scores that
constitutes each category of the crowding scale for its ED.
4)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 30 days,
calculating and recording a crowding score a minimum of every
eight hours.
5)Requires that every licensed general acute care hospital that
has an ED and a census of 14,000 visits annually to calculate
and record the crowding score daily between 4:00 p.m. and 8:00
p.m.
6)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:
a) Notification of hospital administrators, nursing staff,
medical staff, and ancillary services of category changes
on the scale;
b) Hospital operations, including bed utilization,
transfers, elective admissions, discharges, supplies, and
additional staffing;
c) ED operations, including diversion, triage, and
alternative care sites; and,
d) Planned response, if the organized medical staff by the
hospital for rounds discharges, coordination with the ED
and emergency consults for ED patients.
7)Requires every licensed general acute care hospital that
operates an ED to file its full-capacity protocols with the
OSHPD, and annually report any revisions to its protocols.
8)Sunsets the provisions of this bill on January 1, 2016.
EXISTING LAW :
1)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).
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2)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 the following basic services: a) medical; b)
nursing; c) surgical; d) anesthesia; e) laboratory; f)
radiology; g) pharmacy; and, h) dietary services.
3)Permits hospitals to provide emergency medical services, under
specified circumstances.
4)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.
FISCAL EFFECT : According to the Senate Appropriations
Committee, this bill will have unknown, but potentially
significant, costs and savings on publicly-funded health
programs, including Medi-Cal and Healthy Families. The analysis
states the following:
1)If this bill were to result in an ED's ability to see 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.
2)In contrast, there could be savings to the same
publicly-funded health care programs to the extent that ED
efficiencies reduce wait time and thereby decrease the length
of inpatient hospitalizations and correlate with improved
health outcomes.
3)The Senate Appropriations Committee further states that 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
full-capacity protocols, and to train staff, would be minor
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but not reimbursable directly by the state.
COMMENTS :
1)PURPOSE OF THIS BILL . According the authors, overcrowding in
California's EDs is a serious problem and a threat to the
health and safety of patients in need of care. The authors
maintain that California is currently the last in the nation
with regard to the number of EDs available to its residents,
providing only 7.1 EDs for every 1 million people, compared to
an average of 19.9 among other states. The authors assert
that many hospitals across the nation, including Los Angeles
County University of Southern California Medical Center
(LAC-USC), have developed a full-capacity protocol which is
intended to ease tension in EDs and cut wait times for
patients. This plan, according to the authors, assesses the
level of overcrowding in an ED and sets guidelines for
hospital operations at each level of overcrowding. The
authors argue that the full-capacity protocol plan at LAC-USC,
which this bill emulates, has been overwhelmingly successful
in achieving safe and reasonable emergency procedures for both
hospitals and EDs. According to the authors, wait times have
been significantly reduced as a result of the implementation
of the full- capacity protocol plan at LA-USC.
2)BACKGROUND . 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 EDs 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.
A 2003 U.S. General Accounting Office analysis of ED
overcrowding (GAO report), reported that emergency room
overcrowding is a problem that has reached historic levels in
the new millennium 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
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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 are increased, and there is a greater
risk for poor health outcomes. This all leads, according to
the GAO report, to temporary closing of crowded EDs to inbound
ambulance traffic, a process called diversion, which increases
travel time as ambulance drivers seek other hospitals to which
they can transport their patients.
According to the Internet Web site of the American Academy of
Emergency Medicine, in 2004, the Joint Commission issued an
important new guideline on ED overcrowding. The Web site
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
on an inpatient unit.
3)SUPPORT . The California Chapter of the American College of
Emergency Physicians (CAL/ACEP) writes in support that
California's EDs have become the health care safety net and
are the front lines of public health emergency. CAL/ACEP
maintains that with record unemployment rates, deep budget
cuts to state and county funded health care programs and the
uncertainty of economic recovery, the ED safety net is being
stretched to its breaking point. CAL/ACEP argues that this
bill provides an opportunity for relief that is simple and
proven and doesn't require additional funding from the state
or from hospitals. CAL/ACEP asserts that in fact, LAC-USC,
with the largest ED in the state, implemented the approach
specified in this bill at no additional cost and experienced a
dramatic reduction in ED crowding.
4)OPPOSITION . The Association of California Healthcare
Districts (ACHD) writes in opposition that the increasing
demands on California's EDs are a reflection of reductions in
their numbers, as well as increases in the numbers of
Californians, who primarily, for various economic reasons, now
find the local ED to be their only available source of medical
care. ACHD maintains the solution to easing the demands on
existing EDs is not to add an administrative burden to an
already overtaxed system, which is required by law to treat
everyone, but rather to address the reasons for non-emergent
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use, or emergent use that could have been avoided by early
intervention.
ACHD argues that with the ranks of Medi-Cal predicted to soon
equal 25% of the state's population, at a time when only 30%
of the state physicians participate in Medi-Cal that the
strategy for decreasing utilization of EDs is to increase the
numbers of physicians who will treat Medi-Cal, as well as the
uninsured outside of the ED.
5)PREVIOUS LEGISLATION .
a) AB 2153 (Lieu) of 2010 provisions were identical to
those contained in this bill. AB 2153 died on the Senate
Floor inactive file.
b) AB 911 (Lieu) of 2009 also contained provisions
identical to those contained in this bill. AB 911 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 hospital needs.
c) AB 2207 (Lieu) of 2008 would have required hospitals to
assess the condition of an emergency room via the National
Emergency Department Overcrowding Scale Score, or 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. AB 2207 was held in the Assembly
Appropriations Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
American College of Emergency Physicians, State Chapter of
California, Inc.
Opposition
Association of California Healthcare Districts
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097
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