BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 787
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|AUTHOR: |Bates |
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|VERSION: |April 20, 2015 |
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|HEARING DATE: |April 29, 2015 | | |
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|CONSULTANT: |Vince Marchand |
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SUBJECT : Hospitals: closures
SUMMARY : Permits Saddleback Memorial Medical Center to operate an
emergency department at its San Clemente campus, even if the San
Clemente campus stopped providing acute care services thereby
permitting a freestanding emergency department, subject to
specified conditions.
Existing law:
1.Licenses general acute care hospitals under the California
Department of Public Health (CDPH). Defines general acute care
hospitals as hospitals that provide 24-hour inpatient care,
including the following basic services: medical, nursing,
surgical, anesthesia, laboratory, radiology, pharmacy, and
dietary services.
2.Permits general acute care hospitals, in addition to the basic
services all hospitals are required to offer, to be approved
by CDPH to offer special services, including, but not limited
to, a radiation therapy department, a burn center, an
emergency center, a hemodialysis center or unit, psychiatric
services, intensive care newborn nursery, cardiac surgery,
cardiac catheterization laboratory, and renal transplant.
3.Requires CDPH to issue a single consolidated license to a
general acute care hospital that includes more than one
physical plant maintained and operated on separate premises or
that has multiple licenses for a single health facility on the
same premises if the general acute care hospital meets certain
criteria and applicable requirements of licensure.
4.Requires any hospital that provides emergency medical services
to provide notice no later than 90 days prior to a planned
SB 787 (Bates) Page 2 of ?
reduction or elimination of the level of emergency medical
services of the intended change to CDPH, the local emergency
medical services agency, and all health care service plans or
other entities under contract with the hospital to provide
services to enrollees. Additionally requires the hospital to
provide notice of the intended change in a manner that is
likely to reach a significant number of residents of the
community served by the facility.
Existing regulations:
1.Requires an emergency medical service to be so located in the
hospital as to have ready access to all necessary services.
2.Requires a hospital that is approved to offer emergency
medical service to have the following service capabilities:
a. Intensive care service with adequate monitoring and
therapeutic equipment;
b. Laboratory service with the capability of performing
blood gas analysis and electrolyte determinations;
c. Radiological service to be capable of providing the
necessary support for the emergency service;
d. Surgical services immediately available for
life-threatening situations;
e. Post-anesthesia recovery service; and,
f. The services of a blood bank containing common types
of blood and blood derivatives readily available, with
blood storage facilities in or adjacent to the emergency
service.
This bill:
1.Permits Saddleback Memorial Medical Center, notwithstanding
any other law, to operate an emergency department (ED) at its
San Clemente campus, subject to the conditions specified in
this bill.
2.Requires the San Clemente ED to operate under the consolidated
license of Saddleback Memorial Medical Center and to meet all
of the requirements imposed under that license, including
being within 15 miles of its parent hospital.
3.Requires the San Clemente ED to be a conversion from a
previously existing acute care campus and prohibits it from
being a newly developed freestanding ED.
SB 787 (Bates) Page 3 of ?
4.Requires the San Clemente ED to be open 24 hours a day, 365
days a year.
5.Requires the San Clemente ED to be staffed by at least one
board-certified emergency physician at all times.
6.Requires the San Clemente ED to be staff with properly trained
emergency room nurses and meet the minimum staffing
requirements for EDs in this state.
7.Requires the San Clemente ED to have a complete range of
laboratory and diagnostic radiology services, including a
complete array of laboratory test, basic X-ray, computerized
tomography (CT) scan, and ultrasound capabilities.
8.Requires the San Clemente ED to meet the specialty call
requirements, as defined by the Orange County emergency
medical services agency, under its consolidated license.
9.Requires the San Clemente ED to have transfer agreements with
specialty centers, such as trauma, burn, and pediatric
centers, to meet the needs of the injury or patient population
served in the community.
10.Requires the San Clemente ED to have the capabilities to
stabilize patients with emergency medical conditions and to
transport them to its parent hospital or other higher level of
care facilities in a safe and timely manner, consistent with
the standards of care in the local communities.
11.Requires the San Clemente ED to have a fully functioning
transport program with a proven track record of safely
transporting patients who require admission to its parent
hospital or other higher level of care and specialty services
facilities, such as trauma, burn, and pediatric facilities.
12.Requires all applicable federal and state regulatory
requirements to be met under the consolidated license of
Saddleback Memorial Medical Center, including all applicable
regulations of the Centers for Medicare and Medicaid Services
and Title 22 of the California Code of Regulations.
13.Prohibits anything in this bill from being construed to
require Saddleback Memorial Medical Center to provide for
concomitant acute care service at the San Clemente campus or
SB 787 (Bates) Page 4 of ?
to seek additional licensure for operation of the San Clemente
ED that is authorized pursuant to this bill.
14.States legislative findings and declarations that a special
law is necessary and that a general law cannot be made
applicable within the meaning of a specified provision of the
California Constitution because of the unique circumstances
regarding the provision of emergency medical services to the
communities of San Clemente, Dana Point, and San Juan
Capistrano.
15.Contains an urgency clause that will make this bill effective
upon enactment.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, the operator of
San Clemente's Saddleback Memorial Medical Center ("San
Clemente Hospital") is considering plans to convert the
hospital into an ambulatory health care campus that would
provide outpatient surgery and urgent care services. This plan
would eliminate the hospital's 73-bed hospital and emergency
room. This bill authorizes San Clemente Hospital to continue
to provide emergency medical services to patients in the
region if it otherwise transforms its delivery of services.
San Clemente Hospital has served South Orange County for more
than 40 years, and operates the only emergency facility
between Mission Viejo and Oceanside. While the converted San
Clemente Hospital would have an urgent care center, state law
does not allow 911 patients to be transported to urgent care
centers. Ambulances transporting 911 patients to the closest
facilities that could take patients in need of emergency
services from the area that is presently served by San
Clemente Hospital would face longer distances on roads and
highways that are frequently congested with traffic. The
longer ambulance rides could risk the lives of patients.
Additionally, the nearest emergency rooms are already strained
by the number of patients that come in, and could be forced to
turn away additional emergency patients.
2.Background on San Clemente hospital. San Clemente Hospital is
part of Health System, which is a nonprofit health care
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delivery system with six hospitals, as well as a number of
surgical centers and outpatient clinics in Los Angeles and
Orange County. San Clemente Hospital is licensed for 73 beds,
and operates under a consolidated license with Saddleback
Memorial Medical Center - Laguna Hills, which has 252 licensed
beds. The Laguna Hills campus is located about 14 miles north
of San Clemente Hospital, with both hospitals adjacent to the
Interstate 5 highway. According to newspaper articles,
MemorialCare Health System announced in August of 2014 that
they were planning to replace San Clemente Hospital with a new
facility that would offer a wide range of outpatient services,
including an advanced urgent care.
According to the Office of Statewide Health Planning and
Development's Annual Utilization Report for San Clemente
Hospital, the hospital's ED was placed on diversion (meaning
the ED was closed to ambulances because it was full) for a
total of 112 hours in 2014. The following table is San
Clemente Hospital's emergency utilization data for 2014:
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| ED Visit Type | (1) | (2) | (3) |
| | | | |
| | Visits not |Admitted from | Total ED |
| | Resulting in | ED | Traffic |
| | Admission | | (1) + (2) |
| | | | |
|-----------------+--------------+--------------+--------------|
|Minor | 548 | 0 | |
|-----------------+--------------+--------------+--------------|
|Low/Moderate | 4,626 | 4 | |
|-----------------+--------------+--------------+--------------|
|Moderate | 5,403 | 29 | |
|-----------------+--------------+--------------+--------------|
|Severe without | 1,798 | 1,006 | |
|threat | | | |
|-----------------+--------------+--------------+--------------|
|Severe with | 423 | 591 | |
|threat | | | |
|-----------------+--------------+--------------+--------------|
|TOTAL | 12,798 | 1,630 |14,428 |
| | | | |
| | | | |
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SB 787 (Bates) Page 6 of ?
Other hospitals in the surrounding region include:
a. Mission Hospital Laguna Beach, with 123 acute care
beds with somewhat similar ED utilization rates and is
located seven miles north of San Clemente Hospital on
Highway 1;
b. Mission Hospital Regional Medical Center, with 345
acute care beds, a Level II trauma center, and an ED that
is about three times the size of San Clemente Hospital's
ED which went on diversion status for 683 hours in 2014.
Mission Hospital Regional Medical Center is located about
nine miles north of San Clemente Hospital along I-5, in
Mission Viejo; and,
c. Saddleback Memorial Medical Center - Laguna Hills,
the parent hospital of San Clemente Hospital, with 252
acute care beds and an ED that is roughly the size of
Mission Hospital Regional Medical Center, which went on
diversion for a total of 308 hours in 2014. This hospital
is located about 14 miles north of San Clemente Hospital
along I-5.
Under existing law, a hospital that offers emergency medical
services is required to provide CDPH, among others, with at
least 90 days notice of any planned reduction or closure of
the emergency medical service. According to CDPH, San Clemente
Hospital has not provided this notice, but that the
MemorialCare Health System is currently working on a
feasibility study to determine the future of the hospital.
1.Background on freestanding EDs. There are currently no
freestanding EDs licensed in California, although they do
operate in other states. According to an article in Kaiser
Health News in July of 2013, the number of freestanding EDs
doubled to more than 400 between 2009 and 2013. According to a
2013 information paper published by the American College of
Emergency Physicians, there are two distinct types of
freestanding EDs: those that are operated by, or licensed
through, medical centers or hospital systems but are
geographically separate from the hospital, and those that are
independent of a hospital. As an example of the latter, First
Choice ER is a for-profit chain of freestanding, 24-hour
emergency rooms that operate in Texas and Colorado. CHCF
published an issue brief in July of 2009, entitled
"Freestanding Emergency Departments: Do They Have a Role in
California" (CHCF report). According to the CHCF report, the
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growth of freestanding EDs has prompted discussions regarding
their regulation and effect on the health care system. The
CHCF report states that these facilities differ from urgent
care centers in that they can accommodate additional
procedures such as defibrillation, intubation, and conscious
sedation. Additionally, most freestanding EDs are staffed by
trained emergency physicians and nurses, and some have been
permitted to receive ambulance patients. In California, in
order to offer emergency medical services, a facility must
provide certain services, such as intensive care, radiology,
and surgical services that are immediately available for
life-threatening situations, which essentially require an ED
to be part of a full-fledged hospital.
2.Pilot project at Centinela Airport Clinic. Using statutory
authority that authorizes a local EMSA to "approve or conduct
any scientific or trial study of the efficacy of the
pre-hospital emergency use of any drug, device, or treatment
procedure within the local EMS system," the Los Angeles County
EMSA approved a two-year pilot project beginning in 2004 to
allow the Centinela Airport Clinic at Los Angeles
International Airport to receive 911 transports of basic
life-support patients. This was apparently the first time that
an emergency medical services system in California was allowed
to transport patients from 911 dispatch to a facility that was
not part of a hospital. However, both CDPH and the statewide
California EMSA Medical disagreed that the local EMS agency
had the authority to permit the operation of such a facility.
Ultimately, this "freestanding ED" pilot project ended after
one year, partly as a result of low volume that resulted from
a restrictive county ambulance triage policy that limited the
severity of patients that could be transported to this
location.
3.Related legislation. AB 911 (Brough), is nearly identical to
this bill. AB 911 is currently scheduled to be heard in
Assembly Health Committee on April 28, 2015.
AB 579 (Obernolte), permits a general acute care hospital to
operate an ED located more than 15 miles from its main
physical plant, if all applicable requirements of licensure
are satisfied. The bill would also permit a closing general
acute care hospitals' ED to continue to be operated at the
same location or locations by an acquiring general acute care
hospital, as specified. AB 579 creates an exception to permit
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the acquiring general acute care hospital to operate the
closing general acute care hospitals' ED at that location or
locations, even if located more than 15 miles from the
acquiring general acute care hospital's main physical plant,
if all applicable requirements of licensure are satisfied. AB
579 is currently pending in Assembly Health Committee.
4.Prior legislation. AB 717 (Gordon), of 2005, would have
allowed the Centinela Airport Clinic to receive private and
government reimbursement rates equivalent to that of a
contiguous emergency department of a general acute care
hospital if certain specified requirements were met. AB 717
failed passage in the Senate Health Committee.
AB 1050 (Gordon), of 2005, would have created a demonstration
project that required the Department of Health Services to
issue a special permit to up to four general acute care
hospital applicants in Los Angeles County to operate
freestanding emergency receiving centers. AB 1050 was never
heard in Committee.
5.Support. This bill is supported by a group of several
physicians who have formed "Save Saddleback San Clemente
Hospital" (SSSCH). According to SSSCH, MemorialCare Health
System has been planning to close their community's 73-bed
hospital and ED. The hospital is likely to close this year
regardless of this legislation, and SSSCH states that the fate
of the ED hangs on this bill. According to SSSCH, San
Clemente Hospital's ED serves 15,000 people yearly and is the
second busiest ER in the region. SSSCH states that their
community is effectively a peninsula, with Camp Pendleton
south, protected forest to the east, the ocean to the west,
and only one road north, I-5, to access emergency services.
According to SSSCH, an I-5 widening project has just started
closing shoulders and ramps intermittently, and that this
project will last three years. SSSCH states that in 2013 and
2014, the average transport times from a typical San Clemente
residence was 17 minutes to the next closest hospital, Mission
Hospital Regional Medical Center in Mission Viejo, and now
that construction has begun, transport times to this facility
can exceed 30 minutes. According to SSSCH, Mission Hospital,
which will get their 15,000 patients, leads all 26 hospitals
in Orange County in wall time (when emergency personnel must
wait in the ED with their patients while waiting for a bed to
open up) and diversion time (when the ED is closed to
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paramedic traffic because the ED is full). SSSCH states that
with San Clemente Hospital closing, their community will be
left with 75 ED beds to cover more than 400,000 people. SSSCH
states that this bill is critical to keep access to emergency
care in their community.
6.Opposition. The California Chapter of the American College of
Emergency Physicians (CalACEP) states in opposition that
freestanding EDs are facilities that provide urgent care, but
are not attached to acute care hospitals. While the words
"emergency department" are in the title of these facilities,
CalACEP states that they operate like urgent care clinics, not
EDs. According to CalACEP, the very nature of an ED is that it
is a department of a hospital - a place where patients have
immediate access to a wide variety of treatment services and
specialists when necessary to treat their serious condition.
Allowing urgent care facilities to contain the word
"emergency" in the title poses patient safety risks to
patients who arrive at the door assuming they can receive
full-scope ED care. CalACEP points to the example foa patient
presenting at a freestanding ED with chest pains, only to find
out they are having a heart attack and require transfer to a
hospital. The critical, wasted time in transport is time
during which the patient should be receiving life-saving care.
The California Nurses Association (CNA) also opposes this bill,
and points to arguments by the owner of the hospital that
local 911 calls for patients who may have a heart attack,
stroke, or trauma currently bypass San Clemente hospital to go
to cardiac receiving centers, stroke receiving centers, and
trauma centers. According to CNA, in other words, San Clemente
hospital's ED is being bypassed by Orange County emergency
medical services because its ED is insufficiently supported by
certain necessary and specialized urgent support services, and
that this bill would exacerbate such insufficiency by
diminishing even further those support services while
simultaneously holding itself out to the public as an ED. The
California State Council of the Service Employees
International Union (SEIU California) states in opposition
that under existing law, in order to provide emergency
services in California, emergency services must be located
within a hospital so as to have access to all necessary
services. SEIU California states that the reason for these
requirements is that it is difficult to predict the severity
of the medical needs of patients presenting at an ED. Should
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an individual require immediate surgery to save his or her
life, for example, SEIU California states that those services
should be as close and readily available to the patient as
possible.
SUPPORT AND OPPOSITION :
Support: Three individuals
Oppose: California Chapter of the American College of
Emergency Physicians
California Nurses Association
California State Council of Service Employees
International Union
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