BILL ANALYSIS
AB 911
Page 1
Date of Hearing: April 21, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 911 (Lieu) - As Introduced: February 26, 2009
SUBJECT : Emergency rooms: overcrowding.
SUMMARY : Requires every licensed general acute care hospital
to assess the condition of its emergency department (ED) every
three hours and develop and implement capacity protocols to be
submitted to the Office of Statewide Health Planning and
Development (OSHPD). Specifically, this bill :
1)Makes findings and declarations regarding the practice of
boarding admitted patients in hospital EDs and its
contribution to the problem of severe ED overcrowding in
California.
2)Defines the practice of "boarding" as keeping patients who
require hospitalization in the ED until a hospital bed becomes
available.
3)Defines "NEDOCS Score" as the National ED Overcrowding Scale
Score and provides its formula.
4)Defines "overcrowding" based on a NEDOCS score divided into
the six following categories:
a) Not busy, which includes NEDOCS scores of 20 and below;
b) Busy, which includes NEDOCS scores 21 to 60;
c) Extremely busy, which includes NEDOCS scores 61 to 100;
d) Overcrowded, which includes NEDOCS scores of 101 to 140;
e) Severely overcrowded, which includes NEDOCS scores of
141 to 180; and,
f) Dangerously overcrowded, which includes NEDOCS scores of
at least 181.
5)Requires every licensed general acute care hospital to assess
the condition of its ED every three hours and calculate and
record a NEDOCS score.
6)Requires by January 1, 2011, every licensed general acute care
hospital to develop and implement, in consultation with its ED
staff, a full capacity protocol for each of the categories of
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NEDOCS, and requires the protocol to address all of the
following:
a) Notification of hospital administrators, nursing staff,
medical staff, and ancillary services of category changes
on the NEDOCS;
b) Bed utilization;
c) Diversion;
d) Elective admissions;
e) Transfers;
f) Triage;
g) Responsibilities of inpatient medical staff and
specialty service operations for rounds, discharges,
coordination with the ED, and emergency consults for ED
patients;
h) Hospital unit operations;
i) Nursing services;
j) Supplies;
aa) Calling in additional medical staff; and,
bb) Space utilization, including alternate care sites.
7)Requires every licensed general acute care hospital to file
its full-capacity protocols with OSHPD and annually report any
revisions of those protocols.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the American College of
Emergency Physicians State Chapter of California, Inc.
(CAL/ACEP), the sponsor of this bill, ED overcrowding occurs
when there is no space left to meet the timely needs of the
next patient that requires emergency care. CAL/ACEP maintains
that studies show that the most common cause of ED
overcrowding actually occurs when a patient is admitted for
inpatient care and is then "boarded" because there is not a
bed available in the hospital. CAL/ACEP argues that many
hospitals across the nation, including the 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. CAL/ACEP
states that this protocol requires an assessment of
overcrowding in an ED by utilizing the NEDOCS scoring system
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and then sets guidelines for hospital operations at each level
of overcrowding. CAL/ACEP asserts that the full-capacity
protocol has been overwhelmingly successful in achieving safe
and reasonable emergency procedures for both hospitals and
EDs.
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
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
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on an inpatient unit. The IOM report called for the
strengthening of The Joint Commission standards that address
ED overcrowding, boarding, and diversion.
3)NEDOCS SCORE . The NEDOCS score is a five-question tool that
was developed by eight academic EDs to measure ED and hospital
overcrowding. The calculator uses variables found to be
statistically significant in ED overcrowding and the score
corresponds to a given level of operational capacity. The
NEDOCS uses the following variables in its calculation of a
score:
a) Number of ED beds;
b) Number of hospital beds;
c) Total patients in the ED;
d) Number of respirators in use in the ED;
e) Longest admit times (in hours);
f) Total admits in the ED; and,
g) Wait time for the last patient called (from triage).
Emergency and hospital beds referred to in 3 a) and 3 b) above
refer to the budgeted number of beds available for patient
care. The total patients in the ED referred to in 3 c) above,
include normal, doubled-up, and hallway beds, and those
undergoing work-ups in chairs, triage, and the waiting room,
etc. The NEDOCS uses the following formula which includes the
variables in 3 a) through 3 g) above to calculate the NEDOCS
score: Score = 85.8(c/a) + 600(f/b) + 13.4(d) + 0.93(e) +
5.64 (g) - 20.
Hospitals can use a calculator that is available on the
University of New Mexico internet Web site. When hospitals
use the NEDOCS Web site calculator, points are assigned for
each of the conditions summed and then the calculator converts
the point total to the NEDOCS score, which is scaled from
0-200 in the categories described in this bill.
Conditions that will supersede the calculator include a
medical trauma, a mass casualty event or an internal/external
disaster in which case the NEDOCS score will be elevated to
the dangerously overcrowded score.
Under the NEDOCS scoring system, each level corresponds to and
necessitates an institutional response with respect to
systems, space, and supplies. As the overcrowding increases,
the degree of response escalates to prevent or mitigate
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further overcrowding and the consequences of such. Hospitals
across the nation, including LAC+USC, use the NEDOCS score and
have developed corresponding full-capacity protocols. The LAC
+USC protocols, as a part of standardized procedure, call for
conducting a NEDOCS assessment every 2 hours.
4)SUPPORT . The California Medical Association (CMA) and the
American Federation of State, County and Municipal Employees
(AFSCME) support this bill. AFSCME states that California is
last in the nation in the number of EDs available to its
residents with 6.16 EDs per 1,000,000,000 people. AFSCME
maintains that since 1990, this ratio has steadily declined
leading to severe ED overcrowding. CMA states that this bill
establishes a way to increase knowledge of the overcrowding
problems caused by hospital closures and consolidations. CMA
also maintains that having plans established for when
hospitals reach capacity is essential to providing consistent,
quality emergency care.
5)OPPOSE UNLESS AMENDED . The California Hospital Association
(CHA) and the California Children's Hospital Association
(CCHA) are opposed unless this bill is amended. CCHA states
that requiring hospitals to calculate a NEDOCS score every
three hours is an unproven method to determine the level of
crowding in an ED. CCHA further states that the use of
NEDOCS, which they claim is extremely time consuming, would
take direct care givers from patient care, therefore
furthering the problem of long wait times. CHA and CCHA are
requesting that the bill be amended to remove the requirement
of doing a NEDOCS score. CHA and CCHA state they are
committed to working with the author and CAL/ACEP to make
changes in the bill regarding the ED overcrowding plan
required by this bill.
6)PREVIOUS LEGISLATION . AB 2207 (Lieu) of 2008 had similar
elements to this bill. AB 2207 would have required hospitals
to assess the condition of an emergency room via the NEDOCS
score every three hours. AB 2207 also 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 under submission in the Assembly
Appropriations Committee.
REGISTERED SUPPORT / OPPOSITION :
AB 911
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Support
The California Chapter of the American College of Emergency
Physicians (sponsor)
American Federation of State, County and Municipal Employees,
AFL-CIO
California Medical Association
Opposed Unless Amended
California Children's Hospital Association
California Hospital Association
Opposition
None on file.
Analysis Prepared by : John Miller / HEALTH / (916) 319-2097