BILL ANALYSIS
AB 911
Page 1
ASSEMBLY THIRD READING
AB 911 (Lieu)
As Amended June 1, 2009
Majority vote
HEALTH 11-3 APPROPRIATIONS 12-5
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|Ayes:|Jones, Ammiano, Block, |Ayes:|De Leon, Ammiano, Charles |
| |Carter, De Leon, | |Calderon, Davis, Fuentes, |
| |Hall, Hayashi, Hernandez, | |Hall, John A. Perez, |
| |Bonnie Lowenthal, V. | |Price, Skinner, Solorio, |
| |Manuel Perez, Salas | |Torlakson, Krekorian |
| | | | |
|-----+--------------------------+-----+---------------------------|
|Nays:|Fletcher, Gaines, Audra |Nays:|Nielsen, Duvall, Harkey, |
| |Strickland | |Miller, |
| | | |Audra Strickland |
| | | | |
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SUMMARY : Requires every licensed general acute care hospital
to assess the condition of its emergency department (ED) at
specified time intervals 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 of 101 or
above; the NEDOCS scores are 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;
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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 four hours and calculate and
record a NEDOCS score.
6)Permits that if, after calculating and recording a NEDOCS
score pursuant to 4) above, a licensed general acute care
hospital does not record a NEDOCS score over 60 for the
previous 30 days, it may calculate and record a NEDOCS score
every eight hours.
7)Requires that if, a licensed general acute care hospital
calculating and recording a NEDOCS score every eight hours
pursuant to 4) above and subsequently records a score over 60,
to calculate and record a NEDOCS score every four hours again
pursuant to 5) above.
8)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
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,
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bb) Space utilization, including alternate care sites.
9)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 : According to the Assembly Appropriations
Committee:
1)One-time General fund (GF) costs and GF pressures of $125,000
to the University of California medical centers, combined, to
develop full capacity protocols and adjust related computer
programming to make NEDOCS available throughout each medical
center. Unknown related costs to other public hospitals.
2)One-time fee-supported special fund costs of $170,000 to the
California Department of Public Health to establish
regulations and maintain oversight of requirements of this
bill during licensure and certification processes.
3)Savings to public and private payers are possible to the
extent NEDOCS provides an increased focus on reducing ED
overcrowding. Studies focused on ED length-of stay, ambulance
diversions, and quality of ED care show positive impacts when
ED overcrowding is reduced.
COMMENTS : 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 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
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hospitals and EDs.
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:
1)Number of ED beds;
2)Number of hospital beds;
3)Total patients in the ED;
4)Number of respirators in use in the ED;
5)Longest admit times (in hours);
6)Total admits in the ED; and,
7)Wait time for the last patient called (from triage).
Emergency and hospital beds referred to in 1) and 2) above refer
to the budgeted number of beds available for patient care. The
total patients in the ED referred to in 3) 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 1) through 7) 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.
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 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.
The California Medical Association (CMA) and the American
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Federation of State, County and Municipal Employees support this
bill stating that it 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.
The California Hospital Association (CHA), the Emergency Nurses
Association (ENA) and the California Children's Hospital
Association (CCHA) are opposed unless this bill is amended. CCHA
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, ENA
and CCHA are requesting that the bill be amended to remove the
requirement of doing a NEDOCS score.
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097 FN:
0001288