BILL ANALYSIS
AB 2153
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Date of Hearing: April 13, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 2153 (Lieu) - As Introduced: February 18, 2010
SUBJECT : Emergency room crowding.
SUMMARY : Requires every licensed general acute care hospital
with an emergency department (ED) to assess ED 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. 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
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
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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)Provides 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, 2012, 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) Emergency department 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
Office of Statewide Health Planning and Development (OSHPD),
and annually report any revisions to its protocols.
8)Sunsets the provisions of this bill on January 1, 2015.
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.
2)Defines a general acute care hospital as a health facility
having a duly constituted governing body with overall
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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 : 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, overcrowding in
California's EDs is a real and continued threat to the health
and safety of patients in need. Cal/ACEP asserts that the
full-capacity protocol required in this bill has been
overwhelmingly successful in achieving safe and reasonable
emergency procedures for both hospitals and EDs. According to
Cal/ACEP, many hospitals across the nation, including the Los
Angeles County University of Southern California Medical
Center (LAC+USC), with the largest ED in the state,
implemented this approach at no additional cost and
experienced a dramatic reduction in ED overcrowding. Cal/ACEP
maintains that this bill provides an opportunity for relief
that is simple and proven and allows for rapid response with
practical solutions based on the ever-changing conditions in
the ED.
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
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fragmented. As a result, according to the IOM report,
ambulances are turned away from EDs or diverted 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.
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. The IOM report called for the
strengthening of the Joint Commission standards that address
ED overcrowding, boarding, and diversion.
3)FACTORS CONTRIBUTING TO ED OVERCROWDING . There are numerous
potential reasons for the rising use of ED services. Research
has identified the impact of the rising number of uninsured
and underinsured persons who do not have access to a regular
source of medical care. At the same time, studies also reveal
that the ED has become a health care safety net for
individuals who have private insurance, but who are unable to
obtain appointments with primary care or specialty physicians
in a timely manner. Individuals who are covered by public
programs such as Medicare and Medicaid (Medi-Cal in
California), may have trouble finding primary and specialty
care providers willing to accept their coverage, possibly
because of low reimbursement rates or other factors that make
providers less likely to participate.
Physician groups, hospitals, health care advocates, researchers,
and other stakeholders offer a diverse array of contributing
factors that impact hospital ED overcrowding:
a) Reduced Inpatient Capacity . A shrinking supply of
inpatient beds and, in some instances, the lack of staff
available to support those beds, may be affecting patients'
ability to access timely emergency care. According to the
IOM report, in many hospital EDs, patients who have been
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admitted to the hospital end up being "boarded" in the ED,
where they spend hours or even days waiting for an
available hospital bed. Patients who are boarded are often
forced to wait in ED hallways, waiting rooms or other
available spaces which provide for limited privacy and
decreased access to timely services, appropriate expertise
and equipment specific to a patient's condition. The IOM
further states that boarded patients tie up emergency staff
time and resources, ultimately limiting the ED's capacity
for treating other patients. High numbers of boarded
patients waiting for beds can lead to increased waiting
times for new arrivals and raise the risk that the hospital
will have to divert incoming ambulances to other sites.
b) Lack of Access to Primary Care . According to a study
conducted by the California HealthCare Foundation (CHCF),
California's EDs are increasingly used by individuals whose
health conditions are not true emergencies. CHCF concluded
that patients often believe that they have no alternatives
for treatment and diagnosis when faced with a sudden
illness or accident. The CHCF study further found that key
drivers to ED use include: lack of access to preventive and
immediate healthcare; lack of advice or information about
managing immediate health care needs; lack of alternatives
to the ED for immediate medical needs that occur both
during and after business hours; and, to a lesser extent,
prevalence of attitudes that foster the use of the ED for
non-urgent care.
A report by the California Academy of Family Physicians
(CAFP), estimates that there are too few primary care
physicians to care for the current population, much less to
cover the projected demand for services in the next few
decades. According to CAFP, many new physicians and
medical students choose specialty care over primary care,
in part because primary care physicians are at the low end
of the pay scale for physicians.
c) Hospital Closures . Hospital closures have been cited as
contributing to increased demand and ED crowding at the
remaining facilities. A significant number of hospitals
have closed in California in the last decade. Research and
anecdotal reporting reveal a complex mix of potential
reasons for the growing number of closures. According to
the California Hospital Association from 1996 to 2006,
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almost 80 hospitals closed in California, including 39
emergency departments. Nearly 70% of the closures were
located in Southern California. Approximately 20% were
located in Central and Northern California and the
remaining hospital closures were located in the San
Francisco Bay Area. Of the Southern California closures,
32% (25 hospitals) were closed in Los Angeles County alone.
d) Shifting Demographics . Research also suggests that the
use of ED services will continue to rise due to demographic
factors, such as the increasing age of the population. The
U.S. population is growing and life expectancies are
increasing, leading to more people living longer with
complex and chronic debilitating diseases such as diabetes,
cancer, and renal failure. According to CHCF, research
also shows that adults with chronic conditions are
disproportionately represented among recent ED users.
While 32% of the California adult population suffers from
hypertension, heart disease, diabetes, and/or chronic lung
problems, 44% of recent ED users fit this description.
4)SUPPORT . According to Cal/ACEP, the sponsors of this bill,
California's EDs have become the healthcare safety net and are
the front lines of any public health emergency. Cal/ACEP
maintains that ED overcrowding is no longer simply an
uncomfortable and time consuming endeavor for patients, but
waits can be so long they put the lives of Californians in
peril. According to Cal/ACEP, in addition to being a rapid
and practical solution to measuring the changing conditions in
the ED, this bill provides that each hospital develop an
individualized plan that allows for flexibility in the design
that suits each specific hospital. Cal/ACEP maintains that
this bill is a common-sense approach to improving California's
healthcare system using existing resources.
5)OPPOSITION . The San Bernardino County Board of Supervisors
(SBCBS) is opposed to this bill stating 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
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would impose an unnecessary and unfunded state mandate.
6)PREVIOUS LEGISLATION :
a) AB 911 (Lieu) of 2009 contained the same provisions as
this bill. AB 911 was vetoed by Governor Arnold
Schwarzenegger stating in his veto message his support of
the intent of AB 911 and his belief that its provisions
will not provide any significant improvement to the
underlying problem of ED overcrowding. The Governor's veto
message further encouraged hospitals to develop
full-capacity protocols that best address their individual
needs.
b) 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 National ED
Overcrowding Scale 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 died
in the Assembly Appropriations Committee on the Suspense
File.
REGISTERED SUPPORT / OPPOSITION :
Support
American College of Emergency Physicians, California Chapter
(sponsor)
Opposition
San Bernardino County Board of Supervisors
Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916)
319-2097