BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 2153
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AUTHOR: Lieu
B
AMENDED: As Introduced
HEARING DATE: June 16, 2010
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CONSULTANT:
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Tadeo
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SUBJECT
Emergency room crowding
SUMMARY
Requires, until January 1, 2015, 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, by January 1, 2012,
every licensed general acute care hospital that operates an
ED, to develop and implement full capacity protocols.
Requires the full capacity protocols to be filed with the
Office of Statewide Health Planning and Development.
CHANGES TO EXISTING LAW
Existing law:
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).
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
Continued---
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care, including medical, nursing, surgical, anesthesia,
laboratory, radiology, pharmacy and dietary services.
Permits hospitals to provide emergency medical services,
under specified circumstances.
Establishes the Office of Statewide Health Planning and
Development (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.
This bill:
Requires, until January 1, 2015, 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.
Defines "crowding score" as the score calculated to measure
ED and hospital overcrowding, with an equation, as
specified, using the following variables:
Total number of patients within the ED;
Total number of staffed beds in the ED, not to
exceed the number of licensed beds;
Total number of admissions waiting in the ED,
including patients awaiting transfer;
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;
Total number of patients in the ED admitted to the
intensive care-critical care unit;
The longest admit time, in hours, including
transfers; and,
The wait time for the last patient waiting the
longest in the waiting room, in hours.
Defines "crowding scale" as the range of crowding scores
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that are divided into six categories of which level one
represents the lowest level of crowding and level six
represents the highest.
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.
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 thirty
days, calculating and recording a crowding score a minimum
of every eight hours.
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.
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:
Notification of hospital administrators, nursing
staff, medical staff, and ancillary services of
category changes on the scale;
Hospital operations, including bed utilization,
transfers, elective admissions, discharges, supplies,
and additional staffing;
Emergency department operations, including
diversion, triage, and alternative care sites; and,
Planned response, if the organized medical staff by
the hospital for rounds discharges, coordination with
the ED and emergency consults for ED patients.
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.
FISCAL IMPACT
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According to the Assembly Appropriations Committee analysis
of AB 2153, the fiscal impact of this bill is unknown. The
analysis states that AB 2153 would likely create minor
costs to hospitals to periodically calculate the
overcrowding score and to implement the full capacity
protocol; but that this bill generally describes current
practice and policies for hospital emergency services. The
analysis points out that many busy EDs must assess capacity
and patient flow frequently to determine whether they
should go on diversion, for example, during which
ambulances are redirected to other hospitals.
BACKGROUND AND DISCUSSION
According to the author, California emergency departments
are dangerously overcrowded and have reached a crisis
level, ranking last in the nation in the number of
emergency rooms available to its residents. The author
states that California provides only six emergency rooms
for every one million persons. The author argues that the
common misconception surrounding emergency department
overcrowding links congestion with non-urgent patients and
the uninsured, when the real reason for this congestion is
that hospitals keep patients who need hospitalization in
the emergency room until a hospital bed becomes available,
a practice known as boarding a patient.
The author states that there are reported cases in which
patients have been boarded in hallways or waiting rooms for
up to 24 hours before they are admitted into the inpatient
unit of the hospital. The author further states that, the
use of an overcrowding score known as the NEDOCS score,
similar to the crowding score proposed in this bill, and a
subsequent full capacity protocol plan, at LAC/USC Medical
Center have significantly reduced wait times and patient
boarding. The author contends that this approach would
work on a statewide level, and that AB 2153 does not
require the same full capacity protocol plan for all
hospitals; instead, each facility would come up with a plan
that works for that particular hospital.
The crowding tool proposed in AB 2153 was developed by the
American College of Emergency Physicians, State Chapter of
California (CAL/ACEP), sponsor of the bill, the California
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Hospital Association (CHA), and the California Emergency
Nurses Association. According to CHA, the three
organizations hosted an online forum in April to educate
hospitals about the use of this innovative tool and to seek
their participation in a three-month pilot to evaluate its
efficacy. CHA will be evaluating results of the pilot to
identify if this tool can assist hospitals in objectively
determining the amount of ED crowding and assist in the
development of full capacity protocols.
A 2003 U.S. General Accounting Office analysis of emergency
department overcrowding (GAO report), reported that
overcrowding is a problem that has reached historic levels
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 emergency departments
saturate because of patients waiting for beds and nurses to
become available on inpatient units, emergency waiting
rooms become overcrowded, wait times increase, and there is
a greater risk for poor health outcomes. According to the
GAO report, this leads to temporary closure of crowded
emergency departments to inbound ambulance traffic, a
process known as diversion, which increases travel time as
ambulance drivers seek other hospitals to which they can
transport their patients.
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 emergency departments 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 emergency departments 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. The IOM report called for the strengthening of
The Joint Commission standards that address emergency
department overcrowding, boarding, and diversion.
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According to information posted on the American Academy of
Emergency Medicine website, the Joint Commission issued an
important guideline on emergency department overcrowding,
in 2004. The website 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 in an
inpatient unit.
Prior legislation
AB 911 (Lieu) of 2009 contained provisions identical to
those contained in this bill and 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.
AB 2207 (Lieu) of 2008 would have required hospitals to
assess the condition of an emergency room via the 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. This bill was held in the Assembly
Appropriations Committee.
Arguments in support
The American College of Emergency Physicians, California
State Chapter (CAL/ACEP), sponsor of this bill states that
AB 2153 provides an opportunity to relieve ED overcrowding
that is simple, has a proven, successful track record, and
doesn't require additional funding from the state or
hospitals. CAL/ACEP notes that LA County/USC hospital,
with the largest ED in the state, implemented this approach
at no additional cost and experienced a dramatic reduction
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in ED overcrowding.
Arguments in opposition
According to the Department of Public Health (DPH), there
is currently no evidence that using the crowding score
prescribed in this bill is effective or that it would
address the causative factors of ED overcrowding. DPH
states that the scoring system would not necessarily
prevent ED overcrowding, and would take providers away from
patient care, further prolonging wait times. DPH notes
that Governor Schwarzenegger vetoed AB 911 in 2009, which
is identical to AB 2153.
The San Bernardino County Board of Supervisors (SBCBS)
states 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
would impose an unnecessary and unfunded state mandate.
PRIOR ACTIONS
Assembly Health Committee 18-1
Assembly Appropriations Committee17-0
Assembly Floor 68-2
POSITIONS
Support: American College of Emergency Physicians,
California State Chapter
(sponsor)
California Medical Association
California Ambulance Association
Oppose: Department of Public Health
San Bernardino County Board of Supervisors
San Joaquin County Health Care Services
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