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Hospitals Under Stress

Fellowship Story Showcase

Hospitals Under Stress

Picture of Melissa  Evans

Melissa Evans examines the extent of Southern California's hospital backup and emergency room overcrowding.

The Daily Breeze
Tuesday, December 23, 2008

A woman seated near the reception desk stares blankly at the wall, quietly weeping. She's been here more than six hours, she says, waiting to see a doctor for pain in her abdomen.

Another woman in the corner sits beside a ball of blankets and sheets, her eyes shut. Two children snack on Cheetos and play with toy trucks on the floor. Others are slumped beside each other in rows of chairs, reading books or newspapers or staring at soap operas on television.

Asked how long he'd been waiting, Armando Reyes, of Wilmington, paused, slowly removed his glasses and rubbed his face.

"It's going on four, five hours," he said. "I don't know what they're doing back there."

The front entrance to the region's busiest emergency room is guarded by metal detectors, and the line to get in sometimes stretches into the parking lot.

It's not a Friday night, or even the peak of flu season. It's a normal weekday afternoon at County Harbor-UCLA Medical Center near Torrance, a facility that treats some of the county's poorest and sickest patients.

Depending on the severity of the injury, the average wait here is about eight hours, the result of an overburdened hospital network with capacity stretched thin. Hospital capacity

The recent domino effect of hospital closures and bed reductions - four have closed in the South Bay, 10 emergency rooms in the county have shut down and at least two other hospitals have reduced bed capacity - has left many worried that the increasingly fragile network won't be able to cope with an event resulting in mass injury, such as a natural disaster, terrorist attack, freeway pile- up, pandemic flu or plane crash.

"If Southern California's hospitals can't handle patient inflow even during the course of a normal day, I have grave doubts about how the region would do in a disaster scenario," said Jim Lott, executive director of the Hospital Association of Southern California, a trade group. "Any increase in demand would stretch the system beyond what it could handle."

Los Angeles County as a whole has a meager 1,500 excess beds on any given day, according to a 2007 study by PriceWaterhouseCoopers, a consulting firm.

More than half of all hospitals are on diversion - meaning they turn away ambulances due to crowding - at least 20 percent of the time. The numbers are worse for highly skilled facilities: Three- quarters of teaching hospitals such as Harbor-UCLA are either at or over capacity in their emergency department at any given time, according to the 2007 study.

Harbor-UCLA, on Carson Street in an unincorporated area between Harbor Gateway and Carson, is bursting at the seams.

A survey by the Department of Health Services, which runs the hospital, from January to May of this year showed that when the hospital is operating at optimum capacity, even a slight patient surge of 5 percent pushed wait times over 14 hours.

State inspectors cited and fined the hospital twice this year for lapses in care; one incident was directly due to emergency room crowding.

Given the South Bay's proximity to the ports and Los Angeles International Airport, both susceptible targets for disaster, the region's dearth of medical infrastructure has become a politically volatile issue. King-Harbor closure

Los Angeles County Supervisor Mark Ridley-Thomas, who represents Hawthorne, Gardena, Lawndale, Carson and parts of Los Angeles, won election to the board this fall in part on a promise to reopen the beleaguered Martin Luther King Jr.-Harbor Hospital in Willowbrook, which closed its inpatient services in August 2007 because of repeated and highly publicized lapses in care.

"I don't believe the lie that it can't be (reopened)," said Ridley-Thomas, who gave up his seat in the state Senate for his current position. "It can and it must be done."

Opened after the Watts riots in 1965, the hospital once had 537 beds, a trauma unit and a busy emergency room. At the time it closed, the facility was down to 48 beds and had already shut down its trauma care for the most severely injured patients.

Lott notes that the closure of King-Harbor was mostly symbolic; its gradual closure over the years was far more painful. It left a gaping void of health care in the poorest area of Los Angeles.

Over the years, King-Harbor's roughly 50,000 annual emergency room visits have been absorbed by other county facilities, including Harbor-UCLA and Los Angeles County-USC Medical Center downtown (which lost a quarter of its inpatient capacity this fall when it moved to a smaller facility).

Over the past 18 months, the trauma unit at Harbor-UCLA has seen a 54percent increase in patients. Nearby cities, particularly those in southwest Los Angeles County, also felt the pain.

"This has big implications for all of us," Inglewood Councilman Daniel Tabor said regarding the closure of King-Harbor. "This is a regional crisis." Financial woes

The county Department of Health, itself facing a $93million deficit this fiscal year, secured emergency funding from the state to help nine private hospitals in Long Beach, Los Angeles and parts of the South Bay cope with the overflow. Some of these hospitals, however, were already on the brink of bankruptcy.

"It was to the point where it was getting tough to pay our bills," said Von Crockett, chief executive officer of Centinela Hospital Medical Center in Inglewood, which saw about a 15 percent increase in emergency room visits, mostly from patients without insurance. "The day of reckoning was coming."

Centinela, which averted probable closure after being bought by a larger company, is another critical link in the county system. It is the only facility near LAX, serving Inglewood, Hawthorne, Gardena and Lawndale.

Daniel Freeman Memorial Hospital on Prairie Avenue in Inglewood closed its emergency room, and later its inpatient hospital, shortly after the fall of King-Harbor in 2007. Memorial Hospital of Gardena, a small facility on Redondo Beach Boulevard, scaled back its emergency services to about six beds.

Robert F. Kennedy Medical Center in Hawthorne closed in 2004.

"If something happens at the airport, we're it," Crockett said. "They come here."

The Torrance area is better off. Private hospitals such as Little Company of Mary, Torrance Memorial Medical Center and Kaiser Permanente South Bay Medical Center in nearby Harbor City are doing relatively well financially. Bed shortages

But even in the affluent beach cities, where more patients tend to have private insurance and fundraising dollars are more plentiful, the bed shortage has become a pressing concern.

"It requires constant vigilance," said Judy Retter, coordinator of disaster preparedness at Torrance Memorial. "You're constantly opening beds as you can, making sure to use resources efficiently. This is all done on a day-to-day basis."

The Lomita Boulevard facility is planning to construct a seven- story medical tower initially conceived to satisfy strict new seismic standards. The hospital had planned to open the 370,000- square-foot facility in phases, but as the bed shortage becomes more acute, hospital officials now plan to open it all at once in 2014 because they need the capacity. Metrolink crash

A significant test of the county's ability to handle a patient surge came on Sept. 12, when a Metrolink train slammed into an oncoming freight train in the Chatsworth area of the San Fernando Valley.

Despite the bed shortages, health officials say the region passed the test.

The most seriously injured patients were airlifted to trauma centers at Cedars-Sinai Medical Center, Harbor-UCLA and County-USC. About 150 other victims were organized by the severity of injury, and taken by ambulance to the four closest emergency rooms.

Medical personnel came to work on their day off. Nurses worked overtime. Surgeons called in from home.

Twenty-five people died in the crash, but the outcome could have been far worse, officials say.

"In a short-term surge like that, something like the train derailment, we have the ability to move patients," said Cathy Chidester, director of the county's emergency medical services agency. "We can bring in staff. We are able to expand our capacity for the immediate need." Working together

In the wake of the Sept. 11 terrorist attacks, the federal government has funneled millions of dollars to local agencies, including hospitals, to prepare for a wide range of disasters. Last year alone, California received $143.2million; about $12 million of that went to help Los Angeles County hospitals stockpile supplies, including pharmaceuticals, and train personnel.

One of the positive outcomes is that over the past five years, communication among hospitals, city and county fire departments, law enforcement and even municipal governments has vastly improved, many say.

County hospitals are now organized into 13 "disaster regions." Each hospital has hired a designated disaster preparedness planner, and they all meet every other month.

"It's one of those areas where hospitals are eager to work together," said Torrance Memorial's Retter.

If disaster strikes, hospitals immediately report their capacity levels to Chidester's agency, which directs ambulances and shuffles patients accordingly. Depending on the size and reach of the disaster, schools, community centers, churches and other facilities may be used to house patients, and closed medical facilities could be opened.

"I think we all realize that, given our resources, we absolutely have to be prepared," said Claudia Marroquin-

Frometa, disaster planner at Centinela, which recently staged a large, multi-agency drill.

Most hospitals now have enough enough food and water, along with generators, portable ventilators and other equipment, to run for three full days without outside resources.

And, with the infrastructure and cooperation in the city of Torrance, "we could easily double bed capacity if need be," said Chris Riccardi, disaster preparedness planner at Little Company of Mary. "I think we're very fortunate here." Disaster preparation

In a large disaster, such as an earthquake or terrorist attack, normal rules for care - nurse-to-patient ratios, for example - go out the door, said Dr. Roger Lewis, an ER physician at Harbor-UCLA and professor in the Department of Emergency Medicine.

"When you're talking about hundreds of victims, you're operating with a different mind-set," the physician said.

But it may be the smaller, longer-lasting disasters, such as a bad flu season, that cause more hardship for patients and medical personnel, said Lewis, who has written extensively about surge capacity.

"Surge is not just about a shortage of physical beds," he said. "You're also talking about a shortage of staff needed to fill those beds."

Chidester agreed that it would be difficult to handle a lingering surge.

"You can only operate that way for so long," she said. "Staff get sick and resources wear out."

Last spring, Lewis testified before the U.S. House of Representatives Committee on Oversight and Government Reform about the critical bed shortages in Los Angeles County.

He told lawmakers it was "irrational" to think that the county's emergency care system, already overwhelmed by the day-to-day volume of acutely ill patients, could expand its capacity on short notice in response to a terrorist attack or natural disaster.

He cited a 2006 study by the Institute of Medicine, which released a three-volume report on emergency preparedness, concluding that trauma and emergency care in the United States are at the "breaking point."

In spite of all the research, it's tough to make a case for something most people don't see, or for disasters that haven't happened, he and others say.

Once the memory of disaster fades, securing money for preparedness falls behind other priorities, especially in a time of economic decline, said Amy Kaji, a researcher, physician and medical director of the South Bay Disaster Resource Center.

"We're a lot more prepared than we were five years ago, especially in the area of supplies," she said. "But there's a lot more to be done."

Most agree that the biggest need is more physical hospital beds. There are about two beds per 1,000 residents in Los Angeles County; the national average is 3.4.

Lawmakers tend to believe that in an emergency, hospitals can simply move healthier people out, Lewis said. But as insurance companies clamp down on costs, the hospital population has become much sicker than it used to be, he said.

"Not only are we at capacity, but the people in the hospital really need to be in the hospital," he said.

Kaji and Lewis added that one of the reasons for the emergency room crunch is that there's nowhere to admit these patients if they need hospitalization. These patients are "boarded" in the emergency rooms, sometimes in hallways, often for hours. Hopes for King- Harbor

Ridley-Thomas and others are pushing public-private partnerships to reopen King-Harbor, and hope to improve the clinic and urgent care network so fewer people need emergency care, and more beds are available in a disaster.

For many residents across the county, the "disaster" in many ways has already arrived.

Those without health insurance - nearly a quarter of residents in Los Angeles - have to literally camp out for care, usually in urgent care or emergency departments.

The county's waiting list for elective procedures, which can prevent emergencies, is over a year. Most forgo preventative care completely.

After lingering in the emergency room at Harbor-UCLA for nearly five hours, Reyes, the patient from Wilmington, ended up leaving.

"It'll have to wait," he said. "I got to go to work. Maybe I'll come back over the weekend, I don't know."