The State of San Diego’s Emergency Departments: EMOC’s Annual San Diego County Emergency Department Survey
EMOC is the Emergency Medicine Oversight Commission, a commission of the San Diego County Medical Society (SDCMS). Members of the commission include emergency physicians, nurses, paramedics, county EMS officials, and San Diego’s hospital association. Each year EMOC sponsors the San Diego County Overcrowding Summit, bringing together physicians, nurses, administrators, San Diego and California healthcare leaders and guest speakers in order to improve emergency care in San Diego. In preparation for the conference, an annual survey is obtained from all 19 emergency departments with 100 percent participation over the past five years. Some of the data shared are sensitive and competitive and therefore presented in a blinded fashion. Hospitals that gave the data know how they rank among their colleagues. Below are some interesting findings from the 2010 data. Complete survey results are available in PowerPoint format on the EMOC website, which can be found by searching “EMOC” at SDCMS.org.
How busy are San Diego’s emergency departments?
Kaiser Hospital remains the highest-volume emergency department in the county, followed by Sharp Grossmont. Fallbrook and Sharp Coronado are the smaller emergency departments. In the past year, San Diego’s emergency department experienced a 3 percent increase in volume with 12 hospitals seeing an increase in patients.
Hospital Monthly Volume June 2009–June 2010:
- Fallbrook Hospital: 920
- Sharp Coronado Hospital: 1,097
- UCSD Medical Center, Thornton Hospital: 1,921
- Alvarado Hospital Medical Center: 2,243
- Pomerado Hospital: 2,366
- Scripps Memorial Hospital, La Jolla: 2,592
- Paradise Valley Hospital: 2,950
- UCSD Medical Center, Hillcrest: 3,092
- Scripps Memorial Hospital, Encinitas: 3,093
- Scripps Mercy Hospital, Chula Vista: 3,526
- Sharp Chula Vista Medical Center: 4,505
- Scripps Mercy Hospital: 4,592
- Sharp Memorial Hospital: 4,900
- Navy Medical Center San Diego: 4,964
- Palomar Medical Center: 5,512
- Rady Children’s Hospital, San Diego: 5,742
- Tri-City Medical Center: 6,025
- Sharp Grossmont Hospital: 7,790
- San Diego Medical Center, Kaiser Foundation Hospital: 8,250
How impacted are our emergency departments?
Volume alone is not an adequate measure of how impacted an emergency department is. National standards have established guidelines that state emergency departments should not exceed 1,600 visits per emergency bed. Using this guideline, an impact factor was calculated using each emergency department’s reported monthly visits and its official bed capacity.
Hospital Emergency Department Impact: Annual Visits/Beds:
- Scripps Mercy Hospital, Chula Vista: 769
- San Diego Medical Center, Kaiser Foundation Hospital: 1,151
- Sharp Memorial Hospital: 1,225
- Scripps Mercy Hospital: 1,252
- Sharp Grossmont Hospital: 1,395
- Fallbrook Hospital: 1,380
- Pomerado Hospital: 1,494
- UCSD Medical Center, Thornton Hospital: 1,537
- Tri-City Medical Center: 1,538
- UCSD Medical Center, Hillcrest: 1,546
- National Average: 1,600
- Sharp Coronado Hospital: 1,646
- Scripps Memorial Hospital, Encinitas: 1,687
- Rady Children’s Hospital, San Diego: 1,813
- Scripps Memorial Hospital, La Jolla: 1,830
- Paradise Valley Hospital: 1,863
- Alvarado Hospital Medical Center: 2,079
- Palomar Medical Center: 2,281
- Navy Medical Center San Diego: 2,291
- Sharp Chula Vista Medical Center: 2,703
Are emergency departments with higher uninsured patients more crowded than other emergency departments?
No. There is no correlation with payer mix and how impacted our emergency departments are in terms of emergency department visits per emergency department beds. Self-pay is a term used for uninsured patients. In San Diego the range of uninsured emergency department patients is 0–38 percent. The San Diego average is 16.2 percent. According to the 2009 U.S. census, 16.7 percent of the country’s population is uninsured.
How many patients get tired of the waiting room and leave the emergency department before seeing a doctor?
One measurement of emergency crowding is LWOT, left without treatment, which measures how many patients get tired of waiting and simply leave before seeing a doctor or getting treatment. It has been stated that when an emergency department’s LWOT percentage is very high, the safety net for patient care access is broken.
In San Diego the percentage of LWOT ranged from 0.38 percent to 6 percent with a median of 2 percent. The national average is 1.9 percent, so San Diego meets the standard. Over the years the LWOT statistic for the county has improved, going down from 3 percent to 2 percent and with a high of 8 percent to 6 percent.
It should be stated that there is no correlation for hospitals that are impacted in terms of emergency department visits/bed and other emergency department throughput efficiency measures such as LWOT and other throughput measures. Hospitals can have high efficiency standards despite inadequate emergency department beds.
How long do you have to wait to get care in San Diego’s emergency departments?
Length of stay (LOS) for those who need admission is generally longer for patients who get discharged. LOS is the ultimate measure of emergency department efficiency since this is what the patient experiences.
Patients who require admission wait an average of 5.5 hours in the emergency department before they get a bed upstairs. The time in the emergency department is an average of 3.5 hours for patients who get discharged. In the past four years, the LOS of admission for admitted patients has improved by an average of one hour. The LOS for discharged patients has remained stable and represents an acceptable range.
Do emergency departments that have sicker patients have longer waits?
No. There is no correlation with acuity and LOS. The measure used for patient acuity is percentage of admission, so emergency departments that admit more patients presumably have sicker patients. The national average for admitted patients from the emergency departments is 11.7 percent. San Diego has a much higher percentage of admitted patients at 18.9 percent, and, therefore, our emergency department patients are sicker than the national average.
Why do patients have to wait so long?
The higher number of LOS for admitted patients correlated with problems with inpatient bed availability. Inpatient bed availability and boarding of inpatients in the emergency department remains a bottleneck for many hospitals. The correlation for LOS in discharged patients is different for each institution. Psychiatric patients tend to have the longest length of stays. The range in different hospitals does not correlate with their total volume of patients.
It is not the sore-throat patient that is causing emergency department overcrowding.
It is a common misconception that the emergency departments are full of patients who are not sick and should be treated elsewhere. The Abaris Group published data on San Diego’s safety net as well as data from the California Emergency Department Diversion study. This showed that San Diego’s population is one of the lowest emergency department users of any place in California and one of the lowest in the United States. It is assumed that this low utilization is due to the heavy managed care market and a relatively high availability of clinics.
The San Diego emergency department throughput data demonstrated that it is not the discharged patients who are bottlenecking the system, but the patients who require admission. When patients wait for admission for hours in the emergency department, it takes away valuable emergency department bedtime that could be used for treating additional patients from the waiting room, not to mention the fact that the admitted patients are not getting the level of care they would be as inpatients. The sore-throat patient may be crowding the waiting room, but is not crowding the emergency department beds.
Patient boarding in the emergency department is a problem that is debated heavily. It is measured differently at our hospitals. One measurement used by the American College of Emergency Physicians is patients who remain in the emergency department for two hours after an inpatient bed has been ordered. This data is available from 12 out of 19 emergency departments. Of these, seven hospitals have over 70 percent of admitted patients routinely remain in the emergency department waiting for a bed.
How has emergency department patient throughput changed in the past year?
The emergency departments were asked to compare their overall throughput over the past year. The results show that nine emergency departments have improved throughput, one declined, and nine stayed the same.
What are the on-call physician issues in San Diego?
The on-call physician shortage has been a topic of healthcare debate over the years. San Diego has experienced fewer on-call issues than other areas because of our well-established trauma system. All area emergency departments know that they can call any trauma center, and they have an entire panel of on-call specialists. EMTALA law mandates that a request for transfer must be accepted if a higher level of care is available.
Each year the emergency departments are surveyed on their on-call shortages. This year 10 out of 19 emergency departments stated that they had no on-call issues. This is a major shift compared to 2007 when all but three emergency departments experienced some form of on-call physician deficiency. The biggest on-call problem for 2010 is ENT, with five emergency departments reporting problems in coverage.
Where do we stand in diversion of ambulance patients?
EMOC helped spearhead San Diego’s ambulance bypass guidelines. These guidelines have two rules. One, that patient requests to a particular hospital should be honored within safety measures; and two, that hospitals remain on bypass for only one hour and then come off to accept one more ambulance patient before they go on diversion again. Hospitals have agreed to take their own requested patients even if they are on bypass.
The paramedics are trained to honor patient requests for a specific emergency department when possible. This may not correlate with where the patient’s insurance, hospital, or physicians are, but what the patient requests.
Safety measures for this guideline follow county policies. Trauma patients do not get to choose their hospital. Acute-care patients with impending respiratory or cardiopulmonary compromise will be taken to the closest emergency department. A transport of longer than 30 minutes is not within 911 guidelines. A patient with an ST elevation MI diagnosed in the field will be taken to one of San Diego’s STEMI receiving centers.
In 2010, San Diego had the lowest rate of ambulance bypass of any other year. We also had a minimum number of patients bypassed who request a specific facility. Bypass data collected by San Diego County Emergency Medical Services is shared with the hospitals on a monthly basis and methods of improvements are discussed on a regular basis.
Side Effects of the Emergency Department Survey
The annual emergency department survey takes much cooperation, trust, and effort to collect, but has resulted in an unprecedented collaboration and education between our various emergency department and hospitals. Guests at the Annual San Diego Overcrowding Summit comment on the amazing degree of information exchange that occurs in our competitive healthcare environment. The conference includes panels with emergency department directors and hospital CEOs that exchange ideas. One year a hospital mentioned faxing nursing reports for admission instead of waiting on the phone for verbal reports, and now seven hospitals are doing the same. We have shown changes in clinical treatment such as TIA and hypothermia over the years by bringing to the surface different standards of care. In 2010 methods of financial incentives for improved patient flow and alternative triage models were discussed. We should all be proud to live in a community where such cooperation and collaboration exists in improving emergency care.