In Riverside County and across the state, ambulances that have transported patients to hospitals are not zipping off to help others in need. Instead, they are being delayed at those same hospitals, sometimes for up to six hours.
In areas with the worst delays, emergency response systems can be nearly paralyzed, straining the capacity of first responders, officials said.
“The problem is when ambulances are held for long periods of time, they are not available to run 911 calls,” said Bruce Barton, Emergency Medical Services Agency director for Riverside County. Barton, who serves on a statewide task force studying the issue, said Riverside is not the only area in California dealing with the issue. “There are many counties that are right now struggling with this phenomenon.”
Howard Backer, director of the California Emergency Medical Services Authority, said that of the 33 EMS agencies statewide, 13 have reported problems with ambulance wait times. Those 13 agencies serve 70% of the state’s population, he said. Counties grappling with the issue include Los Angeles, San Bernardino, Riverside, Kern and Santa Clara, Barton said. In January, Fresno County Emergency Medical Services filed a complaint with the California Department of Public Health Licensing and Certification Program when nine ambulances were delayed at Community Regional Medical Center.
Wait times are defined as the time it takes to transfer a patient from the oversight of ambulance paramedics to a hospital’s emergency department. In Riverside County, hospitals are expected to be able to take on a patient in 30 minutes, a national standard. After 30 minutes, the EMS agency starts tracking the delay. The half hour target is a goal, not a deadline. In California there are no penalties for delays.
Three hospitals in Riverside County stand out for the worst wait times. Riverside Community Hospital, Parkview Community Hospital Medical Center and Corona Regional Medical Center have average wait times of more than one hour, according to county data. Eisenhower Medical Center in Rancho Mirage has the shortest wait time at 37 minutes. In January, Riverside Community Hospital also led the county with the most delays, 1,503.
“To us, this is blatant cost shifting from the hospitals to the EMS agencies,” Backer said. “This is something the hospitals need to staff for and deal with through their own procedures and protocols. And some consistently do not meet the standards.”
Riverside County officials began to notice that ambulance wait times were becoming a problem in highly populated areas in 2007, which coincided with the economic downturn as more people sought care in EDs.
“Some hospitals have dealt with it just fine or they have found a way to minimize it,” Barton said. “Others are just terrible about letting our ambulances go. It’s not all the hospitals. It’s a few that struggle with this.”
Barton said there have been occasions when 15 to 16 ambulances have been delayed at one time at Riverside Community Hospital.
The county EMS agency monitors how long ambulances are being delayed and will sometimes call hospitals to ask them to let the ambulances go. Sometimes a hospital will expedite a release, other times it won’t, Barton said.
Officials from hospitals and EMS agencies agreed that the issue is a symptom of ED overcrowding. According to the latest data available, in 2011 there were 588,000 patient visits to EDs in the county, Barton said. Of those, 150,000 were ambulance transports through the EMS system.
“This is not a uniform problem,” Backer said. “It is primarily a problem of more populous counties and hospitals that are very busy.”
Backer and Barton collaborated on a report aimed at reducing ambulance off-loading patient delays delivered at the California Hospital Association’s 8th Annual Behavioral Health Care Symposium last December in Huntington Beach.
Problem Called a ‘Throughput’ Issue
Hospital officials said long ambulance wait times are often the result of “throughput issues” — a term used in the computer industry roughly meaning the amount of work a system can accommodate in a given time frame. To address the problem, hospitals can streamline processes, including how quickly they can make beds available to patients and patterns related to discharging patients. Barton said hospitals with internal reporting mechanisms for throughput typically don’t have a problem with ambulance wait times.
The main cause in delays has to do with the hospital’s ability to assign a patient a bed, experts said. If beds are not available in an emergency department or on other floors, a hospital cannot meet demand, causing delays in transferring, admitting and treating patients, officials said.
“It has to come from the highest executive level of the hospitals to look at systemwide changes to move patients through their emergency department and hospital more efficiently,” Backer said. “In some cases there is no incentive for them to go through the trouble and make the major system change.”
Riverside County Regional Medical Center has made strides to bring its wait times down, as have Rancho Springs Medical Center and Inland Valley Medical Center, all in highly populated areas of the county, Barton said.
Riverside County Regional Medical Center set a 10-minute goal to offload patients.
“Our staff does everything they can to make sure it happens,” said Keven Porter, Riverside Regional Medical Center ED manager. “We understand (the ambulance’s) need to get back out into the community.”
In recent years, the hospital has witnessed a surge in patients seeking treatment in the ED. In 2003, Riverside RMC’s emergency department treated approximately 68,000 patients. By 2012, that number had risen to 105,000 patients.
“Emergency room overcrowding is a symptom of other problems,” said Kim Baumgarten, the hospital’s assistant nurse administrator, referring to issues with access to primary care, hospital throughput and hospital priorities.
Like Backer, she pointed out that ambulance delays can reflect a leadership issue. “It needs to be the CEO saying this is our priority,” she said
Barton stressed that it’s important for hospitals that improve their wait times to be consistent, because wait times can slip. Hemet Valley Medical Center worked with the county EMS agency to bring down wait times, but then the hospital’s numbers started going up again, until they were the highest in the county for December 2013 and January 2014, Barton said.
“Sometimes when it gets better, you lose focus,” he said. “We look for incremental improvement and are they willing to work with us?”
Emergency Department Capacity Part of Problem
Steve Popkin, CEO of Parkview Community Hospital in Riverside, which has one of the highest wait times in the county, said ED capacity has contributed to the problem. The hospital is located in the most populous city in the county but has only 13 inpatient beds and receives 46,000 emergency visits per year.
The hospital has a patient flow team that tracks indicators and makes adjustments, but ultimately it comes down to capacity, he said. The hospital is planning to expand the ED by adding 28 beds.
“That will make a huge impact on reducing wait times,” he said.
Mark Uffer, CEO of Corona Regional Medical Center, which also has long wait times, said that the county EMS agency needs to look at more than just wait times because hospitals in the county are dealing with more ambulance visits than in the past. The number of ambulance transports has risen by 27% since 2009 in the county, he said.
“You have flu season hitting. You have nursing shortages,” he said. “Hospitals are filled to capacity in many cases, and the population uses the emergency room for sources of primary care.”
The Corona Regional Medical Center handles 45,000 ED visits per year, he said. The hospital is looking at how to improve workflow in the ED by adding more physicians, nurse practitioners and physician assistants.
“It’s not just Corona. It’s every hospital in the region,” Uffer said. “We all have a throughput problem.”
Searching for Solutions
One of the issues contributing to ambulance wait times is accountability, EMS officials said. There are no repercussions for hospitals that hold ambulances for longer than 30 minutes. Paramedics cannot leave a patient at a hospital until he or she has been admitted to an ED and a final report has been filed.
“We are responsible for the EMS system, but our authority only reaches so far,” Barton said.
In Riverside County, the EMS agency keeps an eye on the ambulances that are stuck at hospitals. If an ambulance is delayed, a dispatcher will call the hospital or if the situation is extreme, the duty officer may respond on scene to a delay. The agency sends letters to hospitals and calls to follow up, Barton said.
The state EMSA and the California Hospital Association have formed a task force to study the issue and offer solutions, Backer said.
One potential solution could be allowing paramedics to match resources in the medical system with a patient’s actual medical need. For example, instead of taking a patient whose symptoms are not acute to an ED, the ambulance could transport the patient to a primary care clinic, Barton said.
In Las Vegas, which like the Inland Empire experienced rapid growth over the past couple decades, long waits at hospitals were becoming a problem. In 2005, the Nevada Legislature passed a law requiring hospitals to transfer patients from EMS to hospital care within 30 minutes. Rather than fining the hospitals, the legislation mandated tracking the issue and addressing what was causing the delays.
Uffer, the CEO of Corona Regional Medical Center, argued against setting a time limit for offloading patients.
“You can’t set a goal that’s probably not achievable,” he said. “If you don’t have the resources — the additional personnel, the doctors, the beds to put the patients — then you’re taking a situation and making it worse.”