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California Legislation

Emergency Nurses Association

American Nurses Association

By Diane Sussman
May 25, 2000
Photo: Dan Foscalina

Ambulances turned away, daylong waits and patients packed in hallways. Increasingly, this is the scene in California’s emergency rooms – the ones that are still open, that is.

Although by no means alone in the trend, California leads the nation in shuttered ERs. In the past 10 years, the number of ERs in the state has dropped from 5,000 to 4,600. In the past 20 years, Los Angeles County saw 20 percent of its ERs disappear. According to the National Health Foundation, unless dramatic action is taken, Los Angeles County will face a serious shortage of emergency regions in all areas except the Westside by 2005.

Bad for patients

The exodus has left the state’s remaining ERs to deal with more and sicker patients, which in turn produces overcrowding and longer waits. According to a January study in the Annals of Emergency Medicine, stressed-out ERs foster a variety of ills, including decreased staff productivity, increased staff frustration and ambulance diversion, putting patients at risk for poorer outcomes, patient dissatisfaction, and prolonged pain and suffering for some patients,

This is not news to health officials in Orange County, which experienced record numbers of ambulance diversions during last year’s flu season.

"When you have a situation like a flu epidemic and a larger volume of patients, the system backs up. It’s hard to work under these conditions. It’s hard on the nurses, the physicians, the patients and families," said Cece Waite, RN, director of emergency services for Orange County.

Then there are the horror stories, all reported by the media:

• A 7-year-old boy who died of spinal meningitis last year after waiting for hours in a crowded waiting room at Kaiser Walnut Creek.
• A 39-year-old woman who died in an ambulance after spending six hours in a standby ER in Richmond.
• An 84-year-old man with shortness of breath who died after waiting four hours for care.

Nationwide concern

The problem is by no means confined to California.

"There are ERs closing all over the country," Benjamin Marett, MSN, RN, president of the Emergency Nurses Association, said. "We have 23,000 members and this is what they’re talking about."

In their Annals of Emergency Medicine study, authors Robert Derlet, MD, and John Richards, MD, of the University of California, Davis, Medical Center, warned: "Unless the problem is solved in the near future, the general public may no longer be able to rely on emergency departments for quality and timely emergency care, placing the safety of the people of this country at risk."

In laying blame, officials point in several directions: to increasing numbers of non-emergency patients who use the ER as a clinic, more Americans without health insurance who have nowhere else to go, and people who turn to ERs out of frustration with managed care programs that deny them ready access to physicians and nurse practitioners when symptoms are easiest to treat.

"It’s not just an ER problem, it’s also a hospital problem," Waite said. "Populations go up and hospitals close. The hospitals that remain don’t have the beds or the staff."

On top of that, there is the nursing shortage, which makes it more difficult to find staff, and looming retrofitting costs, which could force many of the state’s poorer hospitals to close, she added.

Seeking remedies

To forestall more closings, California is considering legislation that would require emergency rooms to get county approval before they can close or downgrade their status to standby levels, a status that was supposed to be reserved for rural hospitals with a shortage of doctors and personnel. The bill, AB 421, was introduced by Assemblywoman Dion Aroner, D-Oakland, and has reached the Senate Health and Human Services Committee.

The California branch of the American Nurses Association (ANA/C) supports the bill – with reservations.

"It’s better than nothing," ANA/C spokeswoman Tricia Hunter said. "But you’re not going to solve anything until you start dealing with outpatient rates. As long as outpatient rates are below cost, it will be impossible for hospitals to have an aggressive emergency program."

The situation also is causing problems for nurses’ careers. "Hospitals are consolidating or closing, and what that does is force nurses to work someplace they didn’t choose to work. It’s forcing them to look elsewhere," Marett said.

The time may have come for a serious look at staffing ratios in the ER, he said, as well as the nursing shortage, hospital policies and improving coordination with local and state emergency services agencies.

"If you’ve ever been in an ER, you know it’s not a place you want to hold someone for very long," Marett said. "We need to start getting states to work on this."