Hospitals counter ER crowding with 'bed czars' and 'zoomer nurses'
Emergency rooms have seen a significant increase in the number of patients in the wake of the Affordable Care Act, with emergency departments reporting 104,000 more patients in 2015 than in 2013. In San Diego County, there were 846,308 ER visits in 2011, and 1,013,372 in 2015, and it has had to counteract the influx of patients by creating job roles that address the key issues that affect ER capacity. Sharp Grossmont Hospital in La Mesa has created the role of “bed czar”, monitoring patient discharges from the hospital and ensuring that ER patients who need to be admitted for an overnight stay get to a bed quickly, creating less pressure on the ER. The Tri-City emergency department has created a “vertical treatment unit” to keep minor issue patients in ER chairs rather than beds, and also has plans to create a “zoomer nurse” position. 

Emergency rooms across San Diego County treated a total of more than 1 million patients in 2015 — a record high — and experts said the demand so far this year has not let up.

Figures from the Hospital Association of San Diego and Imperial Counties show that local ER departments saw 20 percent more patients last year than they did in 2011, straining the capacity of a system that was already pinched in some communities.

The ER caseload has been growing for years, but the Affordable Care Act, which mandated health coverage for most Americans starting in 2014, seems to have accelerated that growth. Emergency departments reported nearly 104,000 more patients last year than they did in 2013.

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This influx has clogged many local waiting rooms and significantly increased the number of hours that the busiest locations must close themselves to ambulance traffic because all of their beds are full.

In the spring, the county and a coalition of hospitals across the region urged the public to use lower-level medical resources — from preventive care at a clinic to treatment at an urgent-care facility — if they have minor problems. But Dimitrios Alexiou, the hospital association’s president, said the crowding issue has not abated and is consistently a source of concern for hospitals, which are required by law to take all comers.

“The issue is on folks’ minds for sure. You hear a lot more about the situation today than you would have five years ago. The emergency departments have become the epicenter of a lot of different needs, and the solutions are going to require more than just hospitals,” Alexiou said.

Emergency room visits in San Diego County

2011: 846,308

2012: 876,205

2013: 909,757

2014: 965,256

2015: 1,013,372

Source: Hospital Association of San Diego and Imperial Counties

That said, some hospitals have recently taken considerable action focused on breaking bottlenecks in their emergency rooms. They are investing in new operational methods, technologies and personnel to help them become more efficient.

Meanwhile, the county’s health department is stepping up funding for dedicated treatment of psychiatric patients, who are putting increasing strain on hospitals’ emergency services.

Some of the most extensive efforts are taking place at Sharp Grossmont Hospital in La Mesa and Tri-City Medical Center in Oceanside, which operate two of the busiest emergency departments in the region. Both have made recent moves that they said are starting to shrink wait times and free up bed space.

At Grossmont, chief executive Scott Evans has spent the past year working to increase the throughput of an ER that sees more than 100,000 patients per year. State data shows that last year, Grossmont had 3,267 hours of ambulance diversion, a nearly 200 percent increase over the figure in 2011. But this year, the number has dropped to nearly zero because Sharp has concentrated on central factors that influence the ER department’s overall capacity, Evans said.

Part of the new success, he said, comes from creating a few new positions at key points in the path from waiting room to hospital bed. Grossmont added a nurse practitioner in its triage department to help make decisions about which patients have minor-enough medical problems to be seen in the hospital’s new “fast track” unit which is designed to handle clear-cut and relatively-minor problems like cuts, bruises and coughs.

Grossmont also created a new position it calls “bed czar” whose job it is to monitor patient discharges from the hospital and make sure that patients in the emergency room who need to be admitted for an overnight stay are quickly transferred.

“It creates room for new patients to come into the ER,” Evans said.

He added that Grossmont has invested in new software that allows him, and other managers, to keep current with what’s going on in emergency.

“Every six hours, I get a report of how long people are waiting in the emergency room. Every day, automatically, it comes out at 12 and 6, 12 and 6,” Evans said.

Grossmont has also started working with local skilled nursing facilities and community clinics in an attempt to prevent patients from returning to the ER shortly after they’re discharged. In nursing homes, Evans said the idea is to have better communication with staff on how illness should progress so that expected symptoms don’t generate a second, third or fourth visit to the hospital when there is no additional treatment that can be provided. Over the last year, the hospital has also invested in software that allows the emergency department to directly schedule follow-up appointments with nearby community clinics for patients who do not have a primary doctor.

The idea is to get patients with chronic diseases such as diabetes, hypertension and congestive heart failure into doctors’ offices for follow up care that can prevent future visits.

“If we can get them into primary care where their chronic diseases can be managed, they don’t need to necessarily bounce back here as often, and we think that’s better for them, obviously,” Evans said.

In Oceanside, Tri-City has been working for years to handle an emergency patient population that keeps climbing. It was one of the first hospitals in the region to put in a fast track unit for more minor maladies and to link its computer systems with a local community clinic for direct scheduling.

Dr. Cary Mells, medical director of Tri-City’s emergency department, said that original fast track plan has recently evolved into a “vertical treatment unit” which keeps patients in chairs if their problems are minor rather than putting them in beds. Keeping them upright, he said, allows the hospital to squeeze more treatment areas into each square foot and does not create the expectation of a leisurely stay that comes along with putting patients in beds.

“This is something we’re finding in emergency medicine: if you keep them vertical, you keep them moving and you can get them home sooner,” Mells said.

So far, Mells said, the new unit appears to be working. The amount of time that patients are spending in the ER, he said, has already dropped from an average of 350 minutes to 270 minutes. Plans are in the works to significantly expand the vertical treatment area, removing 10 ER beds and staffing up additional nurses and other workers to handle the 50 percent of visits that come into the emergency room but are not considered high risk. Plans are also in the works to create a new “zoomer nurse” position. Like Grossmont’s bed czar, this worker will move from patient to patient clearing any obstacles to departing the hospital once a doctor has approved their discharge.

Tri-City has also invested in the latest generation of extremely low-dose computed tomography scanners. The device, which Tri-City said is the first of its kind in the region, can scan a patient’s body in one fifth of a second at extremely high resolution. This, said Dr. Donald Ponec, director of the hospital’s cardiovascular institute and radiology department, allows doctors to diagnose patients with chest pain and stroke symptoms without more invasive, and slower, medical procedures.

“Now we’re turning people around in half the time. It’s had a big impact on ED flow and, with strokes, it buys us time. When you lose blood flow to the brain, every minute is two million brain cells,” Ponec said.

Mental health patients are another big source of emergency department logjams. Patients often arrive in distress and stay in beds for many hours. Just a few weeks ago Tri-City and the county opened a new crisis stabilization unit next door to its main psychiatric wing that can handle 12 patients at a time. The unit, which is funded by the county for Medi-Cal patients, is staffed with psychiatric experts and provides a much more soothing atmosphere — patients sit in comfortable recliners and can stay for up to 24 hours.

Dr. Michael Krelstein, clinical director of behavioral health services for the county Health and Human Services Agency, said Tri-City and Palomar Medical Center in Escondido are the first two facilities in the county to receive these stabilization units, but other hospitals across the region will soon be evaluated for similar investments.

“Emergency rooms are pretty much terrible places for people who are having mental health crises,” Krelstein said. “Studies have shown that hospitalizations can drop between 50 percent and 75 percent when these kinds of units are available.”

There are some, however, who do need long-term psychiatric care. Behavioral health units at many hospitals have been backing up with patients due to a lack of long-term care facilities that will take them once hospitals solve the immediate crises that brought them to the emergency department.

Krelstein said there are many factors that have contributed to this situation. A new federal ratings system created by the Affordable Care Act holds nursing homes accountable for the percentage of their patients who are on anti-psychotic medications, and that law, the director said, has made them much less willing to take long-term psychiatric patients. Several board-and-care facilities have also closed recently, eliminating yet another option to get patients out of hospital wards.

The county is considering contracts with a new kind of skilled nursing facility that offers special treatment programs for psychiatric patients who need longer-term care. For the first time this year, he said, the county’s spending on mental health services has passed $500 million.

paul.sisson@sduniontribune.com

(619) 293-1850

Twitter: @paulsisson