Because of persistent and seemingly insoluble problems with providing patients at the emergency rooms in the High Desert’s various hospitals in a timely manner, the San Bernardino County Civil Grand Jury has suggested that what is ultimately called for is the construction of a publicly-run regional trauma center north of the Cajon Pass.
The Arrowhead Regional Medical Center in Colton, which was completed and opened in 1998, is the main campus of the county hospital. But San Bernardino County, at 20,105 square miles is larger than Rhode Island, Delaware, Connecticut and New Jersey combined. The driving time to Arrowhead Regional from various spots in San Bernardino County’s tremendous outback – the Mojave Desert – can be as long as four hours at some times, contingent upon traffic conditions.
According to the grand jury report, for desert residents, the availability of timely emergency care is exacerbated by the phenomenon of hospital bed delay — the lag between an incoming patient’s arrival at an emergency room either by ambulance or walking in and the time he or she is actually admitted to, or received into, the facility.
Backlogs of patients in the waiting rooms at the High Deserts are so extensive that waits of several hours have now become commonplace.
According to the grand jury report, waiting times have become so long that “The first 25 minutes after arrival to the hospital are excluded from the bed delay calculation.”
The report states, “bed delay contributing factors are the result of several issues,” including “only three High Desert [have] an emergency department, none of which have trauma centers; a lack of ambulances at peak times; the misuse by the public of the emergency departments; and the overuse of 9-1-1 calls for non-emergencies. Other contributions are a lack of interest of private hospitals to expand or build new services which leads to a shortage of beds. Only three hospitals have emergency departments that can receive patients via ambulances. There are a high number of Medicare and Medi-Cal clients in the High Desert. These factors put a strain on the use of resources between San Bernardino County Fire Department and American Medical Response [the county’s franchised ambulance company in the High Desert. The nearest trauma centers for the High Desert are Loma Linda University Medical Center and Arrowhead Regional Medical Center.”
With regard to the cities of Adelanto, Apple Valley, Victorville, Hesperia, and Victor Valley, the report says, “Current trends and changes in the healthcare delivery system suggest that a greater impact on the medical system and higher demand on emergency medical services will continue into the foreseeable future.”
In rendering its report, the grand jury relied upon a document generated by the Inland Counties Emergency Medical Agency, a joint powers authority for San Bernardino, Inyo, and Mono counties which oversees standards and protocols for pre-hospital and trauma care, ambulance and emergency medical transport including ambulance response time monitoring, performance based contracts, and medical disaster preparedness, including hospital preparedness programs, as well as certification of emergency medical technicians, paramedics, and mobile intensive care nurses. All five San Bernardino County supervisors are governing board members of the Inland Counties Emergency Medical Agency, which is known by its acronym, ICEMA. The document referenced in the grand jury report is titled “Centralized Medical Control Proposal.”
The grand jury report quotes the ICEMA document: “Ambulance patient offload delays not only impact the transfer of care of patients, they delay the return of ambulances to respond to other calls for emergency services. The downstream effect of ambulance patient offload delays is that first responders, including fire service and law enforcement personnel, must remain on scene longer than necessary thus delaying responses to a variety of emergencies including medical, fire, hazardous materials and crime related incidents.”
The grand jury report says that the consensus of medical professionals is that an overarching system that monitors and tracks the whereabouts of ambulances and has responsibility for dispatching them is called for.
“In bed delay task force discussions, the Hospital Association of Southern California and the 18 CEOs of San Bernardino County hospitals proposed exploring the creation of a centralized medical control and transportation hub to better address and implement solutions,” the grand jury report states.
American Medical Response is the ambulance company operating under an exclusive operating arrangement conferred upon it by the county in the Victor Valley.
According to the grand jury report, the “San Bernardino County Fire Department mentioned one solution to the bed delay issue is the communication with American Medical Response ambulances. A single source communication system does not exist as the San Bernardino County Fire Department and American Medical Response are not on the same radio frequency. Other solutions include an increase in hospital staff and open bidding on the emergency transportation contract. Finally, the public needs to be educated on appropriate 9-1-1 usage.”
According to the report, a potential solution to addressing bed delays consists of “Implementation and adoption of emerging technologies to assist the EMS personnel in the triage of both 9-1-1 patient responses and in the evolving community paramedicine models, including post discharge patient encounters.” Another solution, the report states, includes “Implementation on pre-hospital triage strategies, such as 9-1-1 call screening and increased utilization of existing nurse advice lines designed to identify patients that do not require the historical emergency medical service response or an emergency department to provide care for the patient’s medical complaint.”
The report defines bed delay as “the inability to move patients from ambulance gurney to emergency department beds or chairs due to emergency department [or hospital] overcrowding.”
Once the ambulance is within 250 feet of one of the three hospitals, the responsibility of care transfers to the hospital and the two ambulance personnel are considered defacto employees of the hospital. Last year, American Medical Response lost 72,000 personnel hours due to bed delay while Riverside County lost 24,000 personnel hours. San Bernardino County had 36,000 hours of bed delay compared to Riverside County that had 12,000 hours of bed delay
According to statistics cited by the grand jury, 20% of the calls coming into American Medical Response in the desert area are initially cataloged as requesting non-life threatening basic life support that fall safely within the non-emergency category. Another 22% of the calls are for what is initially listed as of a slightly higher priority, involving possibly life threatening basic life support, characterized as an emergency. Some 24% of the calls coming into the ambulance company pertain to what is reckoned to be a life threatening advanced life support scenario, considered an emergency. An even higher 32% of the calls to American Medical Response relate to what is at once categorized as a serious life threat requiring advanced life support, considered an emergency. A relatively limited 2% of the calls American Medical Response must deal with are dire emergencies, where the continuing life status of the individual to be transported is in question and the standing policy is that the closest available ambulance should respond, even if committed or called to another pending transport.
According to the report the average number of daily medical responses within the Victor Valley exclusive operating area is 100 to 110. “The High Desert may have as many as 15 American Medical Response ambulances during peak deployment and as few as six during low peak hours,” according to the report. “Exclusive operating areas are designated areas within the county by which ICEMA ensures the effectiveness and success of a medical transportation system. Those ambulance services awarded an exclusive operating area are under contract to ICEMA and San Bernardino County.”
American Medical Response, one of the major donors to the campaign funds of the members of the board of supervisors, is contracted to operate 12 of the 27 exclusive operating areas in San Bernardino County.
According to the grand jury report, the San Bernardino County Fire Department has 16 county-owned ambulances assigned to the High Desert. Ten are assigned in Apple Valley and Victorville; six ambulances are assigned to all the other areas in the High Desert. The San Bernardino County Fire Department and American Medical Response operate on different radio frequencies. The San Bernardino County Fire Department receives all 9-1-1 calls based on the exclusive operating area arrangement and they may be relayed to American Medical Response. “This results in time delays when the San Bernardino County Fire Department units are closer to an American Medical Response call and the response could be handled quicker,” the report states. “The opposite situation may also occur. The San Bernardino County Fire Department covers for American Medical Response when ambulances are not available. In the last calendar year, the San Bernardino County Fire Department took 1,396 calls for American Medical Response and American Medical Response took 300 calls for the San Bernardino County Fire Department. “
There are three hospitals in the Victor Valley, Desert Valley Hospital Center, Saint Mary Medical Center, and Victor Valley Global Medical Center, which operate emergency departments.
“There is no coordination between the three High Desert hospitals when a bed shortage leads to ambulance delays,” according to the grand jury report. “Riverside County does not have the same number of bed delays because there is cooperation between hospitals and their systems utilize an emergency medical dispatch. The clock for response time starts for American Medical Response once the call or relay to American Medical Response is made. American Medical Response has a 9 minute 59 second response time in urban areas. The county and city fire departments do not have any response time expectations because they are not under contract with ICEMA. The San Bernardino County Fire Department tracks and maintains the statistical data of the emergency response time of their ambulances. The San Bernardino County Fire Department starts their tracking from the time they receive the call to the time they arrive at the location. Each ambulance for American Medical Response and the San Bernardino County Fire Department must have, at a minimum, one emergency medical technician and a paramedic. The cost is $1 million to maintain one ambulance on the street for 24 hours for one year. This includes all costs including vehicle cost and maintenance plus staffing. American Medical Response ambulance staff turnover is an issue due to San Bernardino County Fire Department offering benefits and career growth opportunities that are better than what American Medical Response offers.”
At Desert Valley Hospital Center 62.7 percent of patients in need of emergency care experience bed delay. At Saint Mary Medical Center 57.4 percent of patients seeking emergency care experience bed delay. At Victor Valley Global Medical Center, 58 percent of emergency patients needing beds are delayed. Overall, the percentage of emergency patients delayed in being fully admitted is 59.5 percent.
According to the grand jury report, “The contributing factors to the [delays] are an increase in the number of newly insured patients as a result of healthcare reform placing higher demands on already strained, over-crowded emergency departments; further pressure on a county where the demand for inpatient beds is already significantly greater than the supply; a disproportionately low number of local primary and specialty care physicians; an aging population with additional medical needs, and the evolving role of emergency medical service in healthcare systems, e.g., community paramedicine.”
The grand jury concluded that “Demands on the 9-1-1 system are influencing the need for a reevaluation of the emergency medical service system. It was designed ‘to provide better management of resources, real-time exchange of medical information, and improvement in the delivery of appropriate, safe, cost effective, and quality healthcare.’ Bed delay directly affects the safety of patients and the general public who experience emergencies. A shortage of emergency department beds and the lack of a trauma center exist in the High Desert. This shortage leads to hospital and emergency department overcrowding resulting in bed delays. The misuse of the 9-1-1 system on a regular basis overloads dispatch and decreases the availability of ambulances. There is a lack of coordination occurs among the three high desert hospitals, American Medical Response, and the San Bernardino County Fire Department regarding overcrowding. Communication problems result from American Medical Response and the San Bernardino County Fire Department not operating on the same radio frequency. Enhanced call screening data is collected but not utilized. No effective action has taken place to begin implementation of the ICEMA ‘Centralized Medical Control Proposal.’
Accordingly, the grand jury called for the implementation of that proposal and that county officials undertake to educate the general public on the correct use of the 9-1-1 system.” Moreover the grand jury said an effort should be made to “implement and utilize enhanced 9-1-1 call screening of pre-hospital triage strategies” and “include utilization of existing nurse advice lines designed to identify patients who do not require the traditional emergency medical services response or an emergency department to provide care for the patient’s medical complaint.”
The grand jury said it would “track dispatches between American Medical Response and San Bernardino County Fire Department to determine the number of patients each hospital can serve based on the availability of beds to ease the number of bed delays.”
The public and private sectors should also, the grand jury said, “create a process to facilitate access to a common radio frequency between American Medical Response and San Bernardino Fire Department that will aid in the real time monitoring of their ambulances.”
The ultimate solution, the grand jury said would be to “build a new San Bernardino County hospital in the High Desert similar to Arrowhead Regional Medical Center that includes a trauma center.”     -Mark Gutglueck