This past weekend, Zuckerberg San Francisco General Hospital was on diversion for 61 percent, 87 percent and 76 percent of Friday, Saturday and Sunday, respectively.
Diversion is when hospitals do not accept ambulance traffic because there is insufficient capacity to see new patients. That means last Saturday, the emergency department doors were closed to ambulances trying to find a place to deliver their patients for more than 20 hours of the 24-hour period. This delays treatment not only for the patient in the ambulance but all patients who call 911 and need an ambulance since this ambulance is forced to try to find the next closest hospital that is open and is out of service until they drop off that patient.
This is happening across California, and Los Angeles is no exception. In January, during the height of the fast-spreading omicron variant, 52 out of 62 hospitals that Los Angeles City Fire dispatches to were on diversion due to lack of beds and staffing. Similarly, in January 2021, 22 of 25 emergency departments in Orange County were on diversion.
For the most part, hospital crowding isn’t due to a lack of physical beds, but inefficient use of nursing resources. Increasing numbers of hospital staff are quitting their jobs amid COVID-19 burnout. Better-off hospitals have bid up wages and benefits to snag travel nurses. As a result, diversion is more common in hospitals serving poorer patient populations, but the delays in the entire 911 system affect all patients, not just the poor.
What can be done? These foreseeable consequences of the pandemic have occurred around the country and have prompted policymakers to pursue quick fixes at the national level. One proposed stopgap measure gaining traction is minimum patient-to-nurse staffing ratios (PNRs). In Congress, Sen. Sherrod Brown (D-Ohio) and Rep. Jan Schakowsky (D-Ill.) reintroduced legislation to mandate minimum nurse staffing ratios for every hospital unit in the country treating Medicare and Medicaid patients. However, as we know in California, despite over 16 years of such policies, staffing shortages persist, suggesting that a federal policy would yield similar challenges.
Clearly, the problem of health care workforce shortages must be addressed. In the interim, other steps must be taken to optimize the use of the hospital nursing workforce.
One approach is to evaluate hospital resource constraints using the concept of “supply” and “demand.” Patients — the “demand” side of the equation — flow through hospitals, interacting with the “supply” of doctors, nurses, hospital beds and other resources. Studies have documented immense yet predictable fluctuations in this flow — mainly attributable to variations in the volume of elective admissions (mostly surgical), which are a hospital’s financial lifeblood.
At typical U.S. hospitals, elective admissions are scheduled on just a few days each week, often clustered based on surgeons’ preferences. Afterward, recuperating surgical patients typically have first claim on available inpatient staffed beds. Thus, on a day with many scheduled surgeries, patients might fill up all hospital beds, meaning that there’s no room for new emergency department admits — whereas later in the week, beds are underutilized. On days when hospitals are full of patients, nurses are likely to be stressed — even those at well-staffed hospitals — but after the elective surgery patients are gone, the workload significantly decreases.
It is simply not affordable or feasible to staff at a level to handle the patient demand in hospital wards, which leads to emergency department overcrowding. At the same time, it is wasteful to staff at high levels when patient demand is low. By contrast, if hospitals staff nurses well below peak loads, emergency departments become even more overcrowded, overwhelmed staff commit more medical errors and preventable morbidity and mortality result.
The solution is managing the peaks and valleys of patient flow created by elective surgery schedules. This objective can be achieved by “smoothing” surgeries so that they are spread evenly across the week, thereby significantly alleviating nursing stress and burnout. Studies of such surgical smoothing show that it can significantly reduce nurse shortages while simultaneously improving nurse retention, quality of care, and hospital margins while reducing mortality, readmissions, medical errors, and emergency department boarding. This is all the more critical for safety net hospitals. Ambulance diversion, therefore, is a manifestation of the societal inequities in healthcare.
We all depend on a functioning pre-hospital and healthcare system, whether during a pandemic, mass shooting, or multi-casualty incident. Now is the time for all hospitals to adopt proven protocols for smoothing out elective surgeries. Recently, National Academies recommended implementing surgical smoothing nationwide to improve the organ transplant system. Addressing systemic issues in the healthcare system with techniques like surgical smoothing will improve safety for our patients and nurses and ensure a more sustainable system for the long term. If not now, when?
Susan Dentzer, MS, is president and chief executive officer of America’s Physician Groups; former senior policy fellow at the Robert J. Margolis Center for Health Policy at Duke University, former editor-in-chief of Health Affairs, and the former on-air health correspondent for the PBS NewsHour. Renee Y. Hsia, MD, MSc, is professor and associate chair of Health Services Research in the Department of Emergency Medicine and the Philip R. Lee Institute of Health Policy Studies at the University of California San Francisco, and an attending physician in the emergency department at San Francisco General Hospital and Trauma Center. Eugene Litvak, Ph.D. is president and CEO of the non-profit Institute for Healthcare Optimization and an Adjunct Professor at the Harvard T.H. Chan School of Public Health.