The GFD has a dilemma with both its Response and Delivery Time

A 1999 study showed that three-quarters of all New York City emergency room visits between 1994 and 1998 were for avoidable or non-emergency care. Half of all patients in the study said that convenience, rather than financial considerations, caused them to use the emergency room. In 2001 House of Delegates adopted Resolution 108, which calls on the American Medical Association to study the issue of overcrowding of emergency departments (EDs), Emergency Medical Services (EMS) diversions, and lack of hospital beds for admissions. (1)  The effects of the overcrowded conditions in the ED has resulted in long waits resulting in a dramatic increase in ambulance diversions, meaning the hospital stops accepting patients via ambulance that is diverted to other hospitals. Even with diversion, some hospitals that had reduced staff and in-patient capacity found themselves with backlogged EDs and not enough beds, nurses or on-call specialists to undo the gridlock. (1)

EMS diversion creates many problems for patients. Ambulance patients are regularly ending up at hospitals where their insurance is not accepted, and where they are being treated by unfamiliar physicians who do not have access to their medical records. Diversion has become so routine that many are refusing ambulance transport when they find out the vehicle is not headed to their hospital of choice. The consequences include significantly escalating transport times, risk of traffic accidents en route, and potential for poor clinical outcome (1) It’s evident that the City of Glendale’s justification for the majority of its diversions to Glendale Adventist that has nothing to do with overcrowding , backlogs, or lack of hospital beds at other hospitals, particularly Glendale Memorial Hospital and Verdugo Hills Hospital (now USC Verdugo Hills Hospital).

There are three local hospitals in Glendale as follows: (Glendale Adventist, Glendale Memorial and USC-Verdugo Hills) in the City of Glendale.
• Glendale Adventist Medical Center (GAMC) is located at 1509 Wilson Terrace, Glendale, CA 91206, on the border of Glendale and Eagle Rock.
• Glendale Memorial Hospital and Health Center (GMH) is located at 1420 South Central Ave., Glendale, CA 91204, in South Glendale .
• USC-Verdugo Hills Hospital, now part of Keck Medicine of USC, is located at 1812 Verdugo Blvd, Glendale, CA 91208, in North Glendale

In the past few years attention has primarily been focused on fire department response times to the distressed callers location from the time that 911 has been received. Now based on the GFD’s own data of “Receiving Hospital Summary and Facility Most Transported To”, a new disturbing pattern has now come to light.

It’s apparent that GAMC is the preferred hospital for the GFD. The question is why, when the hospital is on the border of Glendale and Eagle Rock? GMH is more centrally located, closer to downtown, and USC Verdugo Hills is located in North Glendale, near Montrose.
Having said that, how many 911 transports over the last few years, where the location of the distress call was closer to GMH or USC Verdugo Hills, was diverted to Glendale Adventist?

Cathy Chidester, director of the Los Angeles County Emergency Medical Services Agency, says most local areas operate under similar principles. When someone places a 911 call, the dispatcher contacts the ambulance company responsible for the zone in which the patient is located. As with other counties nationwide, Los Angeles ambulances go to the closest hospital best geared for the treatment being sought. (2)

When hospitals are comparable in their method of treatment being sought, the 911 transport should go to the closest hospital. How can GAMC be getting over 60% of the medical transport, when GMH is in the Top 3 for California Cardiac Care, and has been ranked in America’s 50 Best Hospitals (top 5%) and was voted Glendale’s best Hospital in 2013 (Glendale News Press)?   If the response time, after a 911 call is received, is a crucial element to a patients survival, who is in cardiac arrest, isn’t it equally important for the delivery time to be critical considering the risks associated with a longer delivery time.

Los Angeles City Atty. Mike Feuer has filed a lawsuit accusing Glendale Adventist Medical Center of dumping mentally ill and disabled homeless patients on L.A.’s skid row. Hospital officials “strongly disagree” with the allegations, but are working with the city attorney to resolve the matter. LA City attorney spokesman Rob Wilcox said settlement negotiations were underway. Even though GAMC is a 515 bed acute hospital, the L.A. County Department of Mental Health designated the facility to admit and treat mentally ill patients brought in on involuntary detention holds, city prosecutors said in the suit.  The LA Times says the Los Angeles City Attorney sued Glendale Adventist Medical Center, alleging that over the past four years it transported mentally ill and homeless patients without their consent, dumping homeless patients in Downtown skid row, known for poverty and crime.  (3) Based on the forgoing, this begs the question, what was the compelling reason for GAMC to dump homeless in downtown Los Angeles skid row, after it was well established that the LA City attorney was going after hospitals who specially violated this law .

Note- The GFD has applied to the County and the State EMSA to participate in two of the pilot studies. Specifically, to transport patients who meet the agreed upon protocols to destinations other than emergency rooms. The second pilot will consist of the follow-up component for specific chronically ill patients that have been recently discharged from hospitals. (4)

Another area of concern is also known as “Wall Time”. When the Fire Department ambulance crews bring a patient to a hospital, the crew stays with the patient until the patient is admitted — that’s required by a state law prohibiting “patient abandonment.” In many cases, the wait is short: with the crew back at work after 10 or 15 minutes of filling out paperwork. Yet other times, a patient arrives with minor injuries or problems, and has to wait for a bed, sometimes for hours. When the ambulance crew has a long wait, it’s called “wall time” because the crew is either leaning against the wall or hold up the wall awaiting to be released.  Hospital bed shortages delayed Los Angeles Fire Department ambulance crews nearly 37,000 hours in 2013 in wall time, costing the city about $6 million. Moreover, the number of hours spent by Los Angeles ambulance personnel stuck in waiting rooms increased by nearly 30% from 2012 to 2013. When ambulance crews wait at the hospital, they’re put out of commission, unavailable to respond to other emergencies, so response time increases and a person in genuine crisis may lose precious minutes before help arrives. (5)

The delays, a common problem at many fire departments across the state prevent ambulances from responding to other 911 calls, according to a staff report. Fire officials said they are exploring other options such as staffing dispatch centers with nurses to help resolve medical issues over the phone, rather than by sending out ambulances. (6)  The Fire Department could also hire nurses or other medical personnel and assign them to hospital emergency rooms, especially at busy hospitals during busy periods. By placing handoff medical personnel in emergency rooms, this would free up crews, alleviate backups, save money and speed up help to people in crisis. When ambulance crews arrive, they could hand over their patients to that nurse, who could then take custody of the patient until he or she was admitted to the hospital, allowing the ambulance to return to service. (5)  Although this would add a small amount to the budget, it is little compared to the cost of fire personnel being put out commission for hours unavailable to take other emergency calls requiring other fire personnel to take their place resulting in unnecessary overtime. Wall time also matters because each marooned ambulance, sitting silently outside the ER in front of a hospital’s emergency room causes other LAFD ambulances to be called to incidents outside of their own jurisdictions. That contorted situation means they arrive late, dangerously slowing LAFD’s emergency-response times. (7)

The prohibition against patient abandonment is a California law, so it applies throughout the state and to private as well as public ambulances service. A common basis for civil cases against EMS providers is “abandonment” which is the unilateral termination of a provider/patient relationship when the patient still needs care, but provision is not made for that care and an injury results. If the paramedic turns the care of the patient over to a person with lesser level of capability, he or she may be responsible for abandonment should the patient encounter any difficulties during the transfer. (8)  This created a double whammy for the GFD, ever since Chief Scoggins shifted all EMS paramedics to fire engines, and assigned Basic Life Support Technicians to the ambulances. As a result, this tied up two BLS technicians and up to four fire fighters, at least two being paramedics at the Hospital Receiving room until ER personnel could properly take custody of the patient and a bed became available.

In several cases, the city’s well-paid firefighter crews aren’t there due to emergencies. They are waiting for people they’ve transported, with non-emergency complaints, to be booked by busy ER staffs, while a patient is admitted for a broken toe or a funny burning feeling in the lower back. Darren Evans, a paramedic at Station 9, says wall time is “anywhere from 20, 30 minutes — to four or five hours.” (7)  On every firefighters shift, intended for an activity that comprises just 2 percent of what’s undertaken — firefighting, the practice of intensely training as firefighters those who then will spend most of their time doing emergency medical work and shuttling people to hospitals, at yearly total compensation of $187,000 — on the low end — shows no sign of letting up. Several cities use private ambulances to shepherd non-emergency patients to ERs, for a lot less money, and they avoid compromising their system for true emergencies. (7) However, this will never happen in large municipalities, due to the powerful firefighters union, which plays a major role in electing L.A. city councilmen, showering their campaigns with money and getting out votes for council members on Election Day.

Los Angeles County firefighters use a “quint,” a hybrid that carries both the water and the aerial ladder. Together. The more nimble county vehicle looks like a small SUV; it whisks two firefighter-paramedics to the fire or medical emergency. At the scene of every L.A. County 911 call, they are met by a private ambulance. If somebody needs to go to the hospital, private paramedics, rather than highly paid L.A. County firefighters, take them to the ER. However, if a patient requires advanced life support an L.A. County Fire Department paramedic rides in the private ambulance with the patient. They’re leaner, yet the county fire department performance outshines LAFD’s. A recent report showed that county emergency-response times in urban areas average 42 seconds faster than LAFD’s. (7)

The City of Glendale will continue to have a dilemma with both its response and delivery time to the hospital ER, as long as it continues to maintain an exclusive relationship with just one hospital, GAMC, that receives the majority of the City’s EMS transports, over 60% in 2013 through April 2014.. Because the GFD is delivering the majority of its patients to GAMC, this is causing GAMC to dump patients, brought in involuntarily under a different program with LAC Dept. of Metal Health, on skid row. GAMC is a 515-bed, acute-care hospital. Shouldn’t the GFD know in advance whether GAMC has bed space available before delivering a 911 patient to the hospital, like other city’s do, i.e. .

• The effects of the overcrowded conditions in the ED has resulted in hospitals declining acceptance of patients via ambulance, diverting them to other area hospitals. 

It’s obvious that per the foregoing, this is not occurring at GAMC, resulting in more overcrowding.  In addition to the excessive cost of Glendale keeping two Basic Life Support technicians and up to four firefighters, two or more paramedics, tied up at the hospital ER, for endless number of hours, aka Wall Time, it also puts patients at tremendous risk that can only result in poor clinical outcomes, putting the city’s stakeholders at risk of multiple future lawsuits, for culpability, by continuing to maintain a failed EMS policy.

Source Reference:
(1) http://www.ama-assn.org/meetings/public/annual02/cms_reports.pdf
(2) http://articles.latimes.com/2014/jan/26/business/la-fi-healthcare-watch-20140126
(3) http://www.latimes.com/local/lanow/la-me-ln-patient-dumping-suit-20140822-story.html
(4) http://www.glendaleca.gov/Home/ShowDocument?id=2315
(5) http://www.latimes.com/opinion/op-ed/la-oe-newton-wall-time-waste-in-fire-department-20140818-column.html
(6) http://kfwbam.com/2014/04/24/ambulance-delays-within-the-lafd/
(7) http://www.glendalecacoalition.org/2013/08/mission-creep-at-the-l-a-fire-department/
(8) https://www.iaff.org/tech/PDF/Monograph3.pdf