Emergency Department Crowding in San Francisco: INCREASING EFFECTS ON THE EMS SYSTEM AND NEW COUNTERMEASURES TO IMPROVE PATIENT FLOW

John Brown, MD; Christopher Colwell, MD and Joseph Cuschieri, MD

The San Francisco Emergency Medical Services (911) System, like much of the City’s health care delivery system, has been struggling to cope with COVID pandemic surges, increases in opiate overdoses, behavioral health patients and staffing challenges despite an overall decrease in patients accessing the system for care. EMS is often the health care provider of last resort especially for patients who cannot access more traditional sources of both primary and emergency care services. Our long standing, strong relationship with our Receiving Hospitals from multiple health care systems, has come under pressure from Emergency Department crowding that threatens to undermine our ability to respond appropriately to EMS calls.

During the past 18 months of the COVID pandemic, EMS call volume dropped precipitously but has been increasing at a rapid pace over the last several months as illustrated in this chart showing the volume of EMS incidents per month since 2017.

Our ambulance diversion policy allows emergency departments that are under stress and believe that they cannot accept another patient without providing them a lowered standard of care can divert ambulances away until the system has 50% of our core receiving facilities on diversion. The rate of change in ambulance diversion has accelerated past EMS transports since mid-May of this year as illustrated in this chart contrasting the percent of change of ambulance diversion and EMS transports.

An additional complication is that ambulance patients have experienced offload delays at an increasing rate in the same timeframe, far exceeding the California state goal of :20 illustrated in this chart of the average number of minutes of APOT interval over the last two years.

These factors, along with staffing issues caused by anti-COVID measures and retirements are causing increased frequency of ambulance depletion in the 911 system. We are having more and more frequent periods of time when we cannot assign an ambulance to a 911 call as shown in the following chart of 30 day average daily events when we ran out of ambulances (called Medic to Follow, or MTF events).

This means that patients who could potentially have the greatest medical need are unable to obtain ambulance assistance more and more frequently in San Francisco. While not the only contributing factor, having ambulances delayed at hospitals or delayed driving longer distances to hospitals not on ambulance diversion adds to this resource depletion. We have never experienced this degree of depletion before even at higher volumes of 911 calls.

The San Francisco EMS Agency recognizes the severity of the problem and the increasing likelihood of negative impact on patient care. We have supported countermeasures to both decrease the flow of patients into the Emergency Departments from EMS and to improve / level load the distribution of patients to hospitals in the system.

Our first intervention will be at the intake of the 911 call at our dispatch center (Division of Emergency Communications). The Department of Emergency Management is pursuing funding for RNs to work side-by-side with 911 dispatchers to refer low acuity calls once processed through our triage protocols to medical advice and appointment lines. We are also pursuing links with non-ambulance transport services and response by behavioral health and other specialized, non-transporting prehospital teams (this has already started with the Crisis Response Teams system). We now have a cadre of over 30 Community Paramedics in partnership with the San Francisco Fire Department that also respond on special “EMS 6” units, engaging patients who are high utilizers of medical services and attempting to redirect their use of 911 to more appropriate and effective services. We continue to promote transport of appropriately screened 911 patients to the Sobering Center and Psychiatric Emergency Services at Zuckerberg San Francisco General Hospital without having to utilize Emergency Department services. We have assisted EMS provider agencies with training material and secured state approval to provide point of care COVID testing of patients so that the capacity of both Sobering and PES facilities will increase to pre-pandemic levels and beyond.

Finally, we developed a means to level load the 911 patient destinations across all receiving hospitals in the system, which is called Centralized Ambulance Dispatch Determination. Currently staffed with either a Base Station Physician or senior Paramedic Supervisor, the CADDie pilot has access to ambulance data system-wide and for the busiest eight system hours per day redirects ambulance traffic away from critically impacted emergency departments. The EMS Agency is actively pursuing ongoing and expanded funding for this system, likely next moving to 12 hours/day live coverage and eventually to 24 hour a day coverage based out of the 911 dispatch center.

Despite these measures, our ability to respond to our patients is diminished. Therefore, we are planning to institute changes in our ambulance diversion and ambulance patient offload time policies to decrease reliance on these measures to solve the emergency department crowding issue. There are many similar jurisdictions in both California and through the United States that have successfully eliminated ambulance diversion and implemented offload delay goals that exceed our own. The state of Massachusetts eliminated ambulance diversion in 2009 and subsequent studies failed to show worsened patient outcomes orincreased ambulance patient offload time delays. While there was interest at the American Medical Association policy level to extend this practice to other states, we have not seen progress elsewhere.

Ambulance patient offload time delays statewide led the legislature in 2019 to task the California EMS Authority to implement a target of :20 and initiate statewide reporting on progress. You can find their current report and background on the EMSA website at https://emsa.ca.gov/apot/

The EMS Agency has embarked on a collaborative effort to make these policy changes as implementable and able to succeed as possible. I am asking the SFMMS members with active hospital practices to engage with their facility’s emergency departments and hospital leadership to help improve the crowding situation. We realize that EMS is only a part of the hospitals’ overall mission, which includes patients that self-present for emergency care, patients who utilize other outpatient services at these facilities and patients in need of urgent, semi-elective and elective in-patient procedures. It is only though systematic, consistent, accountable, and equitable processes that we will be able to lessen the impact of this emergency department crisis and improve the outcomes of our EMS patients.