ER CRUSH FORCES DRASTIC PROCESS CHANGES

Policy lets local hospitals divert all ambulances except for extreme cases

Severe impacts on local emergency departments that have recently forced paramedics to wait for hours before they can deliver their patients prompted unprecedented changes to San Diego County ambulance bypass procedures Tuesday.

The change came as intensive care capacity across the state continued to dwindle, prompting local hospitals to reach out to Sacramento for staffing help even as the first batches of vaccine began to arrive.

During his weekly COVID-19 update, Gov. Gavin Newsom cited intensive care and hospitalization rates that have marched steadily upward, saying there is “light at the end of the tunnel, but we’re still in the tunnel.”

Nothing could have made the point more clearly than the new county ambulance diversion policy sent out by Dr. Kristi Koenig, medical director of county Emergency

Medical Services, Tuesday night.

Diversion is a long-followed process that becomes necessary when emergency departments grow so full that they need a break to catch up.

Generally, diversion means that hospitals take only ambulance deliveries from within their own designated geographic areas, and perhaps a few specialty cases — such as strokes — until the patient load comes under control.

Hospitals, at least those in San Diego County, never divert all ambulance traffic. They just stop receiving runs originating outside their immediate areas of responsibility generally called their “dispatch” areas.

But that approach, Koenig said Tuesday night, simply was not enough to handle the crush of emergency patients that started arriving at many hospitals over the weekend. In one case, she said, two ambulance crews waited five and seven hours before emergency department staff had enough available room to accept them.

The new policy, tested over the weekend, allows hospitals to request “complete ambulance diversion” which, if approved by a county duty officer, stops the f low completely unless emergency patients are suffering “uncontrollable lifethreatening problems” such as immediate cardiac arrest or an obstructed airway that would quickly be fatal if not cleared in minutes.

The change appears to be novel in its scope.

“It’s certainly unprecedented in our county, and I’m not aware of anywhere where it’s used exactly like this,” Koenig said.

She said that the facility, which she declined to name, that used the procedure over the weekend on a trial basis was able to “decompress” within a few hours and come back online. Just after notifying the local emergency medical services community of the change Tuesday, it was immediately used when 17 ambulances carrying patients in need of advanced life support arrived at a single hospital emergency department in “less than one hour.”

After going on full ambulance diversion, Koenig added, the facility was able to return to service not long after declining all ambulance deliveries. It was not clear how many among that rush of 17 ambulances carried COVID-19 patients and how many had other emergency medical needs.

While she said she is proud of how county, hospital and public health planners are working together to take up the slack, the physician said that diversion can only go so far. Driven by local COVID-19 infection rates that have been increasing for weeks, emergency rooms have been going on regular diversion more and more often. Tuesday evening, for example, the executive said 10 local hospitals had been on diversion within the previous four hours.

“The issue is going to be, of course, if we get to the point where everybody’s in a bypass situation all of the time,” Koenig said.

Emergency departments are increasingly reporting back pressure from full or nearly full intensive care or other hospital units which have been admitting larger numbers of COVID-19 patients since shortly after Halloween. In some cases, hospital directors have said, patients end up waiting in ERs for many hours until beds come available.

It is not necessarily a lack of open beds that has clogged up the f low but rather a lack of trained staff, from nurses to respiratory therapists, able to care for those who need everything from special medication to highflow supplemental oxygen in order to fight the out-of-control inf lammation that causes life-threatening breathing and heart problems.

San Diego County hospitals have struggled under the increased volume, with some recently reporting zero staffed and immediately available beds in internal reports published daily by the Hospital Association of San Diego and Imperial Counties.

In an email Tuesday evening, Dimitrios Alexiou, the association’s president, said his organization asked the county Monday to request “staffing support from the state” to help hospitals meet demand. Intensive care nursing, he added, is the primary request but “wasn’t directed to any one facility” or system.

Newsom said he would send additional state-contracted specialists where they’re needed and indicated that more than 500 medical personnel have already been dispatched through the course of the pandemic to locations where patient volume has threatened to overwhelm available resources. Imperial County hospitals, which dealt with a significant surge coming across the border in the early summer and late spring, has already benefited from such help. Locally, some nursing homes have received help from the U.S. National Guard.

Newsom painted the grimmest of pictures of California’s current situation Tuesday, indicating that it has recently been necessary to lay in additional supplies as the number of people across the state dying from the disease has increased from a seven-day average of 41 on Nov. 14 to 167 on Monday.

“We have orders on 60 53foot refrigerated storage units that are currently standing by now in counties and at hospitals,” Newsom said. “We just had to order 5,000 additional body bags we just purchased for the state and we just distributed them down to San Diego, Los Angeles, Inyo counties.

“That should be sobering.”

But Dr. Steven Campman, chief deputy medical examiner for San Diego County, said through a county spokesperson Tuesday that no such orders have recently been made. Such supplies, county off icials said, were laid in early in the course of the pandemic and no additional inventory has been needed.

That’s not to say that the pandemic has suddenly turned merciful. An additional 32 deaths appeared alongside 1,863 more confirmed cases in Tuesday’s county COVID-19 tracking report.

Ages ranged from 56 to 102 and included four additional deaths on Dec. 10, making it the deadliest single day of the pandemic so far with a total of 19, two more than the 17 recorded on Dec. 7.

Newsom said that with overall intensive care capacity wearing very thin in some regions — Southern California’s was estimated at just 1.7 percent Tuesday — the state would begin the process of activating medical stations such as the one that added more than 200 cots to vacant space inside Palomar Medical Center Escondido.

The state has taken steps recently to loosen statewide nursing ratios, a move that frees up treatment capacity at the expense of quality. Generally, intensive care nurses are able to care for no more than two patients at once, but the limit, under emergency action, has now been increased to three by state order.