Longer waits at ERs expected because of nursing ratio rules.

Walk into the emergency room at Long Beach Memorial Medical Center for a non-life threatening condition, and it can be up to four hours before a patient is sent on his way.

Come Jan. 1, these might seem like the good old days.

The Long Beach hospital and others around the state are bracing for implementation of the nation's first-ever nurse staffing ratios that require hospitals to have a specific number of nurses on duty in various wards--or risk having to shut down beds.

While many hospital officials are concerned they will not have enough nurses to satisfy the regulations throughout their facilities, their main concern is the already crowded ER, where especially tough ratios could force them to turn away ambulances and make patients wait even longer for treatment.

"We don't want to see people out on the street on Atlantic Boulevard waiting for care," said Richard DeCarlo, vice president of diagnostic services. "We are anticipating there will be extended waits."

The county's Emergency Medical Services Agency is holding a special hearing next week to take testimony from hospitals, nurses and others on how to handle what it characterizes as a crisis about to hit emergency rooms.

The agency is concerned that a lack of nurses will cause bottlenecks in ERs prompting more hospitals to go on "diversion"--when their emergency rooms become so crowded that ambulances are sent to other facilities.

Another complication: the new law will hit during the height of the flu season.

"It's going to be 100-fold more problematic," said Carol Gunter, chief of the medical services agency, which manages the county's ambulance dispatch system.

Some meet requirements

California's landmark law was enacted in 1999 at the behest of nursing unions that claim decade-long cutbacks of nursing staff as a result of managed care has made the profession intolerable--as well as dangerous for patients.

The law requires ratios that range from 1-1 in trauma units, to 1-4 in pediatric units to 1-6 in the largest medical/surgical wards. But it comes amid a persistent nursing shortage, as fewer women choose the profession.

The fears are not universal. With their vast resources, top facilities like UCLA Medical Center and Cedars-Sinai Medical Center appear to have enough nurses to satisfy the requirements of the new law throughout their wards. So, too, does the Kaiser Permanente system, which operates seven hospitals in the county.

Indeed, the California Nurses Association, the law's prime sponsor, contends that many hospitals are engaging in a systematic fear campaign to get the law overturned or modified.

"Their propaganda campaign is outrageous," said Charles Idelson, a CNA spokesman. "Those hospitals that are actively trying to comply with the law are doing fine."

Still, officials with Catholic Healthcare West, which the union has cited as a good corporate citizen following a recent labor pact, has expressed concern there will be long delays and turned away ambulances.

The San Francisco-based system has 2,000 open nursing positions at its 37 hospitals statewide, including five in Los Angeles County, not accounting for additional hires it expects to make for the ratio law.

"Our biggest concern is that the hospitals will be restricting access and the ER area will be hit the hardest," said Shelly Schleinker, CHW's vice president of public policy and advocacy.

Making preparations

Emergency rooms have emerged as a focus of concern for two reasons.

First, the new laws require especially tough ratios of 1-1 for trauma patients, 1-2 for critical patients, such as heart attack victims, and 1-4 for everyone else, even if they have suffered just a minor broken bone. Hospital officials say it's often tough to meet those ratios, given that emergency rooms most often involve treating unexpected injuries and illnesses.

Perhaps a bigger concern is that problems meeting the ratios in inpatient wards--forcing hospitals to restrict access to those units--will cause a bottleneck at the ER. That's because emergency rooms are one of the primary sources of inpatient admissions.

"It's sort of the gateway to the hospital. If your inpatient units are at capacity, you have no capacity to admit people and they will have to be held in ER," Schleinker said.

While the county allows hospitals to request ambulances be sent to another facility, it still must treat every patient who walks into its emergency room under federal law, even if the wait is hours long.

For several years in anticipation of the law, hospitals have beefed up hiring by offering signing bonuses, recruiting nurses from other states and paying for nursing scholarships. Even so, many are falling short, and now hospital administrators expect to take short-term measures to fill the gap.

Carol Bradley, chief nursing officer for Tenet Healthcare Corp. in California, said Tenet wants to increase work hours of its part-time nurses and make greater use of third-party registries, which are temporary nurse agencies. "We expect that we will have to recruit close to 1,000 nurses at our 39 state hospitals over the next few months. It's pretty challenging," she said.

Other hospital executives said they will ask the state Department of Health Services, which oversees the law, for flexibility in meeting the ratios, if they can show they have made every effort but still cannot get enough nurses.

The nurses union said it will fight hospitals seeking such flexibility and state officials do not seem inclined to grant it (though there are special exceptions for rural hospitals and health care emergencies, such as a plane crash with large numbers of victims).

"There is no provision for (generally) granting hospitals the right to be out of compliance with the regulations," said Gina Hennings, a health services official who was the lead writer of the law's implementing language.

Other hospital administrators are not banking on any help from the state. DeCarlo said the industry "had its day in court" in the Legislature before the law was enacted and now must just learn to cope.

"We are just going to have to treat everyone who shows up in our emergency room," said DeCarlo, who estimates that Long Beach could be as many as 150 nurses short right now.