Existing law provides for the licensure and regulation of health facilities, including general acute care hospitals, by the State Department of Public Health. Existing law authorizes a general acute care hospital, as defined, to offer special services, including, but not limited to, emergency medical services. Existing law requires a hospital that provides emergency medical services to provide notice of the planned reduction or elimination of those services to certain entities and the public, as specified.

This bill would authorize Saddleback Memorial Medical Center to operate an emergency department at its San Clemente campus, subject to specified requirements.

This bill would make legislative findings and declarations as to the necessity of a special statute for the communities of San Clemente, Dana Point, and San Juan Capistrano.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the licensure and regulation of health facilities, including general acute care hospitals, by the State Department of Public Health. Existing law authorizes a general acute care hospital, as defined, to offer special services, including, but not limited to, emergency medical services. Existing law requires a hospital that provides emergency medical services to provide notice of the planned reduction or elimination of those services to certain entities and the public, as specified. Existing law requires a health facility that implements a downgrade or change in services to make a reasonable effort to inform the community that it serves of the downgrade or change, as specified. Existing law authorizes the department to exempt a hospital from those disclosure requirements upon specified circumstances.

This bill would make legislative findings and declarations as to the necessity of a special statute for the communities of San Clemente, Dana Point, and San Juan Capistrano.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law provides for the licensure and regulation of health facilities, including general acute care hospitals, by the State Department of Public Health. Existing law authorizes a general acute care hospital, as defined, to offer special services, including, but not limited to, emergency medical services. Existing law requires a hospital that provides emergency medical services to provide notice of the planned reduction or elimination of those services to certain entities and the public, as specified. Existing law requires a health facility that implements a downgrade or change in services to make a reasonable effort to inform the community that it serves of the downgrade or change, as specified. Existing law authorizes the department to exempt a hospital from those disclosure requirements upon specified circumstances.

This bill would require a general acute care hospital that provides emergency medical services and that is scheduled for closure to conduct public hearings for public review and comment, as specified. The bill would also authorize Saddleback Memorial Medical Center, San Clemente, to continue, under its existing license, to provide emergency medical services to patients in the region if it otherwise transforms its delivery of services.

This bill would make legislative findings and declarations as to the necessity of a special statute for the communities of San Clemente, Dana Point, and San Juan Capistrano.

This bill would declare that it is to take effect immediately as an urgency statute.

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 787

SUBJECT: Hospitals: closures

SUMMARY:

Permits Saddleback Memorial Medical Center to operate an emergency department at its San Clemente campus, subject to approval by the California Department of Public Health (CDPH), even if the San Clemente campus stopped providing acute care services, thereby permitting a freestanding emergency department, subject to specified conditions.

Existing law:

1. Licenses general acute care hospitals under CDPH. Defines general acute care hospitals as hospitals that provide 24-hour inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services.
2. Permits general acute care hospitals, in addition to the basic services all hospitals are required to offer, to be approved by CDPH to offer special services, including, but not limited to, a radiation therapy department, a burn center, an emergency center, a hemodialysis center or unit, psychiatric services, intensive care newborn nursery, cardiac surgery, cardiac catheterization laboratory, and renal transplant.
3. Requires CDPH to issue a single consolidated license to a general acute care hospital that includes more than one physical plant maintained and operated on separate premises or that has multiple licenses for a single health facility on the same premises if the general acute care hospital meets certain criteria and applicable requirements of licensure.
4. Requires any hospital that provides emergency medical services to provide notice no later than 90 days prior to a planned reduction or elimination of the level of emergency medical services of the intended change to CDPH, the local emergency medical services agency, and all health care service plans or other entities under contract with the hospital to provide services to enrollees. Additionally requires the hospital to provide notice of the intended change in a manner that is likely to reach a significant number of residents of the community served by the facility.

Existing regulations:

1. Requires an emergency medical service to be so located in the hospital as to have ready access to all necessary services.
2. Requires a hospital that is approved to offer emergency medical service to have the following service capabilities:
   1. Intensive care service with adequate monitoring and therapeutic equipment;
   2. Laboratory service with the capability of performing blood gas analysis and electrolyte determinations;
   3. Radiological service to be capable of providing the necessary support for the emergency service;
   4. Surgical services immediately available for life-threatening situations;
   5. Post-anesthesia recovery service; and,
   6. The services of a blood bank containing common types of blood and blood derivatives readily available, with blood storage facilities in or adjacent to the emergency service.

This bill:

1. Permits Saddleback Memorial Medical Center, notwithstanding any other law, to operate an emergency department (ED) at its San Clemente campus, subject to the approval by CDPH and all of the conditions specified in this bill.
2. Requires the San Clemente ED to operate under the consolidated license of Saddleback Memorial Medical Center and to meet all of the requirements imposed under that license, including being within 15 miles of its parent hospital.
3. Requires the San Clemente ED to be a conversion from a previously existing acute care campus and prohibits it from being a newly developed freestanding ED.
4. Requires the San Clemente ED to be open 24 hours a day, 365 days a year.
5. Requires the San Clemente ED to be staffed by at least one board-certified emergency physician at all times.
6. Requires the San Clemente ED to be staffed with properly trained emergency room nurses and meet the minimum staffing requirements for EDs in this state.
7. Requires the San Clemente ED to have a complete range of laboratory and diagnostic radiology services, including a complete array of laboratory test, basic X-ray, computerized tomography (CT) scan, and ultrasound capabilities.
8. Requires the San Clemente ED to meet the specialty call requirements, as defined by the Orange County emergency medical services agency, under its consolidated license.
9. Requires the San Clemente ED to have transfer agreements with specialty centers, such as trauma, burn, and pediatric centers, to meet the needs of the injury or patient population served in the community.
10. Requires the San Clemente ED to have the capabilities to stabilize patients with emergency medical conditions and to transport them to its parent hospital or other higher level of care facilities in a safe and timely manner, consistent with the standards of care in the local communities.
11. Requires the San Clemente ED to have a fully functioning transport program with a proven track record of safely transporting patients who require admission to its parent hospital or other higher level of care and specialty services facilities, such as trauma, burn, and pediatric facilities.
12. Requires all applicable federal and state regulatory requirements to be met under the consolidated license of Saddleback Memorial Medical Center, including all applicable regulations of the Centers for Medicare and Medicaid Services and Title 22 of the California Code of Regulations.
13. Requires the San Clemente ED to satisfy any other site-specific criteria that CDPH deems necessary.
14. Prohibits anything in this bill from being construed to require Saddleback Memorial Medical Center to provide for concomitant acute care service at the San Clemente campus or to seek additional licensure for operation of the San Clemente ED that is authorized pursuant to this bill.
15. States legislative findings and declarations that a special law is necessary and that a general law cannot be made applicable within the meaning of a specified provision of the California Constitution because of the unique circumstances regarding the provision of emergency medical services to the communities of San Clemente, Dana Point, and San Juan Capistrano.
16. Contains an urgency clause that will make this bill effective upon enactment.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, the operator of Saddleback Memorial Medical Center’s San Clemente campus (“San Clemente Hospital”) is considering plans to convert the hospital into an ambulatory health care campus that would provide outpatient surgery and urgent care services. This plan would eliminate the hospital’s 73-bed hospital and emergency room. This bill authorizes San Clemente Hospital to continue to provide emergency medical services to patients in the region if it otherwise transforms its delivery of services.
   
   San Clemente Hospital has served South Orange County for more than 40 years, and operates the only emergency facility between Mission Viejo and Oceanside. While the converted San Clemente Hospital would have an urgent care center, state law does not allow 911 patients to be transported to urgent care centers. Ambulances transporting 911 patients to the closest facilities that could take patients in need of emergency services from the area that is presently served by San Clemente Hospital would face longer distances on roads and highways that are frequently congested with traffic. The longer ambulance rides could risk the lives of patients. Additionally, the nearest emergency rooms are already strained by the number of patients that come in, and could be forced to turn away additional emergency patients.
2. Background on San Clemente hospital. San Clemente Hospital is part of MemorialCare Health System, which is a nonprofit health care delivery system with six hospitals, as well as a number of surgical centers and outpatient clinics in Los Angeles and Orange County. San Clemente Hospital is licensed for 73 beds, and operates under a consolidated license with Saddleback Memorial Medical Center – Laguna Hills, which has 252 licensed beds. The Laguna Hills campus is located about 14 miles north of San Clemente Hospital, with both hospitals adjacent to the Interstate 5 highway. According to newspaper articles, MemorialCare Health System announced in August of 2014 that they were planning to replace San Clemente Hospital with a new facility that would offer a wide range of outpatient services, including an advanced urgent care.
   
   According to the Office of Statewide Health Planning and Development’s Annual Utilization Report for San Clemente Hospital, the hospital’s ED was placed on diversion (meaning the ED was closed to ambulances because it was full) for a total of 112 hours in 2014. The following table is San Clemente Hospital’s emergency utilization data for 2014:

Other hospitals in the surrounding region include:

1. Mission Hospital Laguna Beach, with 123 acute care beds with somewhat similar ED utilization rates and is located seven miles north of San Clemente Hospital on Highway 1;
2. Mission Hospital Regional Medical Center, with 345 acute care beds, a Level II trauma center, and an ED that is about three times the size of San Clemente Hospital’s ED which went on diversion status for 683 hours in 2014. Mission Hospital Regional Medical Center is located about nine miles north of San Clemente Hospital along I-5, in Mission Viejo; and,
3. Saddleback Memorial Medical Center – Laguna Hills, the parent hospital of San Clemente Hospital, with 252 acute care beds and an ED that is roughly the size of Mission Hospital Regional Medical Center, which went on diversion for a total of 308 hours in 2014. This hospital is located about 14 miles north of San Clemente Hospital along I-5.

Under existing law, a hospital that offers emergency medical services is required to provide CDPH, among others, with at least 90 days notice of any planned reduction or closure of the emergency medical service. According to CDPH, San Clemente Hospital has not provided this notice, but that the MemorialCare Health System is currently working on a feasibility study to determine the future of the hospital.

1. Background on freestanding EDs. There are currently no freestanding EDs licensed in California, although they do operate in other states. According to an article in Kaiser Health News in July of 2013, the number of freestanding EDs doubled to more than 400 between 2009 and 2013. According to a 2013 information paper published by the American College of Emergency Physicians, there are two distinct types of freestanding EDs: those that are operated by, or licensed through, medical centers or hospital systems but are geographically separate from the hospital, and those that are independent of a hospital. As an example of the latter, First Choice ER is a for-profit chain of freestanding, 24-hour emergency rooms that operate in Texas and Colorado. CHCF published an issue brief in July of 2009, entitled “Freestanding Emergency Departments: Do They Have a Role in California” (CHCF report). According to the CHCF report, the growth of freestanding EDs has prompted discussions regarding their regulation and effect on the health care system. The CHCF report states that these facilities differ from urgent care centers in that they can accommodate additional procedures such as defibrillation, intubation, and conscious sedation. Additionally, most freestanding EDs are staffed by trained emergency physicians and nurses, and some have been permitted to receive ambulance patients. In California, in order to offer emergency medical services, a facility must provide certain services, such as intensive care, radiology, and surgical services that are immediately available for life-threatening situations, which essentially require an ED to be part of a full-fledged hospital.
2. Pilot project at Centinela Airport Clinic. Using statutory authority that authorizes a local EMSA to “approve or conduct any scientific or trial study of the efficacy of the pre-hospital emergency use of any drug, device, or treatment procedure within the local EMS system,” the Los Angeles County EMSA approved a two-year pilot project beginning in 2004 to allow the Centinela Airport Clinic at Los Angeles International Airport to receive 911 transports of basic life-support patients. This was apparently the first time that an emergency medical services system in California was allowed to transport patients from 911 dispatch to a facility that was not part of a hospital. However, both CDPH and the statewide California EMSA Medical disagreed that the local EMS agency had the authority to permit the operation of such a facility. Ultimately, this “freestanding ED” pilot project ended after one year, partly as a result of low volume that resulted from a restrictive county ambulance triage policy that limited the severity of patients that could be transported to this location.
3. Related legislation. AB 911 (Brough), is nearly identical to this bill. AB 911 is currently pending in Assembly Health Committee.

AB 579 (Obernolte) permits a general acute care hospital to operate an ED located more than 15 miles from its main physical plant, if all applicable requirements of licensure are satisfied. The bill would also permit a closing general acute care hospitals' ED to continue to be operated at the same location or locations by an acquiring general acute care hospital, as specified. AB 579 creates an exception to permit the acquiring general acute care hospital to operate the closing general acute care hospitals' ED at that location or locations, even if located more than 15 miles from the acquiring general acute care hospital’s main physical plant, if all applicable requirements of licensure are satisfied. AB 579 is currently pending in Assembly Health Committee.

1. Prior legislation. AB 717 (Gordon of 2005) would have allowed the Centinela Airport Clinic to receive private and government reimbursement rates equivalent to that of a contiguous emergency department of a general acute care hospital if certain specified requirements were met.  AB 717 failed passage in the Senate Health Committee.
   
   AB 1050 (Gordon of 2005) would have created a demonstration project that required the Department of Health Services to issue a special permit to up to four general acute care hospital applicants in Los Angeles County to operate freestanding emergency receiving centers.  AB 1050 was never heard in Committee.
2. Support. This bill is supported by Saddleback Memorial Medical Center (Saddleback), which operates both the larger hospital in Laguna Hills as well as San Clemente Hospital under a consolidated license. According to Saddleback, aggressive investments have been made in chronic disease management infrastructure and care navigation personnel aimed at finding new and innovate ways to care for patients in non-acute care settings. A consequence of these efforts has been that their inpatient volumes have contracted in proportion to the growth of their ambulatory care services. Saddleback states that the San Clemente campus doesn’t perform more sophisticated services such as interventional cardiology or neonatal intensive care, and therefore has had a smaller inpatient census than many hospitals. For the last decade, the average inpatient census has been around 25, but in recent years, it has dropped below 14 on average, with many days being below 10. Saddleback states that as a result of their governing board, a study is being conducted to evaluate transforming the San Clemente campus to an array of coordinated, state of the art ambulatory care services. Pursuant to this effort, Saddleback states that it has had numerous discussions with various stakeholders, and it became very clear that there was a strong desire to maintain emergency services on the San Clemente campus. Saddleback states that preserving emergency services is currently dependent upon preserving the acute care service under current law, but that maintaining acute care with a very small census is becoming increasingly difficult given the market forces.
   
   The City of San Clemente states in support that without this bill, their residents and the residents of the surrounding area will be forced to travel 15 miles north on I-5 to the nearest emergency room, a road whose access and travel time is uncertain due to traffic congestions and road construction. The City of San Clemente notes that this bill does not propose changing the hospital and emergency structure throughout the state, but proposes a standalone emergency department solely for this unique geographic region in South Orange County. The City of San Clemente states that it will leave a 40-mile void in emergency care access between Oceanside and Mission Viejo if it closes.
   
   This bill is also supported by a group of several physicians who have formed “Save Saddleback San Clemente Hospital” (SSSCH). According to SSSCH, San Clemente Hospital’s ED serves 15,000 people yearly and is the second busiest ER in the region. SSSCH states that their community is effectively a peninsula, with Camp Pendleton south, protected forest to the east, the ocean to the west, and only one road north, I-5, to access emergency services. According to SSSCH, an I-5 widening project has just started closing shoulders and ramps intermittently, and that this project will last three years. SSSCH states that in 2013 and 2014, the average transport times from a typical San Clemente residence was 17 minutes to the next closest hospital, Mission Hospital Regional Medical Center in Mission Viejo, and now that construction has begun, transport times to this facility can exceed 30 minutes. According to SSSCH, Mission Hospital, which will get their 15,000 patients, leads all 26 hospitals in Orange County in wall time (when emergency personnel must wait in the ED with their patients while waiting for a bed to open up) and diversion time (when the ED is closed to paramedic traffic because the ED is full). SSSCH states that with San Clemente Hospital closing, their community will be left with 75 ED beds to cover more than 400,000 people. SSSCH states that this bill is critical to keep access to emergency care in their community.
3. Opposition. The California Nurses Association (CNA) opposes this bill, and points to arguments by the owner of the hospital that local 911 calls for patients who may have a heart attack, stroke, or trauma currently bypass San Clemente hospital to go to cardiac receiving centers, stroke receiving centers, and trauma centers. According to CNA, in other words, San Clemente hospital’s ED is being bypassed by Orange County emergency medical services because its ED is insufficiently supported by certain necessary and specialized urgent support services, and that this bill would exacerbate such insufficiency by diminishing even further those support services while simultaneously holding itself out to the public as an ED. The California State Council of the Service Employees International Union (SEIU California) states in opposition that under existing law, in order to provide emergency services in California, emergency services must be located within a hospital so as to have access to all necessary services. SEIU California states that the reason for these requirements is that it is difficult to predict the severity of the medical needs of patients presenting at an ED. Should an individual require immediate surgery to save his or her life, for example, SEIU California states that those services should be as close and readily available to the patient as possible. The California Labor Federation states in opposition that health care consumers have a reasonable expectation that when they visit an emergency department, they will have access to more services than when they visit an urgency care center. This expectation extends to billing procedures as well, and the California Labor Federation notes that patient cost-sharing for emergency departments are often much higher than for urgent care. Patients may end up with much higher bills because they assumed the freestanding emergency department was an urgent care center, or conversely, may end up at the freestanding emergency department expecting a full range of services, only to be transported to a hospital.
4. Oppose unless amended. The California Chapter of the American College of Emergency Physicians (CalACEP) opposes this bill unless amended to include important, more specific patient safety protections. According to CalACEP, their concerns center around allowing facilities to contain the word “emergency” in their title without ensuring that the facility will treat all patients regardless of their ability to pay, as well as their ability to provide patients with full-scope emergency department care. CalACEP is also concerned about placing freestanding emergency departments in areas with little community need where the highest paying patients can be siphoned away from the payer mix of a nearby emergency department, which has a critical effect on the community safety net. As a result, CalACEP states that they are opposed to legislation which would allow for a freestanding emergency department unless it contained important protections to ensure that the freestanding emergency department complied with the Emergency Medical Treatment and Active Labor Act, it is open 24/7, the ownership is open to all, there are reasonable transfer agreements in place, there are minimum standards to ensure quality care, there is an established community need, and there are minimum education and training requirements for providers. CalACEP states that while there are provisions in this bill which seek to address these concerns, it believes more specificity is needed.
   

SUPPORT AND OPPOSITION:

Support: City of Dana Point
City of San Clemente
Saddleback Memorial Medical Center
Several individuals

Oppose: California Chapter of the American College of Emergency Physicians (Unless Amended)

California Labor Federation

California Nurses Association

California State Council of Service Employees International Union

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 787

SUBJECT: Hospitals: closures

SUMMARY:

Permits Saddleback Memorial Medical Center to operate an emergency department at its San Clemente campus, even if the San Clemente campus stopped providing acute care services thereby permitting a freestanding emergency department, subject to specified conditions.

Existing law:

1. Licenses general acute care hospitals under the California Department of Public Health (CDPH). Defines general acute care hospitals as hospitals that provide 24-hour inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services.

2. Permits general acute care hospitals, in addition to the basic services all hospitals are required to offer, to be approved by CDPH to offer special services, including, but not limited to, a radiation therapy department, a burn center, an emergency center, a hemodialysis center or unit, psychiatric services, intensive care newborn nursery, cardiac surgery, cardiac catheterization laboratory, and renal transplant.

3. Requires CDPH to issue a single consolidated license to a general acute care hospital that includes more than one physical plant maintained and operated on separate premises or that has multiple licenses for a single health facility on the same premises if the general acute care hospital meets certain criteria and applicable requirements of licensure.

4. Requires any hospital that provides emergency medical services to provide notice no later than 90 days prior to a planned reduction or elimination of the level of emergency medical services of the intended change to CDPH, the local emergency medical services agency, and all health care service plans or other entities under contract with the hospital to provide services to enrollees. Additionally requires the hospital to provide notice of the intended change in a manner that is likely to reach a significant number of residents of the community served by the facility.

Existing regulations:

1. Requires an emergency medical service to be so located in the hospital as to have ready access to all necessary services.

2. Requires a hospital that is approved to offer emergency medical service to have the following service capabilities:

1. Intensive care service with adequate monitoring and therapeutic equipment;

2. Laboratory service with the capability of performing blood gas analysis and electrolyte determinations;

3. Radiological service to be capable of providing the necessary support for the emergency service;

4. Surgical services immediately available for life-threatening situations;

5. Post-anesthesia recovery service; and,

6. The services of a blood bank containing common types of blood and blood derivatives readily available, with blood storage facilities in or adjacent to the emergency service.

This bill:

1. Permits Saddleback Memorial Medical Center, notwithstanding any other law, to operate an emergency department (ED) at its San Clemente campus, subject to the conditions specified in this bill.

2. Requires the San Clemente ED to operate under the consolidated license of Saddleback Memorial Medical Center and to meet all of the requirements imposed under that license, including being within 15 miles of its parent hospital.

3. Requires the San Clemente ED to be a conversion from a previously existing acute care campus and prohibits it from being a newly developed freestanding ED.

4. Requires the San Clemente ED to be open 24 hours a day, 365 days a year.

5. Requires the San Clemente ED to be staffed by at least one board-certified emergency physician at all times.

6. Requires the San Clemente ED to be staff with properly trained emergency room nurses and meet the minimum staffing requirements for EDs in this state.

7. Requires the San Clemente ED to have a complete range of laboratory and diagnostic radiology services, including a complete array of laboratory test, basic X-ray, computerized tomography (CT) scan, and ultrasound capabilities.

8. Requires the San Clemente ED to meet the specialty call requirements, as defined by the Orange County emergency medical services agency, under its consolidated license.

9. Requires the San Clemente ED to have transfer agreements with specialty centers, such as trauma, burn, and pediatric centers, to meet the needs of the injury or patient population served in the community.

10. Requires the San Clemente ED to have the capabilities to stabilize patients with emergency medical conditions and to transport them to its parent hospital or other higher level of care facilities in a safe and timely manner, consistent with the standards of care in the local communities.

11. Requires the San Clemente ED to have a fully functioning transport program with a proven track record of safely transporting patients who require admission to its parent hospital or other higher level of care and specialty services facilities, such as trauma, burn, and pediatric facilities.

12. Requires all applicable federal and state regulatory requirements to be met under the consolidated license of Saddleback Memorial Medical Center, including all applicable regulations of the Centers for Medicare and Medicaid Services and Title 22 of the California Code of Regulations.

13. Prohibits anything in this bill from being construed to require Saddleback Memorial Medical Center to provide for concomitant acute care service at the San Clemente campus or to seek additional licensure for operation of the San Clemente ED that is authorized pursuant to this bill.

14. States legislative findings and declarations that a special law is necessary and that a general law cannot be made applicable within the meaning of a specified provision of the California Constitution because of the unique circumstances regarding the provision of emergency medical services to the communities of San Clemente, Dana Point, and San Juan Capistrano.

15. Contains an urgency clause that will make this bill effective upon enactment.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, the operator of San Clemente’s Saddleback Memorial Medical Center (“San Clemente Hospital”) is considering plans to convert the hospital into an ambulatory health care campus that would provide outpatient surgery and urgent care services. This plan would eliminate the hospital’s 73-bed hospital and emergency room. This bill authorizes San Clemente Hospital to continue to provide emergency medical services to patients in the region if it otherwise transforms its delivery of services.
   
   San Clemente Hospital has served South Orange County for more than 40 years, and operates the only emergency facility between Mission Viejo and Oceanside. While the converted San Clemente Hospital would have an urgent care center, state law does not allow 911 patients to be transported to urgent care centers. Ambulances transporting 911 patients to the closest facilities that could take patients in need of emergency services from the area that is presently served by San Clemente Hospital would face longer distances on roads and highways that are frequently congested with traffic. The longer ambulance rides could risk the lives of patients. Additionally, the nearest emergency rooms are already strained by the number of patients that come in, and could be forced to turn away additional emergency patients.

2. Background on San Clemente hospital. San Clemente Hospital is part of Health System, which is a nonprofit health care delivery system with six hospitals, as well as a number of surgical centers and outpatient clinics in Los Angeles and Orange County. San Clemente Hospital is licensed for 73 beds, and operates under a consolidated license with Saddleback Memorial Medical Center – Laguna Hills, which has 252 licensed beds. The Laguna Hills campus is located about 14 miles north of San Clemente Hospital, with both hospitals adjacent to the Interstate 5 highway. According to newspaper articles, MemorialCare Health System announced in August of 2014 that they were planning to replace San Clemente Hospital with a new facility that would offer a wide range of outpatient services, including an advanced urgent care.
   
   According to the Office of Statewide Health Planning and Development’s Annual Utilization Report for San Clemente Hospital, the hospital’s ED was placed on diversion (meaning the ED was closed to ambulances because it was full) for a total of 112 hours in 2014. The following table is San Clemente Hospital’s emergency utilization data for 2014:

Other hospitals in the surrounding region include:

1. Mission Hospital Laguna Beach, with 123 acute care beds with somewhat similar ED utilization rates and is located seven miles north of San Clemente Hospital on Highway 1;

2. Mission Hospital Regional Medical Center, with 345 acute care beds, a Level II trauma center, and an ED that is about three times the size of San Clemente Hospital’s ED which went on diversion status for 683 hours in 2014. Mission Hospital Regional Medical Center is located about nine miles north of San Clemente Hospital along I-5, in Mission Viejo; and,

3. Saddleback Memorial Medical Center – Laguna Hills, the parent hospital of San Clemente Hospital, with 252 acute care beds and an ED that is roughly the size of Mission Hospital Regional Medical Center, which went on diversion for a total of 308 hours in 2014. This hospital is located about 14 miles north of San Clemente Hospital along I-5.

Under existing law, a hospital that offers emergency medical services is required to provide CDPH, among others, with at least 90 days notice of any planned reduction or closure of the emergency medical service. According to CDPH, San Clemente Hospital has not provided this notice, but that the MemorialCare Health System is currently working on a feasibility study to determine the future of the hospital.

3. Background on freestanding EDs. There are currently no freestanding EDs licensed in California, although they do operate in other states. According to an article in Kaiser Health News in July of 2013, the number of freestanding EDs doubled to more than 400 between 2009 and 2013. According to a 2013 information paper published by the American College of Emergency Physicians, there are two distinct types of freestanding EDs: those that are operated by, or licensed through, medical centers or hospital systems but are geographically separate from the hospital, and those that are independent of a hospital. As an example of the latter, First Choice ER is a for-profit chain of freestanding, 24-hour emergency rooms that operate in Texas and Colorado. CHCF published an issue brief in July of 2009, entitled “Freestanding Emergency Departments: Do They Have a Role in California” (CHCF report). According to the CHCF report, the growth of freestanding EDs has prompted discussions regarding their regulation and effect on the health care system. The CHCF report states that these facilities differ from urgent care centers in that they can accommodate additional procedures such as defibrillation, intubation, and conscious sedation. Additionally, most freestanding EDs are staffed by trained emergency physicians and nurses, and some have been permitted to receive ambulance patients. In California, in order to offer emergency medical services, a facility must provide certain services, such as intensive care, radiology, and surgical services that are immediately available for life-threatening situations, which essentially require an ED to be part of a full-fledged hospital.

4. Pilot project at Centinela Airport Clinic. Using statutory authority that authorizes a local EMSA to “approve or conduct any scientific or trial study of the efficacy of the pre-hospital emergency use of any drug, device, or treatment procedure within the local EMS system,” the Los Angeles County EMSA approved a two-year pilot project beginning in 2004 to allow the Centinela Airport Clinic at Los Angeles International Airport to receive 911 transports of basic life-support patients. This was apparently the first time that an emergency medical services system in California was allowed to transport patients from 911 dispatch to a facility that was not part of a hospital. However, both CDPH and the statewide California EMSA Medical disagreed that the local EMS agency had the authority to permit the operation of such a facility. Ultimately, this “freestanding ED” pilot project ended after one year, partly as a result of low volume that resulted from a restrictive county ambulance triage policy that limited the severity of patients that could be transported to this location.

5. Related legislation. AB 911 (Brough), is nearly identical to this bill. AB 911 is currently scheduled to be heard in Assembly Health Committee on April 28, 2015.

AB 579 (Obernolte), permits a general acute care hospital to operate an ED located more than 15 miles from its main physical plant, if all applicable requirements of licensure are satisfied. The bill would also permit a closing general acute care hospitals' ED to continue to be operated at the same location or locations by an acquiring general acute care hospital, as specified. AB 579 creates an exception to permit the acquiring general acute care hospital to operate the closing general acute care hospitals' ED at that location or locations, even if located more than 15 miles from the acquiring general acute care hospital’s main physical plant, if all applicable requirements of licensure are satisfied. AB 579 is currently pending in Assembly Health Committee.

6. Prior legislation. AB 717 (Gordon), of 2005, would have allowed the Centinela Airport Clinic to receive private and government reimbursement rates equivalent to that of a contiguous emergency department of a general acute care hospital if certain specified requirements were met.  AB 717 failed passage in the Senate Health Committee.
   
   AB 1050 (Gordon), of 2005, would have created a demonstration project that required the Department of Health Services to issue a special permit to up to four general acute care hospital applicants in Los Angeles County to operate freestanding emergency receiving centers.  AB 1050 was never heard in Committee.

7. Support. This bill is supported by a group of several physicians who have formed “Save Saddleback San Clemente Hospital” (SSSCH). According to SSSCH, MemorialCare Health System has been planning to close their community’s 73-bed hospital and ED. The hospital is likely to close this year regardless of this legislation, and SSSCH states that the fate of the ED hangs on this bill. According to SSSCH, San Clemente Hospital’s ED serves 15,000 people yearly and is the second busiest ER in the region. SSSCH states that their community is effectively a peninsula, with Camp Pendleton south, protected forest to the east, the ocean to the west, and only one road north, I-5, to access emergency services. According to SSSCH, an I-5 widening project has just started closing shoulders and ramps intermittently, and that this project will last three years. SSSCH states that in 2013 and 2014, the average transport times from a typical San Clemente residence was 17 minutes to the next closest hospital, Mission Hospital Regional Medical Center in Mission Viejo, and now that construction has begun, transport times to this facility can exceed 30 minutes. According to SSSCH, Mission Hospital, which will get their 15,000 patients, leads all 26 hospitals in Orange County in wall time (when emergency personnel must wait in the ED with their patients while waiting for a bed to open up) and diversion time (when the ED is closed to paramedic traffic because the ED is full). SSSCH states that with San Clemente Hospital closing, their community will be left with 75 ED beds to cover more than 400,000 people. SSSCH states that this bill is critical to keep access to emergency care in their community.

8. Opposition. The California Chapter of the American College of Emergency Physicians (CalACEP) states in opposition that freestanding EDs are facilities that provide urgent care, but are not attached to acute care hospitals. While the words “emergency department” are in the title of these facilities, CalACEP states that they operate like urgent care clinics, not EDs. According to CalACEP, the very nature of an ED is that it is a department of a hospital – a place where patients have immediate access to a wide variety of treatment services and specialists when necessary to treat their serious condition. Allowing urgent care facilities to contain the word “emergency” in the title poses patient safety risks to patients who arrive at the door assuming they can receive full-scope ED care. CalACEP points to the example foa patient presenting at a freestanding ED with chest pains, only to find out they are having a heart attack and require transfer to a hospital. The critical, wasted time in transport is time during which the patient should be receiving life-saving care.
   
   The California Nurses Association (CNA) also opposes this bill, and points to arguments by the owner of the hospital that local 911 calls for patients who may have a heart attack, stroke, or trauma currently bypass San Clemente hospital to go to cardiac receiving centers, stroke receiving centers, and trauma centers. According to CNA, in other words, San Clemente hospital’s ED is being bypassed by Orange County emergency medical services because its ED is insufficiently supported by certain necessary and specialized urgent support services, and that this bill would exacerbate such insufficiency by diminishing even further those support services while simultaneously holding itself out to the public as an ED. The California State Council of the Service Employees International Union (SEIU California) states in opposition that under existing law, in order to provide emergency services in California, emergency services must be located within a hospital so as to have access to all necessary services. SEIU California states that the reason for these requirements is that it is difficult to predict the severity of the medical needs of patients presenting at an ED. Should an individual require immediate surgery to save his or her life, for example, SEIU California states that those services should be as close and readily available to the patient as possible.

SUPPORT AND OPPOSITION:

Support: Three individuals

Oppose: California Chapter of the American College of Emergency Physicians

California Nurses Association

California State Council of Service Employees International Union

-- END --