On a Monday night in January, Fresno County's ambulance system was perilously close to paralysis when nine ambulances were delayed at Community Regional Medical Center -- two for 3-1/2 hours.
Ambulance staff is required to stay with patients until they are accepted for exams in an emergency room. On Jan. 13, too many ambulance staffers were kept waiting too long at the region's busiest hospital, said Dan Lynch, Fresno County Emergency Medical Services director.
Lynch filed a complaint with the California Department of Public Health Licensing and Certification Program. Department spokesman Corey Egel confirmed Friday the complaint is under investigation.
"If CDPH identifies violations by the hospital of federal and/or state requirements for ambulances waiting at emergency rooms to be released, only then can CDPH issue a deficiency and consider levying penalties as appropriate," Egel said.
When ambulance staff is delayed at a hospital, it causes a ripple effect across the emergency system. Firefighters have to stay longer at medical-aid calls because of ambulance delays and are unable to respond to other emergency calls. Other ambulances are positioned to serve more distant parts of the region and can't reposition quickly to respond to calls. And when ambulance companies don't meet recommended times, they are fined.
County and ambulance officials say that 30 minutes should be the maximum for ambulance teams to be at hospitals with patients.
More than one in three ambulances exceeded the 30-minute recommendation at Community Regional in 2013, according to statistics provided to the Fresno County Emergency Medical Care Committee.
None of the 11 other hospitals monitored by the committee exceeded 30% in any single month last year.
The problems leading to Jan. 13 were building over time, Lynch said, but nothing fully prepared local emergency officials for it.
"It was the peak of an issue," he said. "You saw symptoms leading up to this point."
On that night, eight ambulances were at Community Regional for at least 90 minutes. After some time had elapsed, bad fortune was avoided with some well-placed phone calls to hospital officials who got the ambulances back on the road within a half-hour, Lynch said.
The next morning, he filed the complaint with the state Department of Public Health.
The reason for the delay, said Lynch, is still unknown.
In the crowded emergency room that night, hospital officials said, they did not realize how many ambulance crews were being forced to stay parked.
"When we were notified, we quickly got patients placed," said Brenda Diel, assistant chief nursing officer at Community Regional. "It was an oversight on our part; the patients had been seen by a nurse and were just awaiting a treatment area."
Wait times are a way to evaluate ambulance services. Ambulance companies are fined if they don't, or can't, follow the main rule: arrive fast to emergency calls.
The Central California Emergency Medical Services Committee penalizes ambulance companies for slow responses. Last year, American Ambulance was fined $144,447. Nearly 98% of those fines were for late responses or excessive delays, according to committee records. The companies can be fined even if their ambulances have been stalled at the hospital.
The biggest problem for ambulances is at Community Regional. At times, said Todd Valeri, general manager for American Ambulance, which provides ambulances in Fresno, Madera, Tulare, and Kings counties, the number of ambulances stacked up outside the hospital has risen into the teens.
While there were times when more ambulances were parked outside Community Regional, the problems on Jan. 13 were exacerbated because it was a time when fewer ambulances are normally on duty.
"We can deploy more ambulances, but we don't have unlimited resources," Valeri said. "We have to do our best to identify times when additional staffing will help."
Valeri acknowledges that some delays resulting in fines "are directly related to ambulances caught up at hospitals."
Waits longer than 30 minutes at emergency rooms occurred nearly four times more often at Community Regional than other hospitals in the Valley.
In 2013, ambulances were held up more than 30 minutes at Community Regional about 34% of the time. About 9% of ambulances at the other 11 hospitals monitored by the county's Emergency Medical Care Committee were at hospitals more than 30 minutes.
Those numbers have risen steadily in the past four years. In March 2010, about 19.4% of ambulances were delayed at Community Regional beyond 30 minutes. In December, the rate was about 34.5%.
Valeri doesn't cast blame on Community Regional. "This is not personal and it's not about incompetence. It's about finite resources and unlimited demand."
But Brad Richter, chairman of the Fresno County Emergency Medical Care Committee, is not as charitable toward the hospital. Delays that lead to fines are costly to ambulance service companies, he said.
"If I had a business, I couldn't afford to pay $10,000 or $20,000 a month off the top," he said.
One night last July, he said, 18 ambulances were queued up outside the emergency room. Ambulance crews deliver about 120 patients daily to Community Regional.
"Emergency Medical Services staff has been working very hard to correct this problem over the last couple of years with no improvement," Richter said. "If the current trend continues, in several years, longer response times are going to be the norm in Fresno."
Emergency room patient visits in California increased nearly 20% between 2007 and 2012, according to the Office of Statewide Health Planning and Development.
For Community Regional -- the third busiest emergency room in California with 111,000 patients last year -- about 40% of emergency room patients arrive by ambulance. The rest are driven or walk in. Diel, Community Regional's assistant chief nursing officer, said the emergency room gets 300 patients each day.
Hospital officials are willing to explore other solutions to move ambulances along faster.
But Valeri said hospital officials rejected a proposal by American Ambulance to staff two paramedics at the hospital's emergency room to monitor ambulance patients and free up crews to get on the road.
Diel said no one has broached the subject with her, and she's interested in learning more about it.
Meanwhile, to speed up the process, the hospital began using a new system that lets emergency room officials know the number of ambulances at the hospital and how long they have been waiting, she said.
"We put that in place because of Jan. 13," Diel said. "We want Emergency Medical Services back out and in service as much as anybody else does."
Firefighters get the call
During the late afternoon and early evening hours of Jan. 13, the duration of Fresno Fire Department calls was 27.6% longer than average, said Capt. Gregg Skaggs.
He evaluated 1,725 medical-aid calls from Jan. 1-26, which averaged eight minutes and 57 seconds on scene. But during the peak hours on Jan. 13, he said, the average time at a medical-aid call was 11 minutes and 25 seconds.
Skaggs said he couldn't confirm that the longer calls were due to emergency room delays, "but it's obviously out of the norm."
Fortunately, there were no major fires or auto collisions during those hours.
Sanger Fire Department runs its own paramedic crews and has two ambulances on duty per shift.
Chief Greg Tarascou said his department has to call on other local fire departments or ambulance crews to backfill if several emergencies or medical-aid calls occur at the same time.
"If ambulances are backed up at (Community) Regional Medical Center, then we are stressed to get people to backfill us," he said.
Selma Fire Chief Mike Kain said his department has to call for a backup ambulance "several times a day," he said.
Selma contracts with American Ambulance, which often has to transport patients from Selma's hospital to Fresno or other locations in the state.
"Then you have one ambulance covering the whole city," Kain said.
If both ambulances are on calls, the city relies on trained paramedic firefighters who "will be on scene until the next ambulance arrives."
The next ambulance could come from Sanger Fire Department or Kingsburg.
"We rely on each other for backup," Kain said. "There are times in the system where everybody is on a call and that means your backup is available based upon where the next ambulance becomes available. Who knows where it could be coming from?"
Fresno's not alone
Avoiding similar paralysis is now foremost in the minds of emergency responders, hospital officials and ambulance companies. Ambulance delays are an increasing problem across California and the nation, officials say.
The California Hospital Association and the state Emergency Medical Services Authority convened the Patient-Ambulance Delay Collaborative, made up of officials statewide who are trying to learn why ambulances are spending too much time waiting at hospitals.
"There is not one right, easy answer," said B.J. Bartleson, California Hospital Association's vice president for nursing and clinical services.
She said peaks last month were caused by the flu, but she also said problems may be related to the number of ambulances on the road or hospital staffing levels.
The complaints, Bartleson said, run both ways.
"We hear complaints from hospitals that wonder why they get certain patients and hear from Emergency Medical Service agencies about waiting times," she said.
Longer emergency room delays most frequently occur at urban and county hospitals, said Dr. Howard Backer, medical director of the California Emergency Medical Services Authority. He serves on the Patient-Ambulance Delay Collaborative with Bartleson.
Although 30 minutes is a standard, there are no state rules requiring it be met, he said.
But longer than 30 minutes places a "community at risk of not being able to access emergency services in a way that's expected in life-threatening emergencies," he said.
In some areas it's a seasonal issue, in others it's year-round -- the reasons differ depending on the community.
"There are individual systems that have addressed this problem," Backer said. "It can be fixed if there is a will to do it."
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