If you want quick care for the flu, don’t go to a hospital

Community Regional Medical Center in downtown Fresno has been so busy this winter that the hospital has had to put the emergency department on lockdown, barring visitors from the waiting room to make seats available for patients.

Kaweah Delta Medical Center in Visalia is using a tent as an overflow waiting room for patients and family members who accompany them.

Many of the patients in hospital emergency departments have the flu. This year’s virus strains are extremely infectious and harmful. California has reported 97 influenza deaths of people younger than age 65 through Jan. 20. There could be more – influenza deaths are not tracked by the state for people 65 and older.

But this flu season is not the first time hospitals have been forced to lock down an emergency department or to to erect a tent-waiting room to handle coughing, sneezing, feverish flu patients. Every winter, a bump in patients with influenza makes already-busy emergency departments in the central San Joaquin Valley swell to capacity, increasing the time emergency patients wait to be seen and treated.

“I know people get frustrated waiting and they see patients come in after them and are seen before they are treated,” said Tina Gulbronson, chief of nursing at Community Regional. But the sickest patients are seen first, whether they come by ambulance or walk in, she said.

Overcrowded emergency departments irritate patients and stress doctors and nurses, but more is at stake than patient satisfaction: Patients at overcrowded emergency departments are 5 percent more likely to die and have longer hospital stays than patients at less-crowded hospital emergency departments.

Several hospitals in the Valley have plans to expand emergency departments that are bursting at the seams. And they all have strategies to get patients with minor illnesses seen and out the door as soon as possible. But doctors and nurses said more space and efficiencies at the emergency department can go only so far in reducing the time patients wait for care.

Patients share some of the responsibility for how they use hospital emergency departments, they said. But many patients have no access to care other than the ER for illnesses that otherwise could be dealt with at a doctor’s office.

Overcrowded emergency departments are not unique to the Valley. Nationwide, hospitals are seeing more emergency patients. According to a February 2016 National Health Statistics Report, 18 percent of adults visited an ER one or more times in 2014. Nearly 80 percent said they came to the hospital for a serious problem – but nearly 12 percent said they visited the emergency room because their doctor’s office was not open; and 7 percent said they did not have access to a doctor or other provider.

No place to go

Dr. W. Eugene Egerton, chief medical officer at Saint Agnes Medical Center, said access to care is a problem for many patients in the Valley.

The Valley has a shortage of family doctors, and getting an appointment can be difficult. “If you can’t get in to see your doctor at the time you think you need to see your doctor, or if you’re ill and you can’t wait, you turn to the emergency room,” Egerton said.

Patients also come to the emergency department because they are seeking care at night or on weekends, when the doctor’s office is closed. Emergency departments are always open. And every winter, influenza adds to the bottleneck. The result is full waiting rooms. An emergency visit that should take less than two hours can stretch to four or more.

“It’s frustrating for us, too,” said Dr. Jessica Mason, an emergency physician at Community Regional.

Doctors don’t want to discourage patients from seeking help at hospital emergency departments. “There’s something important about self-triage,” Mason said. People know their bodies, and if they feel sick enough, the emergency room is probably their best option, she said.

The flu can warrant a trip to the hospital. Children, the elderly and people with weakened immune systems are more at risk of influenza-related conditions, such as pneumonia. And someone who is having trouble holding down fluids or is light-headed, has a rapid pulse or is short of breath, needs to seek care.

But many influenza patients can be treated elsewhere.

Urgent care centers, which have extended hours and are open on weekends, can be an answer for people who do not have severe or life-threatening conditions, Egerton said.

The Valley appears to have an adequate supply of the centers, and Egerton said patients need to be educated to use them.

The Urgent Care Association of America lists 35 centers in four counties – Fresno, Kings, Madera and Tulare – to serve 1.7 million people. That meets the association’s benchmark of one center for every 50,000 people.

Many hospitals have urgent care centers located nearby that can treat fever or flu, sprains, urinary tract infections and conditions that may need an X-ray or lab test. And hospitals have prompt-care clinics that can treat patients with minor complaints, such as colds, ingrown toenails and minor cuts.

Community Regional has a prompt-care clinic at the nearby Deran Koligian Ambulatory Care Center. It stays open until 8 p.m. weekdays and weekends.

Saint Agnes opened an urgent care center in northwest Fresno in 2016. Last year, it added a center at the hospital campus in northeast Fresno and installed large signs in the shape of a bandage to direct people there.

And Saint Agnes also collaborated with Clinica Sierra Vista this year to open a primary care clinic across the street from the hospital on Millbrook Avenue. The clinic, which opened Jan. 22, sees patients until 9 p.m. on weekdays and until 7 p.m. on Saturdays.

Saint Agnes saw a need for a primary care clinic to relieve the emergency department, said Ruben Chavez, chief administrative officer at Clinica.

People are using urgent care centers, said Dr. Sakona Seng, medical director for the Kaweah Delta emergency department. “We have a very busy urgent care network. They do a great job of seeing patients and certainly in the right scenarios, it’s a great resource in the community.”

Urgent care centers can be busy, but patients often can be seen quicker than at an emergency department and for less money.

Dr. Roger Hicks, president of the California Urgent Care Association, said according to the insurer Cigna, the average cost of a hospital emergency visit is $2,259 compared to $176 for an urgent care visit.

But economics could deter some patients from choosing an urgent care visit. Not all urgent care centers in California accept Medi-Cal, the state-federal insurance program for people of low income. In some Valley counties, more than 50 percent of the people have Medi-Cal.

The government program pays a center $22 for a visit, which does not cover a center’s cost, Hicks said. He has a center in Grass Valley, but cannot afford to see Medi-Cal patients there, he said. Hospitals, on the other hand, have to see anyone who comes in the door.

Trying to accommodate

With flu season compounding overcrowding, hospitals in the Valley are trying to reduce patient wait times in several ways.

Community Regional, one of the busiest emergency departments in the state, has brought in traveling nurses to help with the increased patient volume.

Community Regional and its sister institution – Clovis Community Medical Center – have cooperated with American Ambulance to help get paramedics back on the road after delivering flu and other less seriously ill patients. “Rather than having let’s say, five ambulance crew members watching five patients in a hallway, we can turn (the patients) over to one team and have them watch all five patients,” said Todd Valeri, American Ambulance president and CEO.

Influenza definitely has increased ambulance calls. In December the crews made an average of 287 transports a day to hospitals in Fresno County. The volume increased to a daily average of 313 transports in January.

And three years ago, Community Regional cut the waiting room in its emergency department in half and built a treatment area for patients with non-urgent health problems. The physician triage area has improved the turnaround for the patients with minor illnesses, Gulbronson said.

But Mason said the physician triage area, with space for five beds, already is too small.

“We need a bigger ER,” she said.

Community Regional is considering expanding the emergency department, Gulbronson said. Saint Agnes, meanwhile, has a similar expansion in its master facilities plan, Egerton said.

In addition to constructing a tent at Kaweah Delta, a doctor has been added at the front end of the emergency department to see patients early in their visit, Seng said. And doctor and physician assistant hours have been adjusted. “We generally find our patients show up about late morning, and in the afternoon about 4 p.m. and then again around 7 or 8 p.m. there’s a third spike.”

Kaweah is doubling the size of its emergency department in 2019. Eight new doctors will be hired to start this summer, Seng said.

All these expansion plans won’t help present-day patients who can expect full hospital waiting rooms at Valley hospitals, possibly until spring.

This flu season has been a doozy. Despite their best efforts, doctors and nurses said it has been hard to keep up with the volume of patients. The H3N2 flu strain is extremely virulent. and more people have serious symptoms that take them to the hospital.

Saint Agnes also considered erecting a tent to handle the emergency room overflow. The hospital recently broke a record for flu patients when 343 were seen on a single day.

But Gulbronson said media coverage of flu deaths and hospitalizations have frightened the public and contributed to overcrowded emergency departments.

“It’s almost a panic,” she said. “People are on edge. They are more concerned than ever. They are not hesitating to come into the emergency department to seek treatment, even if their symptoms are relatively mild, because they’re worried.”

Gulbronson said there’s a remedy for overcrowded ERs. “I urge the public again to be diligent about hand washing, covering their nose when they cough or sneeze … hand washing, hand washing, I can’t stress that enough.”

And Mason said preventing the spread of influenza in the community is the best solution: “The biggest thing is the flu shot.”

This story was originally published January 29, 2018 at 8:00 AM with the headline "If you want quick care for the flu, don’t go to a hospital."