In the weeks following Gov. Gavin Newsom’s March 19 stay-at-home order to curb the spread of the coronavirus, Dr. Brian Anderson noticed an unusual phenomenon at the eight emergency rooms he manages — a sharp decline in patient visits.
“The volume has dropped as much as 50 percent in many of our ERs,” Anderson said. “We’ve never seen declines like this. It has caught most by surprise.”
Like many emergency room doctors and nurses across Southern California, Anderson believes the reason for declining ER visits is mainly two-fold: strict public adherence to the government’s stay-at-home directive and fear of contracting the potentially deadly COVID-19 virus.
But the dramatic drop in overall ER visits is only part of the story of how COVID-19 is disrupting operations at medical facilities throughout Southern California. Hospital admissions also have declined, partly because fewer patients are coming in through the ER and partly because of the ban on elective surgeries in California.
As a result, many hospitals have laid off, furloughed or cut pay for affiliated physicians and staff. The U.S. Bureau of Labor Statistics reported this month that, nationally, health-care employment declined by 43,000 positions in March, though 17,000 of those jobs were in dental offices.
Some of these dynamics played out by design as hospitals worked to reserve hospital beds, particularly in their ICUs, and staff for a predicted surge in COVID-19 patients.
Providence Little Company of Mary Medical Center in Torrance, for example, stopped performing elective procedures, limited rehabilitation services and discharged as many patients as was safe, said Jeremy Baker, who leads the hospital’s quality, risk and safety team.
In March, the hospital, like many others throughout the region, erected a tent to triage those seeking medical treatment.
ER visits decline across the board
Still, the size of the decline in emergency room visits has caught some health-care professionals by surprise.
Anderson, a Redlands resident, said the trend is across the board in the emergency departments he manages, including Arrowhead Regional Medical Center in Colton, St. Bernardine Medical Center in San Bernardino, Riverside University Health System Medical Center, Moreno Valley Medical Center, and Redlands Community Hospital.
Nearly identical scenarios are playing out at hospitals across Southern California, partly because ERs are treating fewer serious injuries from traffic accidents with so many people sheltered at home, as well as traumatic injuries from criminal violence. Anecdotally, law enforcement agencies across Southern California report a significant drop in overall crime rates under stay-at-home orders.
At UCI Medical Center in Orange, ER volume is down 35 percent, hospital spokesman John Murray said.
“Much of this is attributable to fewer visits from people who are insured but treat the ER as their primary care provider,” Murray said via email.
Emergency room visits at Arrowhead Regional Medical Center, San Bernardino County’s public hospital, have declined by more than 50 percent, said Dr. Rodney Borger, director of the hospital’s ER.
At Torrance Memorial Medical Center, emergency medicine physician Dr. Brian Miura said the hospital has seen a significant reduction in general patients in the ER, at a time when more patients have shown up with acute respiratory symptoms.
The hospital has been encouraging the public, unless they suffer from respiratory problems and need evaluation, to seek testing or treatment at nonhospital sites so the hospital can keep capacity at a minimum to prepare for any surge in coronavirus patients.
Riverside Community Hospital has seen a smaller decline in patient visits to the emergency room, about 15% since March, according to Chief Medical Officer Saba Habis.
The same thing is occurring at Emanate Health Queen of the Valley Hospital in West Covina, spokeswoman Diane Martin said. Before the coronavirus crisis began, Queen of the Valley handled 200 to 250 ER patients a day. In the past three weeks, the daily average was down to 100 patients, Martin said.
Dr. Jorge Vournas, director of the Emergency Department at Little Company of Mary, said his facility hasn’t been overwhelmed with either COVID-19 or general patients.
“As far as the stories of New York City, where they are having 20 people ventilated in the ER,” Vournas said, “we are not anywhere near that magnitude. We are seeing very low levels in the Emergency Department.”
Vournas stressed that anyone experiencing a health issue should not worry about the ER being too busy.
Indeed, others expressed the same sentiment as fears of a COVID-19 surge wane.
Dr. Joseph Chan, medical director of the Emergency Department at Beverly Hospital in Montebello, encouraged those with serious medical issues not to stay away from ERs.
“The message went out, it was heard and people overreacted,” Chan said. “There was a fear of what was going to come and it never came. If you’re having a runny nose and want to come, please stay at home.”
But that recommendation never applied to those having issues such as a potential heart attack, stroke or appendicitis, he said.
“We had patients come in four days after having a stroke,” Chan said. “People were staying away when they have real issues.”
Likewise, Centinela Hospital Medical Center in Inglewood is encouraging people not to avoid the ER when it’s necessary.
In a statement this Tuesday, interim CEO Mohammad A. Nasser and ER Medical Director Dr. Jay Melton said, “Lately, we have begun to see patients that have waited too long to come to the Emergency Department for their life-threatening conditions due to an understandable fear of being exposed to COVID-19 or the coronavirus.”
Staying at home, they stressed, “may have detrimental effects on your health and we encourage you to seek immediate medical care in these situations.”
Hospital admissions down as well
Coronavirus fears and stay-at-home orders have not only led to a decline in emergency room patient volume, but overall patient admissions as well. The suspension of elective procedures to free up beds and protective gear for health-care workers has been a major driver of the reduction in hospital admissions.
“It’s decreased overall because ER volume is down and nobody’s doing the elective procedures and surgeries,” said Anderson, the Inland Empire emergency room manager.
At Arrowhead Regional, Borger said, “There’s definitely a lower census of patients. There’s been a lower volume of all types of patients.”
At Pomona Valley Hospital Medical Center, the overall patient census is also lower than average.
“People who typically seek care at the Emergency Department for mild illnesses seem to have been staying home. This is accounting for our lower-than-average patient volume,” said Dr. James Kim, medical director of the hospital’s ER.
Torrance Memorial Medical Center reports its hospital patient population is down about 40% from a month ago, and the surgical department has declined a whopping 80%, CEO Craig Leach said.
Staff reductions, loss of income
For some physicians and specialists, the reduction in noncoronavirus patients at hospitals has resulted in a reduction in hours and pay.
“It’s been a pretty substantial decline. It’s resulted in us having to change around some of our staffing,” said Dr. Evan Houck, director of emergency medicine at Redlands Community, which has seen a 40-50% drop in emergency room visits.
Houck is Anderson’s partner at Vituity Healthcare & Medical Staffing Services in Emeryville, California, a national company that contracts with hospitals, including Redlands Community, for staffing and physician services. Houck said Vituity’s physicians typically would treat 150 to 160 patients daily at Redlands Community, but that figure had dropped to 75 to 90.
“I think almost every doctor is down in their patient volume,” Anderson said. “A lot of our primary care physicians and sub-specialists are down 65-70%. People aren’t getting their hernias repaired, back surgery, joints replaced and so forth. When surgeons aren’t busy, then anesthesiologists aren’t busy and the hospitals aren’t generating a lot of revenue needed to keep hospitals financially profitable.”
The problem is prevalent at staffing firms nationwide. ProPublica recently reported that the country’s top employers of emergency room doctors are cutting their hours, resulting in less pay. The lack of demand for other kinds of health care is straining the business models of hospitals and the companies that staff them.
TeamHealth, for example, is reducing hours for ER staff in some places and asking for voluntary furloughs from anesthesiologists, while multiple ER providers working for a main competitor, KKR-owned Envision Healthcare, said their hours also are being cut, according to ProPublica.
Riverside Community Hospital has managed to avoid pay reductions, in part, because of its donations to a Healthcare Hope Fund set up by the national for-profit HCA Healthcare system to assist employees and their families, Habis said.
“The top priority is to protect the lives and jobs of our front-line employees who are risking their lives to care for patients,” Habis said. “We have not laid off a single front-line employee.”
At Torrance Memorial, patient reductions have left about 80-90 nurses and doctors off work per day out of about 4,000 health-care workers, CEO Leach said. The hospital has been paying these employees 50 percent of their salary, and they also can receive unemployment insurance.
“On a day-to-day basis, we are smaller than we were four weeks ago,” Leach said. “We’re trying to strike the right balance between staffing appropriately and making sure we are well prepared for what the surge might be and the volume we have today.”
Will there be a surge?
Indeed, hospitals are still prepared for a potential influx of COVID-19 patients even though coronavirus cases are showing signs of peaking and ICU hospitalizations are beginning to decline.
Pam Allen, nursing director of emergency services at Redlands Community, said the hospital has increased the number of its patient isolation rooms from eight to 44. Additionally, three operating rooms also have been tailored for patients in need of surgery who have either tested positive or are symptomatic of the coronavirus.
At Torrance Memorial, Miura said the hospital’s emergency management team has developed “hospital-wide plans to support us through this rapidly changing situation.” The hospital has enough beds in its intensive care unit to accommodate an influx of patients, with the ability to add more, Miura said.
At Riverside Community, Habis said the hospital is prepared for any influx of patients and his team is “ready to go.”
“We are prepared to add 120 more (intensive care) beds. We have ventilators secured,” Habis said.. “We feel really good about how prepared we are. We’re certainly going through an unprecedented crisis I think we’re as prepared as we could be to handle this.”
Staff Writers David Rosenfeld and Mike Sprague contributed to this report
