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Why San Franciscans wait so long for ambulances

Ambulances fill the entrance to the emergency department at Saint Mary’s Medical Center. | Benjamin Fanjoy/The Standard

An ambulance crew picked up a young man on Dec. 6 who had probably overdosed on fentanyl. He wasn’t in immediate life-threatening danger, but he needed to see a doctor. The first responders drove the man to St. Mary’s Hospital and brought him inside.

That’s when the waiting began.

One hour passed. Then two hours were gone. Three hours came and went.

The ambulance crew sat in the hallway with the patient on their gurney. Emergency calls continued to come into San Francisco’s 911 system but the ambulance couldn’t leave: the first responders needed to formally pass off care to hospital personnel.

After four hours of watching a steady stream of walk-in patients get assistance, the hospital staff got to the man on their gurney. Four hours until they could respond to the next call for help in the city.

It’s an all-too-common experience for ambulance staff working the streets of San Francisco.

“[The hospital] shouldn’t have a higher priority than getting a patient off of our gurney so we can go back out and get patients who aren’t even at the hospital yet,” said Josh Nultemeier, King-American’s Chief Paramedic, who was not at St. Mary’s that day but oversees the crew and recounted their story to The Standard.

Both the San Francisco Fire Department and private ambulance companies, such as King-American, respond to 911 calls in San Francisco.

“We’re supposed to go out and pick up patients that are super sick with real emergencies that aren’t at a hospital yet. We’re being delayed from being able to do that,” Nultemeier said.

Patients Left Waiting Too Long

For the past year and a half, while paramedics have often been stuck sitting idle in ERs, San Franciscans having heart attacks, strokes and other medical emergencies have waited too long for an ambulance to show up.

The city has a goal for ambulances to respond to life-threatening emergencies within 10 minutes more than 90% of the time; it has only met that goal for one month since May 2021.

“It’s making people wait an unreasonably long time when they need help the most,” said Adam Wood, vice president of the San Francisco Firefighters Local 798 union.

A King-American ambulance on Bush Street in San Francisco. | Benjamin Fanjoy/The Standard

A perfect storm of problems has kept the city’s ambulances responding slowly. As Covid’s grip on the city loosened over the past year, crosstown traffic increased and the number of emergency medical transports to hospitals went up. Pandemic-era staffing shortages in the fire department, which sends paramedics to the majority of medical emergencies, persisted. Making matters worse, the triple threat of winter flu, RSV and Covid packed some SF intensive care units near capacity this month

But the most striking driver of ambulance delays is the jaw-dropping amount of time that crews spend in limbo at hospital emergency rooms, even as calls pile up in other parts of the city. Fire department ambulance crews sometimes wait three to five hours to pass off their patients, said SFFD spokesperson Capt. Jonathan Baxter. 

The amount of time between ambulance arrival at the hospital and ER staff taking over care of the patient, a metric called APOT, steadily climbed throughout the past year at all major hospitals in the city.

Though city regulations state that hospitals should take ambulance patients within 20 minutes more than 90% of the time, none of the city’s largest hospitals hit that goal in a single month in the past year, according to records obtained from the SF Department of Emergency Management (DEM). 

In November, CPMC Van Ness’s APOT time was 61 minutes, triple the regulatory cap.

“That’s too long, it should be faster,” said Dr. Alexander Janke, an emergency medicine physician and research scientist at the Yale School of Medicine with national expertise on how emergency rooms operate. “But it’s not surprising to me to hear these numbers, because I know how bad the bottlenecks are all over the country.”

Short Staffing and Too Many Patients

Local hospitals have struggled with the staffing problems that struck the industry nationwide in recent years. Limited staff and lack of bed availability can cause ambulances to have to wait to offload patients, DEM spokesperson Victor Wai Ho Lim said.

The city’s eight largest hospitals all declined interview requests. St. Mary’s referred The Standard to the Hospital Council industry group, which represents SF’s public and private hospitals.

“As evidenced during the Covid surges over the past three years, when patient utilization of emergency departments increases significantly, APOT events also increase,” Michon Coleman, regional vice president of the Hospital Council of Northern and Central California, said in a statement. “Hospitals are seeing an unprecedented volume of patients of all types and including Covid, flu and RSV, making achieving these targets more challenging.”

A note at the Emergency Room entrance of Saint Francis Memorial Hospital on Dec. 15, 2022. | Benjamin Fanjoy/The Standard

An increase in the number of non-emergency cases coming to emergency departments and a lack of hospital space to take care of patients once they’re stabilized have also impacted ambulance wait times at ERs, according to Coleman. 

Hospitals across the country have run short on space this fall, a situation made worse by a nationwide whittling down of unprofitable pediatric beds over the past two decades and now apparent given RSV’s impact on young patients. 

But King-American’s Nultemeier believes that, to a degree, the ambulance backup has come out of a shift in how the hospitals prioritize patients.

In the past, if a patient came to the hospital in an ambulance, they often got seen faster than if they arrived on their own, he said. Of course, patients experiencing potentially life-threatening emergencies have always taken first priority. But in recent years, the hospitals changed how they prioritize patients, placing more emphasis on clearing their busy waiting rooms than sending waiting paramedics back out to their ambulances, Nultemeier said.

“It’s not an ambulance problem. It’s not a staffing problem,” Nultemeier said. “The hospitals don’t prioritize us dropping patients off and getting them off our gurney so we can get to the next call.”

Kaiser-Permanente, however, didn’t point to any policy change as the reason for the hospital’s high offload times.

“We have sufficient staff to care for our patients, but sometimes lack the physical space at the moment to offload the patient safely, and we will not offload a patient until it is absolutely safe to do so,” a Kaiser Permanente spokesperson said in a statement. 

Yale’s Janke said that the nation’s emergency room backup crisis has been brewing for decades. Hospitals have a huge financial incentive to operate as lean as possible, having the minimum number of staff and beds possible at any given time. Inevitably, when the number of people getting sick spikes, the system isn’t flexible enough to handle the influx, like we’re having right now.

“We have to have a conversation about how we change health care financing to make the acute care system more resilient to these kinds of changes,” Janke said.