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Overcrowding at San Francisco hospital causes major ambulance delays

SFFD and King Ambulance parked at CPMC Van Ness Hospital in San Francisco on March 14, 2023. | Justin Katigbak for The Standard | Source: Justin Katigbak/The Standard

When the emergency room at California Pacific Medical Center’s Van Ness Avenue hospital is overflowing with patients, the nurses are often forced to put people on beds in the hallway until a room frees up.

For some patients, that hallway wait has lasted up to two full days.

“We’ll put screens around them, but that’s their only privacy,” said one charge nurse at the hospital, who, along with other colleagues interviewed for this story, spoke on condition of anonymity for fear of retribution.

“They’re in this hallway near the psych section, where patients are screaming and yelling,” the charge nurse said. Meanwhile, the lights in the hallway stay on all night, and the patients have to use a communal bathroom.

Overcrowding makes the California Pacific Medical Center hospital, known as CPMC Van Ness, unsafe, the charge nurse said, adding that there have been instances when the hospital struggled to find space to treat patients who arrived in critical condition. And the emergency department gets incredibly full multiple days a week, another nurse said.

The ripple effect from overcrowding spreads across San Francisco’s entire emergency response system. A full hospital means ambulance crews must wait—sometimes for hours—before handing off patients. And every ambulance parked at the hospital leaves San Franciscans with one less responding to emergency calls.

“[When] we’re at max capacity, we have no more space,” the charge nurse said. “So when the ambulances come in, I do make it a priority to try to bed them. But there’s really nowhere to go.” 

An ambulance backs into an ambulance bay at a hospital
A King-American ambulance backs up into the CPMC Van Ness hospital in San Francisco on March 14, 2023. | Justin Katigbak for The Standard | Source: Justin Katigbak for The Standard

New data obtained by The Standard shows that in 2022, every hospital in San Francisco failed to meet targets for offloading patients fast enough to avoid jamming the city’s emergency response. That left many waiting too long for an ambulance to pick them up.

And nowhere was the problem more pronounced than at CPMC Van Ness. Ambulances idled far longer at the Van Ness hospital than its peers, according to reports from the San Francisco Emergency Services Agency.

The long delays at CPMC Van Ness are an acute example of a problem plaguing hospitals across California and the rest of the country, experts said. A Southern California assemblymember recently introduced legislation to rein in the severe ambulance delays.

Sutter Health, the parent organization of CPMC Van Ness, declined an interview request. In response to a detailed list of questions laying out the findings of this report, a spokesperson for Sutter Health issued a short statement.

“Throughout Sutter Health, we’re collaborating with local EMS agencies and fire departments to help ensure accurate data is captured regarding ambulance patient offload times and to identify solutions that best serve patients,” it read. “Our nurse and emergency department leaders continually implement best practices to provide patients the right care in the right place inside and outside of Sutter.”

There were 162 incidents where CPMC Van Ness kept ambulance crews waiting for more than two hours before accepting the patients into their care in 2022, according to data from the San Francisco Emergency Services Agency. While those extreme delays represent just 1.5% of the hospital’s ambulance arrivals last year, they reflect a consistent failure to clear the queue so paramedics can respond to new emergencies.

Hospitals should offload patients from ambulances within 20 minutes 90% of the time, by the emergency agency’s standards. CPMC Van Ness failed that standard every single month last year. Instead, it offloaded patients within 52 minutes 90% of the time, according to a monthly report from the San Francisco Department of Emergency Management obtained by The Standard.

Are Hospitals to Blame?

The idea that hospitals are responsible for ambulance delays is a “myth,” according to a document published by several industry groups. The report says the bottleneck is because of a rising number of patients and onerous rules for transfers.  

However, a statewide group of ambulance companies, hospitals and emergency agencies clearly stated that the problem goes back to overcrowded hospitals in its recent report. And some say the problem is state policy—or a lack thereof.

Assemblymember Freddie Rodriguez, D-Pamona, worked as a first responder in Los Angeles County for 30 years. He remembers spending up to 12 hours before hospital staffers took patients off his hands. 

Rodriguez said a lack of enforceable statewide regulation has allowed the problem to continue largely unchecked. Without strong rules, local regulators get to choose how to deal with the issue. That leads to endless meetings and conversations about the problem but no real solutions.

That’s why he introduced a bill last December, AB 40, that would require the California Emergency Medical Services Agency to develop the first statewide standard for ambulance patient offload time: 20 minutes, 90% of the time.

“If we don’t put a time on this, then guess what? It’s just pointless. It’s going to continue as business as usual,” Rodriguez said. “Ambulances are going to be delayed responding to emergency calls and people might die because of the delayed responses of our first responders getting out there.”

Assemblyman Freddie Rodriguez, center right, stands alongside state Sen. Connie Leyva, near left, and Los Angeles-area Assemblywoman Wendy Carrillo, far left. | Rich Pedroncelli/AP Photo

The San Francisco Emergency Services Agency is meeting with hospital leaders to discuss ambulance offload times, according to an agency spokesperson. The San Francisco Fire Department, which operates most of the city’s ambulances, has also participated in those conversations, according to its medical director, Dr. Jeremy Lacocque.

No Solution in Sight

Despite efforts to tweak the city’s emergency response system, the delays persist across all the city’s hospitals. 

“There physically aren’t enough beds or not enough nurses or not enough providers,” Lacocque said. “And that part is really hard to change.”

Adding more beds to a hospital is a massive and expensive undertaking, Lacocque said. Not only would San Francisco’s hospitals have to contend with the city’s famously Byzantine building permit process, they also would have to apply for licenses for new medical beds, and then find new staff in a time when facilities across the country have struggled to keep providers on the payroll.

Dr. Jeremy Lacocque, the medical director of San Francisco Fire Department Emergency Medical Services, poses for a portrait at SFFD Station 49 on March 14, 2023. | Justin Katigbak for The Standard

While conversations about addressing ambulance offload delays are ongoing, the problem shows no signs of slowing. Ambulance demand rises each year in San Francisco while hospital capacity stays flat, Lacocque said.

That’s true across California, with emergency room arrivals surging since the worst of Covid subsided, said Dr. James Dunford, who serves on the California Emergency Medical Services Commission and spent two decades as San Diego’s Emergency Medical Services medical director.

“Hospitals are filled to the brink right now with sicker people than they used to be,” Dunford said.

At CPMC Van Ness, one charge nurse said that in many ways, they’re proud of their work. The hospital’s specialty services—like transplant teams—bring people from hundreds of miles away for care they can’t find elsewhere. But that doesn’t solve ongoing problems, like the overcrowding that prevents staff from providing the best care, the charge nurse said.

“I know people want to quit because it’s so draining on those days,” the charge nurse said.

Despite staff concerns about consistent overcrowding, the hospital’s management has yet to implement a long-term plan to address the issue, according to another charge nurse.

“I feel system breakdown from the top,” they said. “It’s a system error.”

Noah Baustin can be reached at