If you’re rushed to the hospital in an ambulance, you hope for a quick entry. Ideally, medical staff will race to meet you, immediately transfer you to a gurney, and wheel you through the double doors into the capable hands of a physician.
But in San Francisco, this is not usually how it works. In fact, according to city data, patients suffering from overdoses, broken limbs, cardiac pain, and other emergencies often end up caught in limbo between the ambulance and the hospital for 40 minutes — and sometimes a lot longer.
Ambulances in California, by law, are supposed to spend no more than half an hour offloading patients at hospitals. But the average Ambulance Patient Offload Time (APOT) at San Francisco hospitals over the last year was 45 minutes. Some hospitals, like California Pacific Medical Center Van Ness and UCSF Parnassus, had annual averages of close to an hour or more.
“The longer the APOT time, the longer the patient is waiting to get into a bed, the longer it takes us to get started on their care,” said Dr. Chris Colwell, chief of emergency medicine at Zuckerberg San Francisco General Hospital.
APOT delays are one reason SF ambulances don’t arrive at the scene of emergencies as quickly as they should. City data show there hasn’t been a single month since July 2023 when 90% of ambulances arrived within 20 minutes to non-life-threatening 911 calls, the city’s stated goal. For ambulance responses to life-threatening emergencies, the city hasn’t hit its goal of 90% arriving within 10 minutes during any month in the last four years.
Madeline Feldmeier, a researcher with UC San Francisco who published a study on offload times across the state, said the problem isn’t getting any better: nearly 50% of emergency response agencies were missing the state APOT target as of 2023.
“Delays have largely persisted or worsened in recent years, even as the Covid-19 pandemic receded in 2022 and 2023,” Feldmeier said. The Standard first reported on this issue in December 2022.
That’s because even while the pandemic’s impact diminished, the root causes of long offload times remained. One of those causes, experts say, is emergency department overcrowding.
“The whole health system is overwhelmed,” said Colwell, the emergency medicine chief at SF General. “I think there’s no question about that.”
The study on state offload times found that San Francisco’s mean APOT rose from 30 minutes in 2021 to 38 in 2022 and 45 in 2023.
“Even with [the pandemic] subsiding in 2023, we still see this pretty dramatic increase in offload delays in San Francisco,” Feldmeier told The Standard.
So, if it’s not the pandemic, why are emergency rooms still so crowded? One reason is persistent understaffing due to resignations across the healthcare industry. Another, Colwell said, is that hospitals dedicate resources and staff to lucrative elective surgeries, taking resources away from emergency departments in the process.
“Think about yourself in a hospital administration leadership role. What’s your primary source of income to be able to afford to have people there at all?” Colwell said. “It’s often elective surgery.”
Colwell added that while SF General is not financially dependent on elective surgeries, other hospitals he has worked at are. (In 2023, emergency room nurses at UCSF Parnassus told The Standard their employer prioritized expensive surgeries.)
It’s not that all hospitals are cynically depriving emergency patients of timely care so that executives can line their pockets, Colwell said. For some, focusing on elective surgeries is the only way they can stay afloat.
Representatives for Sutter Health, which runs the CPMC hospitals, and Kaiser Permanente said their facilities do not rely on elective surgeries for income and have not directed resources and staff away from emergency departments. A spokesperson for UCSF did not respond to a request for comment on the Parnassus hospital’s APOT.
“Reducing ambulance patient offload times has been a top priority for CPMC,” the Sutter Health spokesperson said via email, “and our efforts this past year have yielded positive results.”
APOTs at all three CPMC hospitals have generally trended downward since last January, the city data show. Sutter Health’s efforts, the spokesperson said, have included attending monthly APOT-focused meetings hosted by local emergency medical services and increasing staffing in the emergency department at CPMC Van Ness. But even so, annual APOT averages remain above 30 minutes.
Colwell said there are no consequences for the emergency response agencies that miss state APOT targets.
California’s Emergency Medical Services Authority (EMSA) was supposed to develop a system to better track the ambulance offload process by the end of 2024, per a 2023 law called AB 40. The law required EMSA to implement an electronic signature that EMTs and emergency department staff could use to mark the time an ambulance arrives and the time EMTs formally transfer custody of the patient to the hospital. The agency missed its deadline.
“EMSA is currently developing regulations to implement the electronic signature requirement within AB 40. A timeline has not been determined,” an agency spokesperson said in an email.