Last year, 65 percent of the hospital’s inpatients were evaluated, treated and admitted through the ED. That’s high, compared with other hospitals nationally, for which about 25 percent of admissions originate from their EDs. SFGH’s high admission rate is due to the severity of patient illness, its designation as a trauma center and the lack of primary care accessed by their patients.

But even as the pace in the ED speeds up – largely due to patients suffering from drug overdoses, crime- or work-related injuries, and traffic accidents – the ED at SFGH has seen a marked decrease in its patient census. A key measure of volume is the hospital’s diversion rate, the times when it signals to ambulances to divert patients away to other hospitals due to overcrowding in the ED. In January 2001, SFGH was on divert status 44 percent of the time – an all-time high – compared with 18 percent in 2006, according to Alan Gelb, clinical professor and chief of the Emergency Department at SFGH.

Gelb points to three significant improvements that have lowered the diversion rate. First, SFGH opened the Integrated Soft Tissue Infection Service (ISIS) clinic, where patients with infections such as abscesses can be treated. Second, it expanded hours at the urgent care clinic, which operates 12 hours a day, seven days a week, treating about 20,000 patients a year and thereby reducing visits to the ED. And third, under the leadership of CEO O’Connell, the hospital is discharging sooner patients who are capable of being cared for in other, less expensive rehabilitation and skilled nursing facilities, Gelb says.

Despite fewer patients, the wait to be seen in the ED and to get a hospital bed can still be long, Gelb says. It can take up to eight hours for non-critical patients to be seen in the ED, depending on the time of day and the severity of a patient’s illness. Designed and constructed in 1976 to serve a maximum of 40,000 patients a year, the ED now sees more than 55,000, according to Gelb.

The gridlock in the ED means that some patients have to lie on gurneys in the hallways until they get a hospital bed and that there are delays in surgeries.

"The average wait time for a patient to go to a (non-Intensive Care Unit) room after they have been admitted from the ED is five to 10 hours, also depending on the severity of illness," says Gelb, a graduate of the UCSF School of Medicine who joined the UCSF faculty in 1980. "Unfortunately, this is not unique at SFGH, but is common across the country."

"The main solution is to have more inpatient beds available and staffed by RNs," Gelb says. "The desire to lower overhead costs and the national nursing shortage make it difficult to accomplish this. The system has already gained as much as it can by keeping people out of the hospital that may be able to fare well at home."

In addition to treating medical and surgical emergencies, SFGH serves as the city's receiving hospital for psychiatric patients. More than 7,000 troubled patients with mental illness are brought to the Psychiatric Emergency Service each year, 40 percent of whom are ultimately admitted to some of the department's 100 psychiatric inpatient beds. 

 To help psychiatric patients avoid inpatient hospitalization when possible, and to help stabilize them after they leave, Okin created intensive case management programs consisting of multidisciplinary teams that help patients find housing, obtain financial entitlements, monitor their medications daily, and link them with medical services, outpatient mental health care, and substance abuse services. The result has been a dramatic decrease in the number of patients needing repeated inpatient care and being arrested for petty crimes.

"One of the most important challenges is how to keep very volatile psychiatric patients stable in the community and how to help them create meaningful lives," Okin says. "Our case management programs have accomplished this for hundreds of patients."