Monday, January 11, 2016 12:00 AM

The One-in-a-Million ER

Shortly before the calendar turned to 2016, the one millionth patient was treated in Community Regional Medical Center’s emergency room. When the Table Mountain Rancheria Trauma Center opened in 2007, its football-field sized emergency department was the largest in California and it quickly became one of the busiest serving an average or 355 patients a day – 17 of them for life-saving trauma care.

Ryan Gravelle, 19Community Regional serves as the region’s hub for higher level care, with 25 outlying hospitals transferring 1,074 patients to us last year. Community Regional’s 86 emergency beds are nearly always full, many days requiring another 60 hallway beds to accommodate the overflow.

Much of the increase in patients is due to the expansion of insurance coverage through the Affordable Care Act (ACA) – particularly Medi-Cal. Community Regional, the state’s fourth largest hospital, has more inpatient Medi-Cal discharges than any hospital in California, surpassing even Los Angeles County/USC Medical Center.

“Medi-Cal patients are always the highest utilizers of emergency departments,” said Dr. Gene Kallsen, a UCSF Fresno clinical professor of emergency medicine who works at Community Regional. “There are not enough doctors accepting Medi-Cal for those patients to go somewhere else. Or they have a doctor who accepts Medi-Cal, but they can never get into them on short notice when they need to get into them.”

Community serves a region where 48 primary care doctors are available for every 100,000 people – much less than the 80 recommended and far less than the 126 available for every 100,000 people in the more populated Bay Area.

Map of Community Regional Medical Centers serviceable areas• Community Regional sees more critically ill patients than any other hospital in California – 25,000 last year in need of immediate, critical care.

• As the second busiest ER in California, it cares for 10,000 patients a month 

Community Regional acts as the region’s safety net, providing primary care in a region where that is in short supply, as well offering access to critical expertise – in burns, Level 1 trauma, high-risk pregnancy – available nowhere else in the Valley. The downtown Fresno hospital is the only provider for many medical specialties for Medi-Cal patients, taking referrals from federally-qualified health centers and outlying hospitals. It also continues to provide services considered as “optional” by Medi-Cal, as the hospital’s clinics continued to provide dental services when these were not reimbursed.


Community Regional ranks among California’s leading safety-net hospitals in the amount of acute-care services provided. Because of the increased impact on the emergency department, Community has done a number of things to speed care and reduce wait times. In 2013 to expedite treatment, Community Regional’s ER staff moved cubicles to waiting areas to triage patients. More than 62% of patients start their care here and 56% of those patients can be treated and discharged without having to wait for an emergency room bed to open up.

The hospital also established a Prompt Care Clinic with extended hours on its campus to care for those with less critical or primary care needs. And a patient flow command center instituted in 2013 has helped increase the number of patients that can be cared for daily in the hospital from an average of 600 to 630. The process also improved the time it takes to get patients admitted to a hospital bed up on the floor by decreasing the time beds sit empty and by doing a better job of discharging patients on time.
In addition to reduce the population’s dependence on emergency care, Community collaborates with various health providers and Fresno County to address chronic health needs that are among the most severe in California.

“Community Regional Medical Center continues to develop innovative partnerships and leading edge-services to provide higher-quality, whole-person care to its overwhelmingly low-income communities,” said Catherine Douglas, president and CEO of Private Essential Access Community Hospitals (PEACH), California’s community safety-net hospital association. “It is a critical part of our state’s healthcare safety net.”

Reported by John G. Taylor and Erin Kennedy. Reach them at