Tuesday, April 8, 2008

Institutional Malpractice?

Emergency Medicine News (March, 2008) has an article “Holding ICU Admits in the ED Increases Mortality 35%.” It is written by Richard Bukata, M.D.

In September 2001, I wrote a letter to Keith Steffen regarding overcrowding in the Emergency Department (ED) at OSF-SFMC in Peoria. Mr. Steffen is Administrator at OSF. I thought that we were endangering the lives of ED patients at OSF-SFMC.

The next day I was placed on probation for six months. A few months later I was fired.

Dr. Bukata’s main points from his article (some written in his own words) and some of my comments:

1. Although reasonable solutions to the problem of overcrowding and keeping patients in the ED for too long have been suggested, most administrators have chosen not to contaminate the rest of the hospital with these excess patients but rather hold them in the ED where they make the department malfunction substantially. Their reasoning: It may offend the medical staff, patients’ families, and hospital floor staff. The philosophy is to sacrifice the ED and its patients for the sake of the rest of the hospital.

2. In my opinion this was the case at OSF-SFMC. I did not think that the leadership in the ED was prepared to handle this ED problem. Doctors George Hevesy and Rick Miller were too tied in with Administration in many ways. Thus, I wrote my letter to Mr. Steffen. (I also copied my letter to all the ED attending staff and other administrators because I considered ED overcrowding at OSF-SFMC to be a “systemic hospital-wide” problem.) When I mentioned to Mr. Steffen “institutional malpractice” (making ED patients wait too long), he asked me what I meant by that. I think he knew what that meant.

3. The ED staff at OSF-SFMC and other ED’s all over the U.S. become frustrated and exasperated because it seems they are powerless. When I took on the problem, I was slapped down right away. The concept that excess patients are, in reality, a hospital challenge rather than simply an ED challenge has been a tough sell when you look at the typically impotent actions taken to address the problem.

4. We need aggressive medical staff leadership driving lengths of stay, we need administrators willing to close the hospital to elective surgery when the ED has no place to put its patients.

5. It would be interesting to review the elective surgical admissions by OSF-SFMC during those years. Was the hospital scheduling too many surgeries for financial reasons and keeping ED patients in the ED too long? The crowded ED is a blatant patient safety issue. It is a matter of life and death for the ED patients. But who will look at OSF-SFMC's “dirty laundry”. JCAHO? Or the ethics committee at OSF-SFMC? I don’t think so.

6. It is obviously dangerous to be working in an environment that is substantially over capacity. It is obviously a problem when ED patients wait hours to see a doctor.

7. Dr. Bukata writes, “Why not offer incentives? If the CEO’s annual bonus were linked to ED patient throughput, it is guaranteed that most hospitals would see their problem solved. This may sound like an inflammatory statement, but truly, the only one who can fix the “ED problem” is the CEO. It is a top down initiative. Driven by money or fear, it can be fixed.” And Mr. Steffen told me that fear amongst employees at OSF-SFMC was a good thing.

8. A study in 2007 showed that the mortality of ICU patients boarded in the ED for six or more hours was 17.4% vs. 12.9% for those boarded less than six hours (a 35% relative increase. ED boarding of patients for six hours or longer was an independent predictor of decreased survival. For every 20 ICU patients boarded in the ED for more than six or more hours, one will die (the ultimate harm).

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