Wednesday, May 27, 2009

ER Crowding...A Moral Dilemma

Moral Consequences of ED Crowding

A family in the area recently called me and told me of their long 10 hour wait in the ER at OSF-SFMC in Peoria.

See my letter written to OSF's Keith Steffen regarding my concerns of dangerous overcrowding in the OSF Emergency Department.

In the May, 2009 issue of Annals of Emergency Medicine there is a two part article regarding crowding in the Emergency Departments in the United States.

Below are key points from these articles and my comments regarding OSF’s Emergency Room:

1. According to Hospital Based Emergency Care: At the Breaking Point, a 2006 report of the Insitute of Medicine (IOM), there is a national crisis of ED crowding.

2. ED overcrowding occurs primarily when sick patients, evaluated by the emergency physician and admitted to the hospital, have no place to go and remain in the ED. It is mainly a symptom of an overcrowded hospital, not the result of “inappropriate” ED use (like patients with sprained ankles, etc.)

This was the exact position I found myself and my patients in on September 26, 2001.

3. Current research on ED crowding strongly suggests that discouraging the use of the ED for non-emergency issues (sprained ankles) will not solve the problem. Rather, output issues, especially the inability to transfer emergency patients to inpatient beds and the resultant “boarding” of admitted patients in the ED for long periods, are most commonly associated with ED crowding.

4. There are moral consequences to ED crowding and serious ethical concerns.

5. ED crowding has a variety of undesirable consequences, including increased patient waiting times, decreased ability to protect patient privacy and confidentiality (if they are lying on a gurney in a busy hallway), impaired evaluation and treatment, and difficulties in delivering person-centered care. ED crowding frequently interferes with the ability of emergency physicians to honor these fundamental principles.

6. When a circumstance such as ED crowding makes it increasingly difficult or even impossible for health care professionals to respect basic moral norms, it is essential to address that circumstance to reduce the likelihood of conflict between these moral norms and to enable professionals to satisfy all of the reasonable moral expectations of their patients.

7. The Joint Commision reported that 55 events associated with delays in care, 29 occurred in EDs. Crowding was noted to contribute to 31% of sentinel events in the ED. Two recent studies found a significant association between ED crowding and increased inpatient mortality. Crowding increased the risk of harmful medical errors in a variety of ways. In a crowded ED, errors may occur as a result of hurried treatment decisions with limited information, of delayed or poorly organized transfer of information from one clinician to another, or of failure to reexamine a patient or to reevaluate a previous physician’s provisional diagnosis or treatment plan.

8. Multiple studies associate ED crowding with delays in access to definitive therapy for emergency conditions, thereby increasing the risk of poorer outcomes. Numerous emergency conditions, including myocardial infarction, stroke, trauma, meningitis, and pneumonia, have been shown to have time-sensitive outcomes.

9. By delaying patient access to assessment and treatment, crowding also forces patient to endure existing harms, including pain and anxiety, for prolonged periods. In all of these ways, crowding impedes clinicians efforts to carry out their duties of beneficence.

10. Patient choice of care is in fact limited by personal and system resources, but enabling patients to choose care that is effective and convenient remains a legitimate moral goal. ED crowding interferes with the satisfaction of that goal when it triggers ambulance diversion and long waiting times for ED care and for hospital admission. Ambulance diversion to other hospitals often thwarts patient strong preference to receive care in the hospital in which their physicians and medical records are located. Diversion also increases transportation time for each patient. Longer transportation times may increase ambulance response time to subsequent patients, there by delaying those patients’ access to out-of-hospital and ED care for their emergency medical conditions.

11. This is what I think is happening at OSF in Peoria:

There are financial barriers that diminish the response of hospital administrators to solve the problem of ED crowding. The IOM report offers the following reason: “No major changes in health care can take place without strong financial incentives, and today hospitals have almost no incentives to address the myriad problems associated with inefficient patient flow or ED crowding. Indeed….hospitals have a number of financial incentives to continue the practices that lead to these problems.”

What are these alleged financial incentives? The IOM report identifies the following 4:

1. Hospitals maximize income by operating at high capacity, making full use of their employees and facilities. The ED can enable its hospital to operate at or near full capacity by acting as an escape valve for excess demand, providing necessary care for seriously ill or injured patients until the hospital can accommodate them as inpatients.

2. Patients awaiting an inpatient bed in the ED compete for beds with patients admitted electively for surgery or other invasive procedures. Such elective admission patients are usually insured and the procedures they undergo are often well reimbursed, generating significant revenue for hospitals. Emergency admissions, in contrast, are more likely to be uninsured or underinsured, to have more severe illnesses, and to have lower rates of reimbursement. Hospitals thus have a financial incentive to prefer elective over emergency admissions. Failure to honor requests for elective admissions, or frequent cancellation of scheduled admissions, may in fact alienate surgeons and other procedural specialists whose patients generate substantial income for the hospital.

3. Hospitals with EDs are required by federal Emergency Medical Treatment and Active Labor Act (EMTALA) regulations to provide a screening examination and necessary emergency care for all patients, regardless of ability to pay. When the ED is crowded, however, access to emergency care is inevitable delayed, and some patients choose to leaves the ED without being seen. In the case of ED closure and ambulance diversion, access to care through the ED is temporarily denied. Thus, hospitals may have a financial incentive to permit ED crowding and subsequent closure because those conditions can limit the hospital’s legal duty to assume the care of uninsured and underinsured patients.

4. Giving elective admissions priority over emergency admissions may enable hospitals to maximize revenues in another easy. If they are denied admission, elective patients may choose not be hospitalized, or to go to a different hospital, and the hospital will lose their patronage. In contrast, patient boarded in the ED are “captive”; they are already in the hospital and cannot easily go elsewhere. So, despite lower priority and longer wait for an inpatient bed, the boarding patients will receive continuing care in the ED and will also eventually be admitted. In this way, the hospital will secure 2 admissions instead of just 1.

If the wait got too long for the patient and their family, on occasion, I directly transported the patient to the inpatient bed myself. I doubt this was looked upon favorably by Dr. Rick Miller, who was in charge of the ED at OSF at the time. Rick did not want waves made that in any way challenged the administrative powers that controlled Dr. Miller and his assistant director, George Hevesy, M.D. Unfortunately for ED patients and staff, there was a dangerous parasitic relationship between the ED directors and OSF Administration.

According to May, 2009 Annals of Emergency Medicine:

Hospitals can implement “full capacity protocols” in periods of severe hospital and ED crowding. Under these protocols, patient boarding in hallways or other unsafe areas in the ED are moved to hallways in various inpatient units. Such protocols alleviate the burden on the ED of boarded patients by distributing those patient throughout the hospital. This strategy may also increase hospital-wide awareness of crowded conditions and thereby motivate physicians and staff to make beds available.

Several years after I was fired from OSF-SFMC, OSF created an observation unit to attempt to relieve ED crowding. Clinical decision units or observation units, for example, can monitor patients with symptoms such as chest pain, abdominal pain, or shortness of breath who may or may not ultimately need hospitalization. Admission pending units can provide continuing evaluation and treatment for admitted patients outside the ED when other inpatient units are full. Discharge units, sometimes referred to as discharge lounges, can accommodate patients who have been discharged by their physician and are merely awaiting discharge instructions or a ride home for the the hospital.

In the early ‘90’s I gave an Emergency Department Grand Rounds regarding creating an Observation Unit at OSF in order to decompress the ER. I asked Jim Moore to attend and explain the financial reasons regarding an observation unit. He agreed to be there. Mr. Moore was Administrator of OSF at the time and is now CEO of OSF Coroprotate. I also asked a general surgeon, and adult cardiologist to attend. All attended the ED Grand Rounds except Mr. Moore.

And as mentioned above, 10 more years went by until OSF implemented an Observation Unit.

In Summary:

1. To maximize efficiency hospitals must decide how to distribute resource among their current patients to do the best job of caring for all.

2. Although emergency physicians and other emergency care professionals confront the moral challenges of ED crowding firsthand, effective response must come from the institutional and system-wide level. Although emergency physicians do not have the power to change the health care system, they certainly can and should participate in addressing the problem of ED crowding.

3. When I wrote Keith Steffen in 2001, I was hoping for his guidance. Instead, he referred to me as a cancer in the emergency room at OSF and I was placed on “probation” the next day.

4. In April 2005, emergency physicians at Vancouver General Hospital, frustrated by their ongoing failure to persuade hospital administration “to address the crisis of admitted patients in our ED,” began giving selected patients a statement expressing their “non-confidence in the ability of the Vancouver Gerneral Hospital ED to provide safe, timely, and appropriate emergency medical care.” This action stimulated heated public, political, and professional debate in British Columbia. After emergency physicians at other Vancouver area hospitals publicly expressed similar concerns about patient safety, the provincial Ministry of Health funded a $7 million campaign to address the problem. Despite this campaign, however, the ED at Vancouver General Hospital remained gridlocked with admitted patients in 2006.

5. The Vancouver no-confidence statement certainly called attention to the problem and it evoked an official governmental response. The Vancouver emergency physician’s proposed strategy for alleviating ED crowding, namely, the use of time limits on ED stays to trigger protocols that distribute admitted ED patients throughout hospital hallways, is also intended to raise the visibility of the crowding problem by spreading the burden to areas other than the ED. This strategy is obviously not an ideal solution, because patients are likely to feel almost as exposed and uncomfortable in a hallway of an inpatient unit as in a hallway of the ED.

6. If hospital EDs in the United States have a moral and legal mandate to provide quality emergency care to all who need it, it is important that emergency physicians and nurses make governmental and institutional leaders aware of the significant problem of ED crowding and that they participate in efforts to address this problem.

Friday, May 22, 2009

Diverting Diversion

On September 26, 2001, I worked a PM shift in the OSF-SFMC Emergency Room.

I thought that the ER was overcrowded and dangerous for my patients.

I wrote the letter documented in this post to OSF's Administrator, Keith Steffen.

The next day I was put on "probation" and then fired from OSF-SFMC in December, 2001.

The following article appeared in Emergency Medical News this month (May, 2009).

It stresses that hospital administrators have to be "on board" with overcrowding and long waits in their Emergency Rooms and seek to find solutions.

Simply, in my opinion, OSF-SFMC was and is mismanaged, caters to elective insured admissions, which puts patients coming to the ER at risk.

From Emergency Medicine News:

EMN Diversion
May, 2009

Diverting the Diversion Diversion

SoRelle, Ruth MPH

Paul Dreyer, PhD, the director of Health Care Safety and Quality at the Massachusetts Department of Public, was coming out of a task force meeting on rules for ambulance diversion more than 18 months ago when he had an epiphany. Diversion was not the problem.

In fact, it was diverting attention and resources away from the real problem plaguing the state's emergency departments. The real issue was crowding.
I discussed it with a number of the members of the committee who were chatting. Instead of talking about diversion rules, I suggested we eliminate diversion. I circulated the idea informally among the members, and at the next meeting, we discussed it formally, and came to a consensus decision that was essentially policy, he said.

On Jan. 1, 2009, Massachusetts eliminated ambulance diversion within its borders except when an internal emergency closes a hospital to all patients. It gets diversion off the table as a potential solution, and enables us to focus on the real issues, said Dr. Dreyer. And it focuses the attention of hospital CEOs and others on the issue of crowding itself. They can't say 'go on diversion' when the emergency department is crowded.

In fact, many emergency experts have long criticized diversion because it simply pushes the problem from one hospital to the next until too many hospitals are on diversion and the system has to open again. Historically, the situation has been that in areas that went on diversion, the situation that led one hospital to go on diversion would lead all hospitals to be on diversion, said Dr. Dreyer.

In two conference calls prior to the no-diversion policy taking effect, he was struck by the steps hospitals had taken to address patient flow issues in anticipation of the new rules. One prior worry had been that the policy would increase the turnaround time for ambulances taking patients to the hospitals.

We heard from the head of a large municipal ambulance service in Boston that contrary to his expectations, the turnaround time had gone down in every single Boston hospital, Dr. Dreyer said. It was a sort of clearing of the decks. Now the focus is on crowding, and the solution to crowding is upstream. Diversion was a diversion so we just got it off the table.

Alasdair Conn, MD, the chief of emergency services at Massachusetts General Hospital in Boston, said diversion created a number of problems for patients and physicians. Patients tend to come to the hospitals where their physicians are. If we were on divert, it created an enormous issue for the patients. They had to see a strange specialist, and the hospitals tried to transfer them later in the day. We all sort of bit the bullet on this, and decided to see how it goes. His hospital and Brigham and Women's Hospital accounted for the highest number of divert hours in the city. We said we had to step to the plate here. We did a pilot of 'no divert' for two weeks a year and a half ago. That went okay. There were no giant catastrophes. Now it looks a though some of our fears have not been realized.

In fact, the length of time ambulance crews had to wait in the emergency department decreased. One downside is that it has put a lot of pressure on the emergency departments, he said. Comparing January 2008 (when the hospitals could divert) with January 2009 (when they could not), he found that while ambulance arrivals went up 17 percent at his institution, the total volume was up only six percent. Thirty percent of patients come by ambulance, but the rest are walk-ins, he said, noting that ambulance arrivals do often generate hospital admissions and stress the hospital's inpatient units.

Because his hospital's leaders knew that the no-diversion policy was in the works, they have changed the way their emergency department works, Dr. Conn said.

Physician-led triage for eight hours a day has dropped the walkout rate from seven percent to two percent, he said, and decreased door-to-doctor time. We implemented this with our existing physical plant and the redesigned the triage area and four screen rooms last October, he said. It has certainly helped. We have sent patients from triage directly to observation or an inpatient bed.

While the emergency department's boarding time has decreased, it is still high, he said. Patients were waiting an average of ten and a half hours for a hospital bed. Now it's down to seven hours. We have also speeded throughput on the inpatient units and boarded more medical patients on the surgical units. All of these have been possible by a hospital administration that agreed that this was the hospital's issue and not just limited to the emergency department.

When Massachusetts General went on divert in previous years, the neighboring hospitals got the overflow and often within 30 minutes went on divert themselves, Dr. Conn said. Now everybody is open. If there is an equal distribution of patients throughout the system, then we all can bear the pain. If the distribution changes slightly, then one hospital suffers more than the others. His department's volume is up six percent month-to-month, but another facility's volume is down and others are only slightly increased.

If you built an emergency department for 70,000 visits annually, and you are now dealing with 80,000, then a change in referrals or ambulance destinations pushes your volume up to 85,000, it will cause a problem long-term, Dr. Conn said. And if one hospital closes its doors, increasing his emergency department volume by 18 or 20 percent, we can't take that, he said.

Opening more hospital beds seems the easy answer, but it will not happen overnight. His hospital is in the process of constructing a new building and opening 150 more beds, but making the inpatient side more efficient over the long term also reduces pressure. If the average length of stay is 5.8 days, reducing it to 5.6 days is the equivalent of opening 24 more beds, he said. A length of stay of 5.5 days is the equivalent of 36 beds.

Changing the timing of elective admissions might also help, Dr. Conn said. Sometimes, a hospital goes on divert because surgeons do most of their cases on Tuesdays and Wednesdays, taking up the inpatient beds and causing others to be boarded in the emergency department. If the admissions were spread out more equitably across the week, the pressure would be reduced and the need to divert goes away. Such plans not only reduce emergency department stress, they also reduce health care costs, he said.

We absolutely have no plan to go back, Dr. Dreyer said. One emergency department director in Boston said things had been busy and in previous times, he might have been tempted to press the divert button. They managed, and he thinks things are better because patient flow is smoother. Because no one goes on diversion, no one gets an excess load.

Dr. Dreyer's ED is also collecting data on patient boarding to track the progress in patient flow over time. In future meetings, they will broach improving patient flow in greater detail. We didn't expect the elimination of diversion to solve anything, but we took diversion as a bad solution off the table, he said. It seems to have had positive consequences because it forced hospitals to take serious measures to improve patient flow. We made it a hospital problem, not just one of the emergency department.

And the state group that previously dealt with diversion? They've renamed it, said Dr. Dreyer. It's now the Boarding and Crowding Task Force.

© 2009 Lippincott Williams & Wilkins, Inc.

Monday, May 11, 2009

A Mother's Love

This lady ran barefoot through the streets of Soleil carrying her seizing two year old daughter.

Her daughter, Abagaille, started having a fit out of the blue last Thursday morning. She hadn't had a fever and never had seizures prior to this one.

Mom and her 7 kids live in Beleco which is about one and one-half miles from the pediatric clinic.

As Abagaille seized, this lady suffered. She cried, shook her head, and extended her arms pleading to her God to stop this. But she held on to Abagaelle and kept running.

When I examined Abagaille, she seemed post ictal, and then would clench her teeth and seem to smile. But she blinked when I touched her eyelids and cried when she received an IM injection. Her vital signs were stable.

Abagaille's seizures stopped. Her blood glucose came back at 47. We gave her sips of powdered milk forumla. She looked around and appeared normal.

I should have done much more from a diagnostic workup, but I couldn't under the circumstances, that I should not explain.

Mom was relieved that her terrible seizures had stopped, and I told mom to come back the next morning.

Mom and Abagaielle returned the next morning and both looked fine.

The hundreds of thousands of people in Soleil like Abagaielle and her mom deserve so much more.

Sunday, May 10, 2009

Peoria's Ambulance Monopoly is Falling Apart

Very slowly, Peoria's corrupt ambulance system is changing.

Last week this article reported that Peoria Fire Station 12 is paramedic.

This took almost two decades to happen.

OSF has supported AMT for the same period of time. OSF's ambulance director was on AMT's salary.

A short Forum article of mine was printed yesterday in the Journal Star.

It will be important for the PFD Station 12 to document the number of people that it helps. The entire city of Peoria needs to be served by the PFD paramedics with advanced life support drugs and technology that AMT has had for years.


Forum: Keep improving Fire Department equipment

Posted May 08, 2009 @ 10:30 PM

Re. May 2 story, "Specialized fire engine looks to save lives":

The people covered by Peoria Fire Station 12 are now in good hands. But what about the rest of Peoria?

I wonder if it will take two more decades to permit Peoria Fire Department paramedics to obtain a second "advanced life support engine" to save even more Peorians.

John A. Carroll, M.D.

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1 day ago
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The 'advanced life support engines' that I refer to in the article are simply regular fire engines with advanced life support medication and equipment. The medication and equipment are very cheap but can be very effective in saving lives.... especially when used immediately upon arrival.

The Peoria Fire Department has had Paramedics and Intermediate EMT's for years. Unfortunately for Peoria, they were not allowed to use these individuals for their advanced medical expertise.

The real question is: How long will it take until OSF and the other 'powers that be' to permit other PFD engines to be supplied with advanced technology? Or will local power and greed continue to keep the Peoria ambulance monopoly in AMT's hands?

John A. Carroll, M.D.

1 day ago
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Well put John. And also maybe the city should support this and not have to only rely on AMT to get it started. I wonder how much the city has budgeted for the ALS? ? I dont care how broke a city may be, common sense tells me that if this will help save lives then maybe we should budget some money toward this and make it happen. This is a great addition to the City of Peoria.

23 hours ago
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This article reported on a staged event.

OSF and its Emergency physician leaders were not quoted, if you noticed. They have been telling the public for years that everything was fine with Peoria's Emergency Medical Services, when it was not.

And both OSF and its Emergency physician leaders have been fighting against the PFD from advancing its medical care for years, while they supported Advanced Medical Transport (AMT).

In 2003, when AMT did not get the vote they needed for a multi year contract with the City, they pulled their offer to help the PFD advance its medical care education. So I doubt AMT is thrilled about even one PFD Station giving Paramedic care now. AMT was told what to say by OSF.

You are right. This is a great addition for the City of Peoria. Hopefully, the political support will be there for more PFD Paramedics and more engines carrying advanced life support medication very soon.


5 hours ago
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The iretrucks almost always get to the scene before the ambulance. It only makes sense that the firetrucks should have the equipment that is most urgently needed in emergency situations.

46 minutes ago
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And the main thing Kate is that people like you and me and anyone elso out there need to speek up to the city council, and maybe things will get done.

One of Haiti's Scourges...Rheumatic Fever

New Haitian Hearts Patients

This week, on the same day, I examined three new patients with congenital heart problems.

I will describe two of the cases. (My satellite signal for the internet is weak right now. I will load pictures of the kids as soon as the signal improves.)

The first patient is five month old Merlinda. She lives with her mom and dad just north of Port-au-Prince.

Merlinda had a fever of 101.5 F and a heart rate of 180/minute. However, she did not appear to be in any respiratory distress. She avidly took her mother's breast. I think her fever was from a recent vaccination.

Merlinda appeared quite healthy.

Her exam revealed a loud blowing murmur to the left of her sternum that radiated everywhere across her chest. The murmur was classic for a hole between the lower chambers of her heart (ventricular septal defect).

Sometimes these holes can "heal themselves", but the location of this hole is up high on the septum and not as amenable to seal over on its own.

So Haitian Hearts will begin its search for a medical center to evaluate and possibly operate Merlinda.

The second patient is Jimi.

Jimi is 5 years old and weighed 17 kilograms. He was brought to me by his father.

Last August, during the hurricaine season, heavy rains caused the river to rise near their home. Their home was flooded, a wall was destroyed, and they lost their garden. Both Jimi and his father are rail thin.

Jimi's heart exam was the same as Merlinda's above.

Jimi was so sweet and did not say a word.

We will do our best with Jimi too. His father has already started on Jimi's passport.

If any one out there in cyberspace has any connections with pediatric medical centers for these two kids, we really need your help.


Dr. John

Saturday, May 9, 2009

Ti Pierre Dies

Haitian Hearts could not find a medical center for Ti Pierre and he died.

The principal of his school in Port-au-Prince called me yesterday to tell me this terrible news. She was very frustrated with his death.

Ti Pierre needed a new mitral valve. That is all he needed.

She said he is in a better place now. I am sure he is.

New Haitian Hearts Patients

This week, on the same day, I examined three new patients with congenital heart problems.

I will describe two of the cases. (My satellite signal for the internet is weak right now. I will load pictures of the kids as soon as the signal improves.)

The first patient is five month old Merlinda. She lives with her mom and dad just north of Port-au-Prince.

Merlinda had a fever of 101.5 F and a heart rate of 180/minute. However, she did not appear to be in any respiratory distress. She avidly took her mother's breast. I think her fever was from a recent vaccination.

Merlinda appeared quite healthy.

Her exam revealed a loud blowing murmur to the left of her sternum that radiated everywhere across her chest. The murmur was classic for a hole between the lower chambers of her heart (ventricular septal defect).

Sometimes these holes can "heal themselves", but the location of this hole is up high on the septum and not as amenable to seal over on its own.

So Haitian Hearts will begin its search for a medical center to evaluate and possibly operate Merlinda.

The second patient is Jimi.

Jimi is 5 years old and weighed 17 kilograms. He was brought to me by his father.

Last August, during the hurricaine season, heavy rains caused the river to rise near their home. Their home was flooded, a wall was destroyed, and they lost their garden. Both Jimi and his father are rail thin.

Jimi's heart exam was the same as Merlinda's above.

Jimi was so sweet and did not say a word.

We will do our best with Jimi too. His father has already started on Jimi's passport.

If any one out there in cyberspace has any connections with pediatric medical centers for these two kids, we really need your help.


Dr. John

Wednesday, May 6, 2009

Ninety-One Minutes Away

JH, thank you for all of your support as we seek the truth.

Time for OSF and the Diocese to Explain

Here was the first patient in pediatric clinic this morning.

And things didn't improve.

About two hundred patients showed up even though four hours of heavy rain last night flooded Port-au-Prince. And since water runs down hill, the Soleil clinic courtyard was inundated with water.

The only hospital in Soleil, across the flooded field from the clinic, had water in the main hallway. And lying on a bench in the main hallway was the uncovered body of a young man who had come in yesterday with an abscess on his neck. His arms were tied together resting on his abdomen.

American Airlines flights come in and go out over Soleil. The noise of their engines is deafening inside the hospital. Miami is 91 minutes away.

Sunday, May 3, 2009

Time for Dr. Hevesy to Explain

Now that Fire Station 12 in Peoria can give paramedic care, I think it would be a good idea if OSF and Dr. George Hevesy would make a statement regarding Dr. Hevesy receiving a salary from Advanced Medical Transport.

The time is now.

If people clearly understood what has happened, and understood the seriousness of the conflict of interest, they would push the policy makers harder for the Peoria Fire Department (PFD) to expand its paramedic service for all of Peoria.

Waiting on AMT to arrive on scene and give advanced life support to patients in extremis would be a thing of the past.

Many people in the Peoria area believe there has been a conflict of interest with Dr. Hevesy receiving a salary from AMT. He worked for many years as the local Project Medical Director (physician who controls all ambulances in the area) and is now the Director of Emergency Medicine at OSF.

Why did it take the PFD almost two decades to be able to administer advanced life support? AMT wanted to be the only ambulance providers of this service in Peoria and Dr. Hevesy supported AMT while he was paid by AMT.

Did Dr. Hevesy support the PFD and encourage them to advance their care as Station 12 just did? Did he ever discourage the PFD or influence the Peoria City Council in any way that would slow the PFD from advancing? Journal Star archived articles say yes.

OSF, AMT, University of Illinois College of Medicine in Peoria, and Dr. Hevesy all need to admit to the public in Peoria (an advertisement in the Journal Star?) that Dr. Hevesy is on AMT’s payroll.

Then, maybe it wouldn't take two more decades for the PFD to save some lives.

Peorians need to know. It is time for Dr. Hevesy to tell us.

Read the first few paragraphs of this weeks New England Journal of Medicine (April 29, 2009) regarding medical conflict of interest. In my opinion, it is very relevant in Peoria.

Controlling Conflict of Interest — Proposals from the Institute of Medicine
Robert Steinbrook, M.D.

As Congress considers mandating the disclosure of industry gifts and payments to physicians on a searchable federal government Web site, others have been developing proposals for reforming physician–industry relations, and key changes are being made to policies at various academic medical centers, professional societies, and companies.

In late April 2009, the Institute of Medicine (IOM) issued a report on conflicts of interest that is notable for its breadth — it covers many aspects of medical research, education, and practice as well as both individual and institutional financial relationships — and the variety of its proposals (see Overview of IOM Recommendations about Conflict of Interest in Medicine).

The IOM defined a conflict of interest as "a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest." The primary interests of concern include "promoting and protecting the integrity of research, the welfare of patients, and the quality of medical education." Secondary interests "may include not only financial gain but also the desire for professional advancement, recognition for personal achievement, and favors to friends and family or to students and colleagues."

Of course, public attention has focused primarily on financial conflicts of interest, and the IOM did so as well, viewing them as "not . . . necessarily more corrupting" than other secondary interests but "relatively more objective, fungible and quantifiable" and "more effectively and fairly regulated."

Saturday, May 2, 2009

"Highly Unique Story"

For almost two decades Emergency Medicine physicians at OSF, who have been Directors of Peoria's Emergency Medical Services (EMS), have told the public that Peoria's EMS was just fine.

At least one of the physicians is on Advanced Medical Transport's (AMT) payroll, and according to the Peoria Fire Department (PFD), this physican threw up roadblocks during the past 15 years when the PFD tried to advance their level of care for Peorians.

Despite what the OSF physicians would have us believe, an article in the Journal Star today clearly indicates that not all has been fine in Peoria's emergency services.

The PFD finally has an engine and their paramedics are now allowed to give Peorians the emergency care they deserve when 911 is called.

And what the Journal does not report is the conflict of interest that has been hidden from the public.

I wonder how many lives have been needlessly lost in Peoria during the last two decades?

Here is the article:

Specialized Fire Engine Looks to Save Lives

Vehicle to treat more patients made possible by cooperative effort
By RYAN ORI of the Journal Star

Posted May 01, 2009 @ 08:05 PM

Nearly two decades after first seeking an advanced life support engine, the Peoria Fire Department has one on the streets.

Friday morning at Station 12, 3006 NE Adams St., Peoria fire Chief Kent Tomblin, Mayor Jim Ardis, Advanced Medical Transport Executive Director Andrew Rand, Firefighters Local 50 union President Tony Ardis and other officials gathered to discuss details of the cooperative effort that brought the first ALS engine to Peoria.

"This cooperative effort involves a municipal government, a non-profit organization and a fire union," Rand said. "This is a highly unique story. I don't know of any other agreement like this."

Other than East Peoria, where the fire department also operates the city's ambulance service, Peoria is the only city in the area now offering an ALS engine.

The actual vehicle remains the same, but it is now stocked with higher-tech equipment and many more types of medications to treat patients with life-threatening conditions such as heart attacks. Another key difference is that to maintain ALS status, an engine must have at least one firefighter with paramedic-level training on board at all times.

In many cases, that means the first people responding to a scene will now have a higher level of medical training than in years past.

All Peoria firefighters are required to have a minimum of emergency medical technician training. There are nine current firefighters with paramedic training and 10 more in training for that level of certification.

"With an ALS engine, we can now intubate - put a tube down someone's throat to assist with their breathing - as well as administer an IV, shock or pace the heart, and use a lot more medications," said engineer Clint Kuhlman, who has paramedic training. "When we're there before an ambulance, we can start advanced life support more quickly. This will save lives that we previously may not have been able to save."

Kuhlman said Station 12 used its new ALS capabilities in the first week since initiating the engine April 24.

"When we get the kinks out of it, our goal is to add ALS service throughout the city," Tomblin said.

The Fire Department had discussed adding an ALS engine in the early 1990s, but there has been a long-running territorial battle between AMT - which provides ambulance service to Peoria - and the city of Peoria.

In November 2007, AMT and the City Council passed an ordinance providing AMT with franchise protection for 20 years.

Rand said with its place in Peoria secure, AMT was able to join the city in ironing out details of an ALS engine. As part of its requirements as a not-for-profit organization, AMT is providing the Fire Department with $10,000 worth of start-up equipment and medical supplies and will continue to provide those items as more patients are served.

As Peoria adds other ALS engines, Rand said AMT will provide more equipment, supplies and training of firefighters.

"It should always be about patients, but a lot of the time it's about political turf," Rand said. "Mayor Ardis has a greater skill set than more people I've met for getting people into a room to talk and do the right thing."

Tomblin said the timing also was improved by the increasing number of paramedic-certified firefighters in the department.

"We've always from the get-go wanted to do what's best for the patient," Tomblin said. "We have the right people in place to do this now. We have an amazing partnership with all the people involved.

"I've been here 30 years, and there were times our partnership wasn't that amazing."

Ryan Ori can be reached at 686-3264 or
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