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OHSU's 21,500-square-foot emergency department is a modern marvel. Staffers pad across the freshly mopped 42-room space in their Nikes and Adidas, wearing Dick Tracy-style miniature radios while a computer-regulated intercom system digitally tracks every doc's whereabouts. Unveiled a year ago this week, the $7.5 million, high-tech emergency
department includes a monitoring system that allows staff to observe patients' medical status from all corners of the floor by pointing and clicking with a computer mouse. It also houses a special room to deal with toxic spill victims, a psychiatric ward, a children's emergency unit and an urgent-care ward for minor emergencies such as broken arms. OHSU's emergency room has everything--except, according to some, enough nurses. On Aug. 4, 1997, barely a month after the emergency room opened, an elderly Russian patient collapsed and died there. His death wasn't the result of a failure of the high-tech equipment. According to OHSU emergency department RNs on the scene, part of the problem was a shortage of staff. The man, whom nurses believe had a heart attack, went unattended for 20 minutes in the emergency department before dying. "That was the turning point," says one RN, a 10-year veteran of the OHSU emergency room. "We went ballistic. That mobilized a lot of the RNs to file a complaint with the state." OHSU won't release patient names, but Multnomah County Medical Examiner records show that 85-year-old Vasyl Zhylin died at the hospital Aug. 4. Shortly after Zhylin's death, several emergency-room RNs filed a complaint with the Oregon Health Division. The state investigated their complaint and reported that "the hospital failed to assure that it had adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed.... Problems become pronounced during trauma events." Today, OHSU emergency department director Dick Cates says the staffing problems have been addressed. The nurses aren't so sure. Just last week, emergency-department nurses filed two new staffing complaints with their union, the Oregon Nurses Association. The battle over staffing at OHSU's new emergency department is more than a standoff between labor and management. It directly reflects the controversy surrounding managed care--the tension between cutting costs and caring for patients. With a 1998-99 emergency department budget that's down 3 percent from last year (adjusted for inflation), nurses in OHSU's emergency department believe managed care has pushed the cost-cutting scalpel too deep. "What happened last summer," a veteran nurse cautions, "could easily happen again this year." The changes that have taken place in the health-care industry during the last 15 years are at least as dramatic as the ballyhooed revolution in high tech. The impact on our lives from the convulsions racking the health-care industry is more urgent than the effects of the Internet. After all, we're talking about your blood pressure, your CAT scan results, your ulcer medication. At first glance, the changes in the health-care industry seem just as confusing as the mindboggling advances in Silicon Valley. With HMOs, PPOs, PPMs, formularies, PBMs and capitation, you're as likely to figure out the landscape of health care as you are to comprehend HTML code. There is, however, a dummies' guide to understanding what is happening in the health-care business. Chapter 1 is cost cutting. Back in the fee-for-service age of medicine, health costs (and inflation in general) spiraled into the stratosphere when doctors counted on insurance companies to pay for everything they prescribed, every test they ran and every operation they tried. Now, things are quite different. Today's efforts to cut costs by insurance companies have forced doctors to keep an eye on the bottom line and have required hospitals--hungry for the business, or the "covered lives," that HMOs can deliver--to streamline costs. There's no doubt it has worked. Growth in annual health-care spending dropped from 12.2 percent in 1990 to 4.4 percent in 1996. The problem is, we've gone from one extreme to the other. Critics of managed care say medical treatment now is elusive and shoddy. You don't have to look very hard to find HMO horror stories. The front page of USA Today on Friday, June 19,blared the stories of 16-year-old Melody Louise Johnson, who died of cystic fibrosis after her HMO stopped her from seeing specialists; Phyllis Cannon, who died of leukemia after her HMO denied her the bone-marrow transplant that her physician recommended; and Bill Beaver, who says his HMO misdiagnosed a brain tumor for two years, then told him his condition was inoperable and hopeless. Earlier this year, one of the nation's most outspoken critics of managed care, Dr. Linda Peeno, came to Portland to address a health-care conference sponsored by Oregon Health Action. Peeno has worked as a medical claims examiner for several HMOs, and she spoke bluntly about her profession. "I wish to begin by making a public confession," she said. "In the spring of 1987, as a physician, I caused the death of a man. This act secured my reputation as a 'good' company doctor and ensured my advancement in the health-care industry. I was repeatedly told that I was not denying care; I was only denying payment." Peeno called managed care "an organized system of limitation and denial--an unprecedented market-driven system of rationing medical resources." On July 1, 1995, OHSU seceded from the state. For more than 100 years, OHSU--which includes University Hospital, Doernbecher Children's Hospital and several medical schools and research facilities--had been governed by the state. Three years ago, facing decreasing public revenues and a health-care industry transformed by managed care, OHSU board members persuaded state legislators to cut the hospital loose from the state's apron strings so it could better compete with private hospitals for consumer dollars. The 1995 Legislature passed a bill exempting OHSU from submitting its budget for approval. This freed the hospital from cumbersome state-governed procedures that hindered the hiring and contracting process. Although OHSU still receives more than $13 million in general budget funds annually, the hospital on the hill now calls its own shots. "Being embedded within the state kept us from being competitive," says Jim Walker, executive vice president of OHSU. "We're very unlike a state agency [because] we had to compete for patients. And the competitive marketplace was changing in the last four years, moving from fee-for-service to HMOs." This change, from fee-for-service to HMOs, meant that OHSU had to tighten its belt to attract the business of health plans. "All of a sudden OHSU's dynamics changed," says Ken Rutledge, executive director of the Oregon Association of Hospitals and Health Systems. "They had to find new patients, and they had to find a way to reduce costs. This is a very competitive marketplace, and the main thing about competition is getting cost structures under control." OHSU has succeeded at increasing business and cutting costs, Rutledge says. According to audited financial statements filed with the Oregon Association of Hospitals and Health Systems, the hospital's market share is up 13.5 percent since 1993, and total revenues went up $20 million between 1995 and 1997. Meanwhile, the number of full-time-equivalent employees per occupied bed has gone down 3.7 percent, and total expenses per stay has dropped 1.4 percent. Perhaps more telling is that, between 1996 and 1997, wages and benefits dropped 3 percent while patient revenue jumped from $276 million to $296.4 million. Walker, OHSU's executive vice president, says he understands the anxiety that staffers may feel. "Every hospital out there is facing the same thing," he says. "We're all being forced to make cuts. Management has the responsibility to make sure those cuts aren't going to affect quality of care. Human nature on this issue is that when you're looking at ways to cut cost, people are always worried that you're cutting care." One need look no further than OHSU's emergency department to find this kind of employee anxiety. The new emergency room was equipped to handle 42 patients, a 133 percent increase over the old ER. Nursing staff, however, was increased by only 17 percent. Cates, the director of nursing staff in OHSU's emergency department, has the difficult task of balancing cost cutting and health care. A 50-year-old RN from Kansas City, Cates came to OHSU as a manager in November 1996. Armed with national averages on nursing hours per patient visit and charts and graphs that track patient flow at OHSU's emergency department throughout the day, Cates has been on the defensive ever since he arrived at OHSU. Especially after the Aug. 4 death that sent nurses complaining to the Oregon Health Division. OHSU's emergency room can go from zero to 60 mph in less than a second, and when there's not enough staff, high-speed situations can swerve toward tragedy. That's exactly what happened that August afternoon when a distraught Russian family brought a man, believed to be Zhylin, into the department. A young woman who accompanied the man managed to indicate in a mix of Russian, English and waving arms that he was suffering severe abdominal pain. The triage nurse entered his name into the computer and labeled him "emergent"--which means he needed to be tended to within five to 10 minutes. The man died 20 minutes after arriving at OHSU's emergency room. With a line of emergencies queuing up at the front desk, no one ever got to him. Investigators from the Health Division--the office within the Department of Human Resources that certifies and licenses Oregon hospitals--didn't mince words. After surveying the emergency department in action for two days in September, interviewing staffers at all levels--from the department director of emergency services to RNs to physicians--and reviewing patient medical records, health division officials issued a 14-page report. It concluded that the number of patients and the serious nature of their condition "strain current staffing levels making it difficult to meet the nursing needs of patients." Calling the deficiencies regular occurrences rather than isolated events, state investigators reported examples that demonstrated the significance of the staffing problems in OHSU's emergency department. OHSU guidelines say that in the case of an urgent trauma, three RNs are required for each patient. State investigators reported that on one weekday morning there were four nurses on duty. One nurse and one nurse's assistant were covering the observation unit, watching over three patients. The three remaining nurses were watching the stabilization unit and the acute care area--where there were 15 patients, three on cardiac monitors. When two traumas arrived simultaneously, two RNs responded, providing only one registered nurse per trauma--a violation of the hospital's own regulations. Meanwhile, only one nurse remained to cover the 15 patients in acute care, and--after pulling the one RN from the observation unit--an assistant was saddled with three patients. Staff reported to the state that these factors "created an unsafe environment for patients in all areas." In another instance, investigators found that, although the department manager said the observation unit RN would not be required to help in the acute area when there were patients who needed close observation, it was common practice for the observation unit RN to be pulled from the unit for as long as eight hours. This practice leaves underqualified assistants responsible for the nursing care of the observation patients, which may include monitoring of intravenous solutions, vital signs and cardiac monitors. The investigation also found that no one was being assigned to monitor the central display that tracks cardiac status on all patients in the emergency department. In conclusion, state investigators wrote, "The hospital did not meet the requirements of federal regulation [that requires] the immediate availability of a registered nurse for bedside care of any patient. The facility also did not meet the requirements...that there shall not be fewer than one registered nurse and one other nursing care staff member on duty when a patient is present." Cates says the staffing problems at OHSU have been solved by the addition of a critical response nurse position--a 24-hour position filled by five different RNs during the course of a week. The critical response nurse provides backup for all trauma cases. Cates also added one evening-shift RN and filled two general RN positions that were vacant last summer. It doesn't seem to have helped. RNs from OHSU's emergency room recently filed two new staffing complaints with the Oregon Nurses Association. In a June 13 complaint, a nurse who was covering both day and evening shifts expressed alarm about staffing shortages, writing, "We were very lucky that there were no negative outcomes on this shift." A June 14 night-shift complaint described an inadequate number of nursing staff resulting in "delayed or omitted treatments and delayed medications." Cates defends his management of the department. "Emergency departments are not a daytime, Monday-through-Friday business," he says. "You must balance resources over 24 hours matching cost with need. If you have imbalances, eventually you can't provide any health care at all. "There's only a problem if you're not looking at real data," Cates continues. "I'm not counting beans, I'm counting patients. I'm looking at real numbers of real visits in the emergency department." This week, Cates' nursing staff started working under a new schedule that Cates says will make the department more efficient. Willamette Week obtained a copy of the new schedule; on average, it cuts nursing care by five hours per week compared with the current schedule. As one emergency department RN explains it, the schedule is based on static averages that don't account for real-life situations. "If two traumas came in on my shift we would not be prepared," the nurse says. "The problem is, management is counting on real life to follow a chart. That's the way to sell shoes, but we're not selling shoes. You can't apply business principles to medicine and make it work for people." OHSU's emergency department nurses aren't the only local RNs who are alarmed. In the last year, the Oregon Nurses Association has received 70 reports from nurses around the state about inadequate staffing that has had a negative impact on patient care. The problem is national. In 1996 and '97, after surveying nearly 10,000 nurses nationwide, The American Journal of Nursing released a major study of trends in the nursing industry in the age of managed care. Thestudy found that 60 percent of the respondents believe the most prominent change in their nursing department since the advent of managed care was that fewer RNs were available to provide direct patient care. Almost 42 percent of respondents reported that unlicensed assistant personnel were being substituted for RNs. "Based on these changes," the study concluded, "the most deleterious labor trend affecting nursing is...forcing fewer RNs to do more work in less time." |
