Monday, August 24, 2009

Crowded ER's Put Patients at Risk

A recent article in the Peoria Journal Star reported that the new ER at OSF would grow from 19 rooms to 55 rooms.

This seems like a good move but studies have shown that the main problem with ER overcrowding is lack of beds in the hospital to move ER patients that are waiting to be admitted.

This was the problem that I faced eight years ago when I worked a busy shift in the ER at OSF. A couple of elderly patients of mine "signed out" and went home because I could not get them admitted to OSF in a timely fashion.

Studies during this decade have shown that patients that are "boarded" in the ER have worse outcomes. In other words they get sicker, have more complications, and die more often than patients efficiently admitted.

I wrote a letter to Keith Steffen on September 27, 2001 explaining my fear of this problem in the ER at OSF. I was placed on probabtion the next day and fired in December, 2001.

A wise administrative decision by Mr. Steffen was what was needed at the time. The ER chaos at OSF was unsafe for patients. Elective surgical and cardiac admissions needed to be controlled at OSF to allow room for ER patients.

And ER patient and employee disatisfaction was the highest in the medical center.

Here is a recent article describing ER overcrowding in the US in 2009. Not much different than 2001 in Peoria....

Emergency Medicine News:Volume 31(8)August 2009

Crowding Irrefutably Puts Patients and EPs at Risk

Glauser, Jonathan MD, MBA

Dr. Glauser is an assistant professor of medicine at Case Western Reserve University and attending faculty in emergency medicine at the Cleveland Clinic Foundation in Cleveland.

So much has been written about emergency department crowding in recent years that I would be remiss not to mention this as a legal risk to emergency physicians and a medical risk to patients. ED crowding as a major health problem and public issue has been in our literature for years (Ann Emerg Med 2002; 39[4]:430), and can safely be claimed to be irrefutable.

A striking fact worth noting is that the patients who wait more than 30 minutes to see a physician are five times more likely to sue than those who are seen within 30 minutes. (Emergency Department Crowding: High-Impact Solutions. ACEP Task Force on Boarding. April 2008; ) This is especially disturbing because, failing a completely dysfunctional triage system, those patients not seen in 30 minutes should theoretically be less sick than the ones seen immediately. The implication that an irate patient with an ankle sprain is more likely a litigant than a patient with a STEMI seen promptly should grab our attention.

We should be alarmed at a recent survey finding that 44 percent of emergency physicians polled said their EDs are understaffed, and 40 percent said understaffing negatively affected patient safety. (EPM 2009;16[5]:1.) Of course, our productivity is measured in patients seen per hour, RVUs generated per hour, or overall census. If ED crowding is all about held admissions, then the reported workload and nursing and physician staffing patterns of the ED should reflect the number of patients being cared for at any given time.

Problem Isn't Going Away

It may be that there is no or insufficient surge capacity in this country. It simply does not pay for hospitals to keep empty beds staffed waiting for emergencies and disasters. In our current reimbursement system, elective surgery and cardiac workups pay well. Even if they did not, emergency admissions are disruptive to planned processes, especially scheduled operating room procedures. The market is not going to create more inpatient availability for ED admissions; it is debatable whether government regulation to mandate a number of beds for unscheduled admissions is feasible, but short of outside intervention, this isn't going to happen.

Other factors are not going away either. Data only a decade or two ago indicated that EPs might see 1.8 to 5.0 patients per hour in an undifferentiated emergency department. That figure was scaled down to 2.4 patients per hour in one widely cited publication more than 20 years ago. (Emergency Medicine Risk Management. Irving, TX: American College of Emergency Physicians; 1997; Physician Staffing in Management of Emergency Services. Rockville, MD: Aspen Publishers; 1987.) The population is aging, and has more complex disorders on presentation. If the ED of the future is one that sees a progressively older and sicker population, we will have to rethink how we approach care of the elderly. Many experts challenge anyone to undress an octogenarian referred from a long-term facility, obtain a reliable list of his medications, and secure a urine specimen in under 20 minutes.

Who is Responsible?

There are hardly any publications regarding ED crowding that do not cite boarded patients as the primary cause. Because a fair amount of literature has documented bad outcomes and prolonged hospital stays among boarded patients (Acad Emerg Med 2005;12[5 Suppl 1]:49; Med J Aust 2006;184[5]: 213), it's fair to ask which providers are responsible for admitted ED patients waiting for a bed. Emergency medicine's answer is unequivocal: Boarded patients are the responsibility of the admitting service. That, by the way, has to be the stance of any emergency physician, or the number of new patients we are expected to see per hour becomes a moot point.

Experts advise EPs not to skip meals during a long shift and to limit the number of patients being actively managed to six. (Six!) At that number, sensory overload presumably kicks in, and we should be making some dispositions. With sick inpatients to manage, it becomes impossible to adhere to any given number of active new patients per hour.

Is crowding a defense for bad outcomes? This is not a winnable argument, in court or with one's hospital administration or medical staff. Eight people may be sympathetic to a doctor who has to manage many patients in hallways while a hospital is booking lucrative elective surgeries, but it is perilous and unwise to be at odds with one's hospital, financially or in court.

We should make it clear that the official care of admitted patients changes hands at the time of admission, but we also know that we have to take responsibility for adverse outcomes in the ED, for preventing those results, and for the comfort of any patient in our department.

The Bottom Line

Moving patients from ED hallways to inpatient hallways may work in some settings but not most. This is the most frequently cited solution to ED crowding, but patients are dissatisfied sitting in any hallway. Still, the most unsafe place for a patient is in the waiting room, unseen. Do whatever it takes to avoid this within the culture of your institution. I always work under the assumption that patient safety will ultimately reward us in the tort system.

It is besides the point whether all those EPs who feel they are working in understaffed EDs really are in an unsafe environment. The perception should be enough to change the way we practice. I personally take people at their word when they feel overwhelmed. Some people are whiners, some are lazier than others, but a perception of understaffing is enough to worry me. We need to look hard at the processes and resources brought to this problem.

I have never really had much use for tracking patient census as an excuse for an untoward event. I know attorneys will always look at staffing patterns and patient census when an EP discharged a patient with crescendo angina. Yet the activity of an ED cannot be tracked accurately by number of arrivals, especially if held admissions are not counted in the workload for physicians and nurses. No tracking system I have found will accurately reflect how time-consuming each patient was at the time. Numbers may not lie, but they can mislead.

© 2009 Lippincott Williams & Wilkins, Inc.


Saturday, August 22, 2009

Don't Wait for Clerical Leadership...Sounds Like Peoria's Problem

From Judie Brown's American Life League

August 17, 2009

There are valuable lessons to be learned from the Catholic trenches in Boston in terms of what lies ahead nationally. In late February of this year, the Caritas Christi health care delivery network sought and was awarded a contract that includes providing abortions, family planning services and other moral evils to the uncatechized, the unsuspecting poor and women emotionally distraught due to an unplanned pregnancy.

It should be noted that Cardinal O’Malley tried to generate support for the arrangement by purporting that Catholic theology permitted entering into a contract that binds a Catholic in the performance of moral evils; in effect, he claimed that even though we realize the sinful nature of performing those moral evils, so long as we recruit others to perform the evils, it does not violate Catholic ethics. Theologically, spiritually and ethically, nothing could be more unsound. Knowing something is wrong and sinful, and then baiting somebody else into doing it who doesn’t know, compounds the sin. The Caritas arrangement is as ethical as hiring Kevorkian to kill your elderly parents when they become a personal and financial burden.

The Catechism of the Catholic Church is clear about those who give scandal by becoming their “neighbor’s tempter” (Sections 2284–2287). Leading others to do evil “takes on a particular gravity” for those in authority who cause it:

Anyone who uses the power at his disposal in such a way that it leads others to do wrong becomes guilty of scandal and responsible for the evil that he has directly or indirectly encouraged. “Temptations to sin are sure to come; but woe to him by whom they come!” (Section 2287)

The fight for life, liberty and the pursuit of happiness for the next generation of Catholics is in the hands of lay leaders. Every one of us must raise our voices in the public square.

Judie Brown

Thursday, August 20, 2009

Another Baffling Phone Conversation with OSF's Ethicist Joe Piccione

I had another phone conversation with OSF's Corporate Ethicist Joe Piccione on August 6, 2009.

Joe called me as a follow up to our conversation in mid-July.

In July, Joe told me that he did not know if the physicians at OSF Medical Group--College Avenue in Bloomington would be OSF employees. And when I asked him other questions regarding OSF's new purchase of this Carle Clinic practice, he said he did not know most of the answers. Amazingly, when I spoke with this OSF office in Bloomington, they seemed to know all of the answers to my questions. Why Joe Piccione at OSF Corporate was allegedly kept in the dark remains a mystery to me.

However, during the August 6 phone call Joe seemed to know all of the answers. He had done his homework. But he spoke in fragmented sentences and seemed quite hesitant and sad.

Joe started out the conversation about "limited private practice" at OSF Medical Group in Bloomington.

He said that when he was hired by OSF in the mid 90's he did not know that he would be a major player in creating this policy which he referred to as "regretable" and even said "we mourn this practice" (limited private practice). This policy allows OSF physicians to prescribe oral contraceptives.

Joe said there are a declining number of OSF physicians using the limited private practice option which implied that fewer OSF physicians in the OSF HealthCare System are prescribing birth contol pills. However he did not provide me with any numbers to prove this.

He then quickly moved on to the OB-GYN department in the OSF Medical Group in Bloomington and said that the OB-GYN doctors would be "partial employees" of OSF. I don't understand what "partial employees" means but I do understand why he described them that way. He called OB-GYN doctors "moving targets" and implied that OSF may not be able to control what these physicans do for about 6 months.

Joe stated that he had not met with the OB-GYN docs at this new facility but he sure seemed focused on them. I think he is quite afraid of what they may intend to do in OSF's facility.

My take is that Joe and OSF are cobbling together a new set of ethical loopholes. OSF Medical Group OB-GYN doctors who will be labeled "partial employees" of OSF is just another "ethical firewall" created by Joe to separate the OSF Sisters from "cooperation" with "evil acts" most likely to occur by these physicians at OSF Medical Group in Bloomington.

Joe continued and said that tubal ligation would not be part of limited private practice in Bloomington. He said that sterilization could not be scheduled at this new facility and a separate phone number would need to be used. I didn't understand Joe's "separate phone number" statement at all...

I was really getting confused at this point with my talk with Joe. So a few days later I called the clinic in Bloomington to see what they had to say about tubal ligations.

I talked to Jan in the OB/GYN department and she told me very clearly and directly that a decision had not been made regarding tubal ligations (sterilization for females) and that this topic was still being discussed. This of course is not good because it should have been settled by now and Jan seemed to know much more about all of this than OSF's Corporate Ethicist.

My take on all of this as I attempt to sort out Joe's speech is that tubal ligations will be scheduled at OSF Medical Group in least for the first six months. If someone knows different please let Joe and me know.

When I asked Joe if the remaining 40 doctors at the new OSF facility would be OSF employees, he knew the answer now. Yes, they would be OSF employees and all 40 physicians would be able to write for oral contraceptives using OSF's "regretable" limited private practice policy.

Interestingly, Joe said that OSF would rent the building in Bloomington, they would not own it. I think he said this to act as another "ethical firewall" other words, anything that goes on inside OSF-Medical Group College Avenue is not really happening in an OSF building because OSF is just renting the building. Maybe the phones are being rented too.

Joe ended his disjointed dialogue by saying something like he wanted us all to "be proud of our Catholicism"...

Wednesday, August 19, 2009

Peoria Pastor Doesn't Open Mail

During the last two weeks, my brother and I have sent out over 200 letters. The letter went to all of the pastors of all of the Catholic parishes in The Diocese of Peoria. Bishop Jenky, OSF "leaders", and The Catholic Post of Peoria were also recipients. (The letter is published at the end of this post.)

The letter is very self explanatory and explains the OSF contraceptive policy created in the mid-90's in Peoria. OSF's new purchase, OSF Medical Group--College Avenue in Bloomington, Illinois, will use this unfortunate policy to allow their 40 new OSF physicians to prescribe oral contraceptives. This is, of course, against the teachings of the Catholic Church.

In response to the letter we have received remarks from different pastors wondering how are they going to explain this scandal to their parishoners. And they have called OSF's oral contraceptive policy "disturbing". Even OSF Corporate Ethicist Joe Piccione explained to me that this policy that he helped create is "regretable" and also stated, "We are mourning this policy."

Joe and OSF may be mourning the policy but 40 new OSF physicians are getting ready to use it.

When we sent the letters out we were worried that some priests may not even open their letter out of fear.

Today I received an unopened letter from Father David Heinz, Pastor of Saint Anthony's in Bartonville, Illinois. The photo of the letter is above.

Father Heinz appeared to have written in red ink that he will receive no correspondence from my address. Our names were not on the return address.

HOW did he know not to open this letter? Why would he NOT want to open this letter?

I have never met Father Heinz and I think he probably has many good qualities. I just think it is very painful for him and for many other priests in the Catholic Diocese of Peoria to witness their Bishop give into the secular/economic forces at OSF.

Father Heinz and the other pastors have watched as Haitian Hearts patients have been denied care at OSF and have died. As OSF continues with their hypocrisy Father Heinz probably does not want to know about it, and may well have been instructed not to read the letter. The Catholic Church is not a democracy and the priests must be obedient to their bishop. We just wish Bishop Jenky was leading his priests and flock the right way.

I fully believe that OSF controls much of what The Catholic Diocese does. When I spoke with Bishop Jenky in person, I could see how much he feared OSF's power and money.

And we can't forget that Father Heinz gets his paycheck and health insurance from the Diocese.

We feel sorry for Fr. Heinz and will continue to pray for him.

Here is the letter Fr. Heinz returned to us.

23 July, 2009

Dear Father,

Are you aware that another OSF medical facility will soon be prescribing oral contraceptives? This letter concerns OSF HealthCare’s recent acquisition of Carle Clinic in Bloomington, Illinois. Please refer to the article in the July 12, 2009 issue of The Catholic Post for details of the acquisition.

At Mass on Sunday July 19, our pastor announced the month of July was designated Natural Family Planning Month by the US Conference of Catholic Bishops. The bulletin stated, "NFP is a completely Church-approved alternative to contraception and sterilization." The bulletin also stated: “The Church condemns artificial contraception not just because of its bad consequences. She condemns artificial contraception because it is intrinsically evil (and because it is evil it has bad consequences.)"

For many years, OSF has had a policy called "limited private practice.” This policy allows OSF physicians to write prescriptions for oral contraceptives. For the few seconds it takes to write the prescription, OSF physicians are not considered to be OSF employees. This contrived change in employment status is how OSF justifies allowing their physicians to prescribe oral contraceptives despite the fact that the physicians are in an OSF office building and are still being paid as full-time employees.

Last week OSF Corporate Ethicist Joe Piccione, when contacted by phone, said that he did not know if the physicians presently employed at Carle Clinic in Bloomington will become employees of OSF. However, a representative of Carle Clinic, contacted by phone, said the approximately 40 physicians at Carle would be OSF employees and that they would be able to prescribe oral contraceptives.

It does not take a theological degree to see the grave moral contradiction in permitting employees to prescribe oral contraceptives while saying, “They are not our employees when writing those prescriptions.” OSF should change their policy to prohibit their employees prescribing oral contraceptives rather than allowing it. The limited private practice policy should not be allowed to be placed into effect in the newly acquired OSF clinic anymore than it should be allowed to continue anywhere in the OSF HealthCare System.

The transition from “Carle Clinic” to “OSF Medical Group – College Avenue” will occur on September 13. The OSF policy is obviously not supportive of Humane Vitae and respect for life. Please, after prayerfully considering this matter, advise Bishop Jenky that you disagree with OSF’s policy and advise your parishioners to do the same. Ask Bishop Jenky to reverse OSF’s contraceptive policy. It is important that you act soon since the policy will be harder to reverse once it is put into effect.


John Carroll, M.D.

Tom Carroll

Saturday, August 1, 2009

Heurese Survives Port-au-Prince and Peoria

Heurese went back to Haiti yesterday.

She is back in her one room shack with her two kids and her brother in a massive slum named Carefour.

You may remember Heurese.

During the last 12 months Heurese survived:

Four tropical storms that devastated Haiti last year;

Congestive heart failure;

Extreme poverty with very little food and water for herself and her kids;

UN soldiers who prey on Haitian women;

Haitian gangs who prey on Haitian women;

Peoria's OSF refusal to accept her back for heart surgery;

The silence of The Catholic Diocese of Peoria, the OSF Sisters and OSF Administration, and the Children's Hospital of Illinois Advisory Board who were notified last year that Heurese would die without surgery;

The Haitian government that provides next to nothing for sick people like Heurese;

Giving her children away while she waited to die in the Haitian slum;

Major heart surgery at the top rated heart surgery medical center in the United States;

OSF's Charity Assistance program who refused to do a post operative outpatient echocardiogram for her, but instead had OSF's attorney Douglass Marshall contact the Amercian Embassy in Haiti and request classified information on her visa status;

The pleas of her family in Haiti who told her NOT to return to Haiti now because life is almost impossible.

And to make things even worse for the hypocrisy in Peoria, the July 7 issue of The Catholic Post in Peoria had articles on Pope Benedict's encyclical "Caritas in Veritate" (Charity in Truth).

The pope's main concern in his encyclical is the dignity of the human person.

My family and I have never seen anyone with more dignity than Heurese....a dignity that was totally ignored by Peoria's spiritual and secular leaders.

Joe Piccione, OSF's Corporate Ethicist, who turned his back on Haitian Hearts patients too, called the encyclical "beautiful".

From The Catholic Post in Peoria:

"The new encyclical states that ethical values are needed to overcome the current global economic crisis as well as to eradicate hunger and promote the real development of all the world's peoples.

"The truth that God is the creator of human life, that every life is sacred, that the earth was given to humanity to use and protect and that God has a plan for each person must be respected in development programs and in economic recovery efforts if they are to have real and lasting benefits, the pope said.

"Charity or love is not an option for Christians, he said, and "practicing charity in truth helps people understand that adhering to0 the values of Christianity is not merely useful, but essential for building a good society and for true integral development.

"In addressing the global economic crisis and the ending poverty of the world's poorest countries, he said, "the primary capital to be safeguarded and valued is man, the human person in his or her integrity".

"The global dimension of the financial crisis is an expression of the moral failure of greedy financiers and investors, of the lack of oversight by national governments and of a lack of understanding that the global economy required internationally recognized global control, Pope Benedict said.

"The pope also said that "more economically developed nations should do all they can to allocate larger portions of their gross domestic product to development aid," respecting the obligations they made to the U.N. Millennium Development Goals aimed at significantly reducing poverty by 2015.

"Pope Benedict said food and water are the "universal rights of all human beings without distinction or discrimination" and are part of the basic right to life.

"He also said that being pro-life means being pro-development, especially given the connection between poverty and infant mortality, and that the only way to promote the true development of people is to promote a culture in which every human life is welcomed and valued."

It seems to me that the OSF and The Catholic Diocese of Peoria is not promoting a culture where every human life is welcomed and valued.

As mentioned above, OSF's Coroporate Ethicist Joe Piccione commented on the "beauty" of this encyclical in another article in the same issue of The Catholic Post.

"He (Pope Benedict) is speaking to the conscience of the world. What is possible when human persons interact for the common good."

I spoke to Joe on the phone recently about OSF's abandonment of their Haitian Hearts patients. I asked Joe what Pope Benedict would say about this abandonment.

Joe's response was that he thought that Benedict would say that barriers need to be broken down to allow these Haitian kids to return to OSF.

I reminded Joe that OSF and their attorney Douglass Marshall had banned all Haitian Hearts patients from returning to OSF. (Joe told me that he was unaware of this.) I also reminded Joe again that my Haitian patients were suffering and dying with this policy of patient abandonment.

Therefore, it seems like the first barrier to be broken down at OSF would OSF's embargo against my Haitian kids.

Another barrier that could be broken down would be the "fear barrier". Mr. Steffen, OSF's Administrator, told me that fear at OSF is a "good thing" among OSF employees. If this barrier were broken down, the OSF International Committee could speak up for the Haitian Hearts patients like Heurese that need to come back to OSF and OSF's ethicists could act in the Haitian patients' best interests. (The OSF-SFMC ethicist has not responded to three different requests for help with Haitian Hearts patients.) This barrier of fear working against Haitian kids is significant.

So I do agree with OSF Corporate Ethicist Joe Piccione that Pope Benedict's encyclical is beautiful and that barriers do need to be lifted at OSF in Peoria to prevent Haitian kids from dying.