Peoria's Medical Mafia

An account of how a large Catholic medical center has lost its way. Go to pmmdaily.blogspot.com to see recent updates.

Wednesday, October 11, 2006

Pre-Introduction Peoria's Medical Mafia


Pre-Introduction--Peoria´s Medical Mafia

Dear Readers,

Jackson Jean-Baptiste is pictured to the right in a photo from Haiti during the Spring, 2005. Jackson died in January, 2006.

The following are the first 12 posts. There are 66 posts on this site. At the bottom of each post is an option for a "newer post" or "older post".

Synopsis of Emergency Medical Services
Introduction--Peoria's Medical Mafia
Keith's Letter
Conversations with Keith
Conflict of Interest
OSF-AMT Relationship
Emergency Room Overcrowding
OSF Emergency Room Patient Satisfaction
Fear at OSF
Conversation with Sister Canisia
Conversations in Church
Sister Judith Ann


Please go to PMMDaily.blogspot.com for updates.

Wednesday, July 12, 2006

Synopsis of Emergency Medical Services in Peoria


Synopsis of Emergency Medical Services in Peoria

Peoria’s Medical Mafia documents thoughts regarding Emergency Medical Services (EMS) in Peoria, Illinois. There are approximately 65 posts on this web log, many of them regarding EMS.

Peoria has a population of 113,000. The Peoria Fire Department (PFD) is non transport and provides service at Basic-D level with basic medication. Several years ago the PFD purchased a very nice ambulance using the Foreign Fire Fund. The PFD applied to the Peoria Project Medical Director for permission to outfit this vehicle, their only ambulance, with various basic and advanced life support materials and equipment. This request was denied by the Project Medical Director. The PFD then sold this ambulance because it was not being used.

Peoria has an advanced life support company, Advanced Medical Transport (AMT), which transports patients and gives the only paramedic care in Peoria. It is considered a not-for- profit entity but grosses over 7 million dollars per year. AMT is supported by all three of Peoria’s hospitals. OSF-SFMC, the largest medical center in downstate Illinois, is considered the “resource hospital” for the Peoria Area EMS. All three medical centers have administrators that sit on the AMT Board of Directors. AMT suffered significant legal troubles several years ago when the federal government investigated it for Medicare fraud based on coding and charging. AMT was fined over 2 million dollars by the federal government.

The OSF-SFMC Emergency Department Director is also the Corporate Medical Director for AMT. He was the Project Medical Director for many years in the Peoria area and was salaried by both AMT and OSF-SFMC for his services. Numerous people in the area believe this arrangement constitutes conflict of interest. The PFD also believe that many obstacles have been created over the years to keep them at a basic non transport level so AMT can continue as the only paramedic and transport agency in Peoria.

I believe that Peorians have suffered and died in the pre hospital setting and continue to do so because of the paramedic/transport monopoly. Incredibly, the PFD has paramedics that cannot use their life saving abilities at the scene when they work as firefighters; however, when they “moonlight” for AMT, they are able to use their advanced life support skills.

Similar business arrangements as described above probably occur in other locations around the nation. But just because banks are robbed in many cities, does not mean it is right to rob banks in Peoria.

I hope this web site is informative. Some day Peoria will change for the better regarding EMS and pre hospital care. The system took a while to become this ill and it will take a while to recover.

John A. Carroll, MD
July 12, 2006
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September 30, 2006

Arthur Kellermann, M.D., M.P.H. published an article in the September 28, 2006 New England Journal of Medicine. He is chairman of the Emergency Department at Emory University School of Medicine.

Dr. Kellermann begins his article describing waiting in the ambulance bay at Grady Memorial Hospital in Atlanta on July 27, 1996, awaiting 35 severely injured bombing victims in Atlanta. It sounds like things went as well as possible and the ER was working normally five hours later. Would that happen in Peoria? I don’t think so.

The Institute of Medicine recently released three reports regarding Emergency Medical Care in the United States. It can be seen at www.iom.edu. Dr. Kellermann sat on a committee which did the report.

Collectively, the committees describe an over burdened emergency system that is rapidly approaching its limits. Dr. Kellermann states, “With more patients needing care and fewer resources to care for them, emergency department crowding was inevitable.”

Dr. Kellermann writes about “boarding patients in exam rooms or hallways who need inpatient care”. He notes the very negative and dark side of ambulance diversion and that cities may experience the “health care equivalent of a “rolling blackout”. Everyone’s care is affected…”

Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) in 1986 which allowed everyone in the United States to acquire legal rights to emergency care. However, Dr. Kellermann argues that because this mandate (EMTALA) was unfunded, it created a perverse incentive for hospitals such as OSF-SFMC to tolerate Emergency Department overcrowding and divert ambulances while continuing to accept elective admissions.

My letter to OSF CEO Keith Steffen in September, 2001 was asking for his leadership and help for problems in Peoria that were very similar to problems addressed by the IOM in 2006. I was fired several months after writing Mr. Steffen in 2001.

I communicated with Dr. Kellermann and spoke to the Project Medical Director of another city with 5 million people regarding the unfortunate EMS situation in Peoria. The Project Medical Director asked me what would happen in Peoria if there was a mass casualty with the Peoria Fire Department at a Basic level and nontransport. Good question, but I doubt this will be answered in Peoria, until after the problem occurs. Peoria will be in for a cruel awakening.

Dr. Kellermann stated in the article that the “IOM committee calls on hospitals to end the boarding of admitted patients in emergency rooms and the diversion of ambulances, except in extreme cases, such as community wide disasters”. OSF, are you listening?

He concludes that the IOM envisions a “coordinated, regionalized, and accountable emergency care system that is capable of delivering lifesaving treatment to all in need”.

Currently, this is not the system in Peoria for reasons outlined in this web log.
----------------------------

October 20, 2006:

The September, 2006 issue of Emergency Medicine News published a letter I wrote regarding emergency department overcrowding in Peoria and the consequences of what happens when doctors bring up sensitive topics. ("Paying the Price for Speaking Up").


Emergency Medicine News:
September 2006 - Volume 28 - Issue 9 - p 10-11



Paying the Price for Speaking Up

Carroll, John A. MD
Peoria, IL

Editor:

I agree with Dr. Edwin Leap's opinion in his March column, What Are We Afraid Of? (2006;28[3]:15.) Physicians need to go public with patient care concerns. I believe physicians don't speak up because they fear losing their jobs and being marginalized in their community. That was my experience.

I live in a mid-sized, Midwestern city, and in September 2001, I was placed on six months' probation from my job as an emergency physician at a large medical center. I was confined to working in the urgent care center. My probation occurred the day after I wrote a letter to the hospital administrator (with copies to all the attending physicians in the ED including the director) about my concerns regarding long waits in the ED. When I wrote the letter, the ED was crowded, patients were lying on gurneys in ED hallways, and patients were signing out because I could not admit them to a bed in a timely fashion.

After I started my probationary period, the ED director told me that I could return to the main ED if I were evaluated by the hospital's wellness committee for burnout (a point not mentioned in the probationary letter). The hospital administrator referred to me as a cancer in the department who needed to be cut out before it metastasizes.

The ED had a dismal patient satisfaction rating of 33 percent and a low employee satisfaction level at that point. As the weeks went by, I continued to work in urgent care, but I refused to be evaluated by the wellness committee. The administrator who had referred to me as a cancer was discussing my case inside and outside the hospital. I was made the problem rather than placing the blame on the systematic deficiencies that plagued the ED.

While working an urgent care shift in December 2001, I was called to the administrator's office, and with another administrator, the ED director, and hospital legal counsel present, I was fired. After 20 good years as a resident and staff physician there, I packed up my gear and left.

The reason I wrote to the hospital administrator that September was that ED crowding and hospital bed capacity are systemic hospital issues. I also did not think the ED director would do much. Besides being the ED director, he had been the project medical director for the previous eight years, and he was still on the payroll of the city's only private ambulance company, the exclusive provider of the city's paramedic and transport prehospital care. The hospital is the base station for the area, and is the main supporter of the lucrative private ambulance service. Our fire department is held to a nontransport basic level, and according to the firefighters, obstacles were thrown up over the years by my boss when they attempted to advance their level of care for the citizens of the city. This arrangement was known all over the state in EMS circles and considered a serious conflict of interest by many.

Before and after I was fired, I attempted to go through channels within the medical center to explain my concerns for the prehospital patient and about the long waits in the ED. Administrators, corporate, and the ethics committee would not address my complaints. Letters to the JCAHO and the state department of public health were not helpful.

I have picketed the hospital, written letters to the local newspaper, and presented frequently to the citizens' forum at city council meetings. I also have written a web log, www.peoriasmedicalmafia.com about the past five years. Recently, a local newspaper editorial stated that our ED was seeing almost twice the number of patients that the original ED was designed to accommodate safely, and it noted that diversion of patients due to insufficient hospital bed capacity was a significant issue.

The most difficult part of this experience isn't being unemployed. It is abandonment by people who I thought would stand up for quality care issues facing our community. Many of my physician mentors who taught me patient care when I did my residency there no longer will see me or speak to me. The religious community that founded the medical center is silent, and the business community in our close-knit city supports the medical center and the private ambulance company. The EMS issues here that could be improved for public health reasons are relegated to secondary importance, with money taking precedence.

I would do this again but only reluctantly. Going public is necessary for physicians if we want positive change. It is not a heroic thing to do. It should be expected. But be ready to pay the price.

John A. Carroll, MD
Peoria, IL

© 2006 Lippincott Williams Wilkins

Wednesday, March 15, 2006

Introduction--Peoria's Medical Mafia

Introduction-Peoria’s Medical Mafia

Medical mafia—I have never forgotten when a well-known Peoria physician used this term to describe for me how the medical system operates here in River City. Physicians and institutions in central Illinois sometimes make decisions based on what is best for their bottom line rather than the patient’s health. Greed motivates this situation and fear—fear of job loss and other financial punishments, fear of ostracization by a close knit community—keeps it in place. The term medical mafia perfectly explains much of the four-year saga I have been on since being fired from OSF St. Francis Medical Center in 2001.

In the hopes that constructive changes can be made regarding some dangerous situations, I want to share my experiences with as many people as possible. After years of attempting to work within the confines of OSF and the Catholic Diocese of Peoria, I finally realized that there is no adequate checks and balances within either system. Silence and denial are integral components to stifle ideas. Although not ideal by any means, a weblog (blog) seems the best way to disseminate this information.

My objectives are to detail serious problems related to OSF, Emergency Medical Services in Peoria, The Catholic Diocese of Peoria, and Haitian Hearts. I will show how the problems involving all four entities are linked. I will discuss how powerful men and women can hurt the not-so-powerful people in central Illinois as well as sick Haitian children needing heart surgery.

The first step toward change is an awareness of the problem. I want to educate people as to how these organizations really operate. I have 4 years of letters, articles, and notes of conversations that I have used in this blog. These sources will provide evidence for the events I will describe. I will include names at times and will leave other names out to protect people from injury.

The blog is divided into 3 main sections: OSF, Haitian Hearts, and Emergency Medical Services in Peoria. All are written in as much of a chronologic order as I could to keep 4 years of material as understandable as possible.

It is possible this site will anger powerful people and institutions. If I am told to “cease and desist” from further writing, I will let you know and take appropriate action. If changes occur in systems that our failing us now, I will also let you know.


John Carroll, M.D.

Keith's Letter


Keith’s Letter

On September 26, 2001, I worked the 3-11 shift in the ER at OSF. I had elderly patients as usual and several signed out and went home when they realized how long they were going to wait for a bed in the hospital. They were sick, and I intended to admit them, but they just couldn’t take lying on a stretcher for many hours and so politely told me that they “needed to go home”.

The ER has an administrator on call every night to call at home if there are problems an attending physician in the ER would want to discuss. These calls usually did not help at the time the call was made.

On September 27, 2001 I decided that Keith Steffen, CEO at OSF-SFMC, should at least know of my concerns and wrote him a letter and copied it to all of my colleagues in the ER and to other OSF administrators. (See letter below.) Someone warned me that I might get fired if I sent the letter. I knew that to be true, but thought it needed to be done.

I did not hear back from Keith but did hear the next day from Dr. George Hevesy who had been promoted to ER director on August 1 to replace Dr. Rick Miller. His secretary handed me his letter to me as I was starting to resuscitate a man in the ER who had a cardiac arrest and was brought in by ambulance.

George’s letter put me on probabation for 6 months. It also stated that starting in November, I would only work in OSF Prompt Care. Hevesy did not disagree with the content of my letter but told me that I had gone around normal communication channels and that I would be suspended from the ED for 6 months. After I read the letter, I called George at OSF’s new Center for Health where he was working and asked him if he was really serious about what he had written. He said that he was and for me to stop in and see him sometime so we could talk.


-----------------------


September 27, 2001

Keith Steffen, Administrator
OSF Saint Francis Medical Center
Peoria, Illinois 61637

Dear Keith:

I started working at OSF-SFMC in 1971 as an orderly on 8B. Most of my last 30 years have been spent inside this building. OSF-SFMC means everything to me. Please interpret the following knowing my heart and spirit are with St. Francis and always will be.

I worked 3-11 last night in the main ER. The ER mayhem and disarray that usually exists was actually somewhat manageable. However, patient-waiting time from disposition to arrival on the floor was unbearable. Two sick patients of mine, rather than staying in the ER all night, politely decided to sign out, go home, and hope for the best.

Giving appropriate care in the ER can be challenging but having no room upstairs to admit the patient can be life threatening to the patient. Should I call other medical centers around the area/state for their admission and subsequent care before I see the patient or after? Studies have shown increasing time spent in the ER increases patient morbidity. Obviously, I don't want to do this. Please tell me what to do.

An ER crisis has been occurring for many years in our ER. But last night with "home diversion" of patients we have reached an all time low. This cannot continue.
I need an immediate answer from you today as to how I should approach these sick patients and their families. I will meet with you any time today or tonight.
My pager is always on (679-1980.)

Sincerely,

John A. Carroll, MD

cc: Sue Wozniak, Chief Operating Officer
Tim Miller, MD, Director of Medical Affairs
Susan Ehlers, Assistant Admimstrator Patient Care Delivery Systems
Paul Kramer, Executive Director of Children's Hospital of Illinois .
Lynn Gillespie, Assistant Administrator Organizational Development
Emergency Department Attendings
---------------------------------

On April 6, 2006 the Peoria Journal Star published the article below regarding the new Children's Hospital that will be built. Please note Mr. Steffen's comments regarding bed capacity problems and patient diversion at OSF. Was this institutional neglect by OSF attempting to stack to many patients inside the medical center? How many people suffered under this system? When I wrote him almost five years earlier, I was immediately placed on probation and then fired three months later. Will that be Mr. Steffen's fate as well?

What the Journal Star did not report was that Jackson Jean-Baptiste, a Haitian Hearts patient, was refused care at OSF and died several months ago. Many Haitian Hearts patients are now suffering and being denied care at OSF. This is contrary to what Catholic social teaching states and the Catholic Bishops Ethical and Religious Directives mandate.

Haitian Hearts obviously did not financially break OSF with the announcement of their new 200 million dollar building. It is truly a blessing for central Illinois children. However, Haitian children deserve the best available as well.

Until OSF can change its heart and return to the founding Sisters mission philosophy, they will have the technolgy but not the touch. The picture is of a Haitian baby where I work in Haiti. This hospital has no running water...a bit different than OSF-CHOI.


A medical milestone
Saint Francis expansion will alter Downtown landscape


Thursday, April 6, 2006

BY DAYNA R. BROWN

OF THE JOURNAL STAR

An eight-story, concrete and glass addition to OSF Saint Francis Medical
Center will permanently enhance Peoria's medical skyline - and the area's
economy. This new facility will be home to the Children's Hospital of Illinois and
is the largest building construction project in Peoria history.

"It's unusual for a community of this size to have its own children's
hospital," said pediatrician Dr. Rodney Lorenz, who also is interim dean at
Peoria's medical school. "We are blessed."

The new building will be located north of the hospital's main facility. It
will sit on the site of Medi-Park 1, which will be torn down when a new $33
million parking deck is completed later this year.

Construction is difficult on the site because it slopes 60 feet from top to
bottom. But it was the only area on the hospital's 33-acre campus where
there was enough room for this facility, administrators said. The
Children's Hospital wanted to stay on the Downtown campus because there is
$45 million in annual savings by sharing services with St. Francis.

The expansion is needed because the hospital is out of space,
administrators said.

St. Francis had to divert patients to other hospitals Wednesday, and it has
been that way much of the past month because there aren't enough beds, CEO
Keith Steffen said. Just last year, more than 200 patients had to be sent
to other locations.

But when the $234 million construction project is completed, that no longer
will be a problem, Steffen said.

"We've seen significant growth over the past few years," Steffen
said. "We'd be remise . . . if we didn't respond."

The new building will be 440,000 square feet, almost twice the size of the
hospital's Gerlach Building, which houses surgery, the emergency
department, most of medical imaging and five intensive care units.

It will allow for the consolidation of all of the Children's Hospital
services, which are currently located in six buildings, and provide all
pediatric patients private rooms.

"Right now it is hard for people to find the Children's Hospital because
it's buried in St. Francis," said Dr. Rick Pearl, surgeon-in-chief of
Children's Hospital. "I just run in circles, all day long."

The new facility, which will be physically attached to St. Francis but will
have its own entrance, will bring the hospitals staffed beds from 560 to
616. It will have three floors dedicated solely to children. Another three
floors will have shared services for adults and children, including surgery
rooms and the emergency department.

The decor will be "kid-friendly," with bright colors, play areas, music and
favorite children's characters, doctors said. And the rooms will provide
space for parents to stay with their child.

"I think it's very important for a child to feel comfortable," said Dr.
Ravindra Vegunta, director of pediatric minimally invasive surgery at
Children's Hospital. "The more happy the patient, the more cooperative a
patient and that will aid in recovery."

There will be one adult cardiac floor in the new building because more
space was needed for that department, administrators said.

Moving the pediatric services out of the current facility will free up
needed space for adult patients and other hospital needs, administrators
said.

The project also will include a "much needed" emergency department
expansion. The current emergency room was constructed to serve 32,000
patients annually, but this year it will surpass 62,000, Steffen said.

St. Francis is the largest hospital in downstate Illinois, employing
approximately 5,200 people, and the only Level 1 trauma center in the area.
In addition to 850 construction jobs, the project will create a need for
another 1,000 jobs related to health care.

Children's Hospital of Illinois was formed in January 1990, and draws from
a 30-county area. Annually, it admits about 5,000 children and treats
30,000 outpatients.

Areas hospitals - including Methodist Medical Center, Proctor Hospital and
Pekin Hospital - have given support for the project, Steffen said.

If the plans are approved by the state, which is required, construction
will begin in spring 2007, with a completion date of 2009. Hospital
officials plan to file for state approval by the end of the month, and said
they believe they will be approved.

"We are in the business of patient care," Steffen said. "This project
says . . . we are going to do it more efficiently, more effectively, more
conveniently."


Dayna R. Brown can be reached at 686-3194 or dbrown@pjstar.com.

----------------------------

The Journal Star then offered this editorial--

Monday, April 10, 2006

When Keith Steffen, OSF Saint Francis Medical Center CEO, got to work Wednesday morning, he was greeted with familiar news: the intensive care unit was full. Because of overcrowding, St. Francis annually diverts 200 patients to other hospitals, 100 of them children. That space crunch is precisely why Steffen would announce later in the day a $234 million expansion of St. Francis. The largest medical center in downstate Illinois isn't big enough.

The single biggest private building project in Peoria's history, if approved by state regulators, will shoehorn an eight-story building onto the Downtown campus and position St. Francis to meet the medical needs of central Illinois and beyond for the next 25 years. Once the so-called Milestone Project is done, St. Francis will have three new floors for the Children's Hospital of Illinois, three more for diagnostic services and surgery, one for adult cardiac patients and a new and bigger emergency room.

With the expansion, all of the hospital's 616 rooms - it has 560 now - will be private, which has health and customer satisfaction advantages. New surgery rooms will be large enough to accommodate robotics and other technology, some $47 million worth. A larger ER will no longer have to operate at twice capacity.

Simply put, the 440,000-square-foot addition - twice the size of the Gerlach Building that spans Glen Oak Avenue - will make St. Francis more competitive in a changing marketplace. Rural hospitals are referring more patients to Peoria than ever before. Some 35 percent of St. Francis' customers come from outside the Tri-County. One of the biggest growth areas is pediatric care, especially for high-risk infants.

OSF officials say the added efficiency will help keep a lid on inflation-shattering medical costs. The Children's Hospital, for example, is spread across six buildings. Now make that one. Administrative offices scattered across the city also will come under one roof after construction is completed in 2009.

This project benefits more than just St. Francis. First, it will create 850 construction jobs and up to 1,000 more permanent ones, including 300 more nurses and technicians. Second, it anchors Peoria's medical community Downtown for as far as the eye can see. When St. Francis built its Center for Health on Route 91 five years ago, there was a fear the hospital might eventually move north. No more. Between this project, OSF's $33 million parking deck now under construction and Peoria Surgical Group moving to the medical school campus, private medical investment Downtown will approach $300 million. What a boost for Renaissance Park.

This also will create a new front door for St. Francis off a rebuilt Interstate 74. Anything that makes it easier to navigate this labyrinth of a hospital is a plus. Finally, this expansion was endorsed by Methodist and Proctor hospitals. Hallelujah. Doesn't happen enough.

There will be naysayers. Indeed, it's a lot of money to add fewer than 50 patient rooms. Then there is the question of need. The Illinois Health Facilities Planning Board initially refused to approve the Center for Health on that basis. Ultimately jam-packed surgery rooms and full intensive care beds showed the flaws in that analysis. It's hard to imagine state regulators not looking favorably on this request.
----------------

My comments:

Finally, after many years, it was stated that the ER at OSF was operating at twice its capacity. Even Mr. Steffen stated that they would be "remiss" if changes weren't made. OSF has been "remiss" for many years now regarding excessive patients in the ER and inadequate bed capacity in the main house.

In the April, 2006 issue of Academic Emergency Medicine an article regarding overcrowding in the emergency department describes the problem very clearly. The journal reports, "The phenomenon of emergency department crowding has become recognized across the globe as a serious public health threat. ...experts widely agree that crowding in the emergency department (ED) is a system-wide problem, not one that results solely from problems in the ED or one that can be addressed using only ED based solutions. Crowding has become a shared burden for emergency providers. Each of us has a collection of stories to tell about how crowding has affected our patients, their families, our cowokers, and our own professional satisfaction."
----------------------------
June 16, 2006
Emergency System Called Very Ill

On June 15, 2006, USA TODAY had the above headline over an article on their front page.

The nation’s emergency medical system is in a dangerous state of crisis, says a new series of landmark reports. The Institute of Medicine recently released extensive reports which were prepared by a 40-member board after a two-year investigation. The IOM report states that the U.S. life saving system is failing.

The IOM reports detail how hundreds of thousands of lives are affected every year by EMS deficiencies that are not obvious. The chair of the panel, Gail Warden, stated that “in most communities, there is a crisis under the surface.”

Many emergency rooms barely can handle their daily patient loads, children don’t always get good care, and the quality of rescue services is erratic, the report says. A USA TODAY probe found a 10-fold difference between major cities in cardiac arrest survival rates.

Dr. Arthur Kellermann, director of the Center for Injury Control at Emory University School of Medicine in Atlanta stated that the problem with hospital bed capacity slows the emergency department admission of sick patients and more patients are diverted to other hospitals. In every minute of every day, an ambulance carrying a patient is turned away “diverted” when an emergency room says it is too full to take patients.

This sounds very much like OSF in Peoria. Throughout this website, I have questioned the monopoly of paramedic transport care in Peoria. The IOM report mentions, crowding and ambulance diversion also occur because of lack of coordination among emergency medical response teams and hospitals…as well as entrenched professional interests. With regards to Peoria, I would say the “entrenched professional interests” are centered around the medical centers and their relationship with Advanced Medical Transport.

There is a “crisis under the surface” in Peoria that will eventually become apparent.
-------------------

Emergency Medical News
October, 2008

In 2006 there were 119.2 million ED visits in the United States.

Dr. Arthur Kellerman agreed that it was easy to blame the problems of crowding on the uninsured. "It gives the decision-makers an excuse to ignore it or blame an unempowered segment of society. These aren't contributing to the growth of emergency department visits," he said. "We know the major problem in crowding is the boarding of patients."

Dr. Peter Viccellio commented on crowding in the ED: "...the problems and solutions are necessarily institutional, and cannot be addressed by focusing on the ED in isolation."

I believed in 2001 and still believe in 2008 that my letter to Mr. Steffen, other OSF administrators, and to my colleagues in the ER was was appropriate and that changes needed to be made to protect our ER patients.
-----------------------

February, 2009

Well, the financial crisis in the U.S that is putting many people out of home and job is also putting many of them in our overcrowded ER's. See this post.

So in addition to OSF's greed, the dismal national economic picture in 2009 will imperil people's health all the more.

--------------------

October, 2009

Annals of Emergency Medicine, October, 2009

ED crowding affects care negatively.

Not only does it reduce access to emergency medical services, but also it is associated with delays in care for cardiac, and stroke patients, as well as those with pneumonia, and is associated with an increase in patient mortality. ED crowding has been associated with prolonged patient transport time, inadequate pain management, violence of angry patients against staff, increased costs of patient care, and decreased physician job satisfaction.
--------------

More about ED crowding...even in 2010. Why would Dr. Hevesy put me on probation in 2001 after I wrote Mr. Steffen about my concerns?


www.medscape.com
From American Academy of Emergency Medicine
Washington Watch: CDC Report on ED Capacity
Kathleen Ream


Posted: 02/05/2010

The Centers for Disease Control and Prevention (CDC) recently released a report entitled Estimates of Emergency Department Capacity: United States, 2007. This report is based on data from the CDC's 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Inaugurated in 1992, the NHAMCS is now the longest continuously running national survey of hospital ED use.

The report notes that over the last several decades, the role of the ED has expanded from primarily treating seriously ill and injured patients. The report recognizes that EDs now also provide urgent and unscheduled care to patients unable to access their providers in a timely fashion and provide primary care to Medicaid beneficiaries and uninsured patients. As a result, EDs are frequently overcrowded with the most common contributing factor being the inability to transfer ED patients to an inpatient bed once the decision is made to admit them. "As the ED begins to 'board' patients, the space, the staff, and the resources available to treat new patients are further reduced," the report states. It continues, "A consequence of overcrowded EDs is ambulance diversion, in which EDs close their doors to incoming ambulances. The resulting treatment delay can be catastrophic for the patient."

According to the CDC survey, approximately 500,000 ambulances are diverted annually in the United States. The survey also shows that large EDs serving more than 50,000 patients each year represent just 17.7% of all EDs in the nation, but account for 43.8% of all ED visits in 2007. The implication, according to the report, is that small EDs with annual visit volumes of less than 20,000 patients may not experience crowding.

Other data from the survey show that about one-half of all hospitals with EDs had a bed coordinator or "bed czar," 58% had elective surgeries scheduled five days a week, and 66% had bed census data available instantaneously. Electronic medical records (EMRs), either all electronic or part paper and part electronic, were used in 62% of EDs. Basic EMR systems containing patient demographics, problem lists, clinical notes, prescription orders, and laboratory and imaging results were reported in l5% of EDs. However, the CDC could not accurately determine the prevalence of fully functional EMRs that also include features such as electronic transfer of prescription orders, warnings of drug interactions or contraindications, and reminders for guideline-based interventions.

Additional survey data show:

Overall, 62.5% of EDs reported that they board admitted ED patients for more than two hours while waiting for an inpatient bed. Among EDs that board patients, 14.8% use inpatient hallways or other space outside of the ED when critically overloaded. A "full capacity protocol" that allows some admitted patients to move from the ED to inpatient corridors while awaiting a bed was used by 21.1% of EDs.
EDs with more than 20,000 annual visits comprised more than 70% of EDs in metropolitan statistical areas (MSAs). When compared to EDs in rural areas, EDs in MSAs were more than twice as likely to board patients for more than two hours in the ED while waiting for an inpatient bed (77.4% versus 32.8%).
More than one-third of EDs had an observation or clinical decision unit. About a third of EDs used a separate fast track unit for non-urgent care.
In the previous two years, 24.3% of EDs increased their number of standard treatment spaces, and 19.5% expanded their physical space. Of those EDs that did not expand their physical space, 31.5% plan to do so within the next two years.
Zone nursing was employed in 35.3% of EDs. "Pool nurses" that can be pulled to the ED to respond to surges in demand were available in 33.2% of EDs.
Bedside registration was used in 66.1% of EDs, with 40% using computer-assisted triage. Electronic dashboards were utilized by 35.2% of EDs, and 9.8% used radio frequency identification tracking.
GAO Study Finds ED Crowding Continues
According to a Government Accountability Office (GAO) report released June 1, hospital EDs continue to be overcrowded, with lack of access to inpatient beds continuing as the main contributing factor. The GAO first reported that most emergency departments experienced some degree of crowding in 2003 (Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities, GAO-03-460). The GAO was asked to revisit this issue in response to several studies that have associated crowded conditions in EDs with adverse effects on patient quality of care.

The GAO examined three indicators of ED crowding - ambulance diversion, wait times, and patient boarding - along with various factors that contribute to crowding. In doing so, the GAO reviewed national data, conducted a literature review of 197 articles, and interviewed individual subject-matter experts and officials from the Department of Health and Human Services (HHS) and professional and research organizations.

National data showed that about one-fourth of hospitals reported going on ambulance diversion at least once in 2006. According to the GAO's analysis of 2006 data from the HHS's National Center for Health Statistics, average wait times continued to increase, with significant numbers of visits exceeding recommended wait times based on patient acuity levels, as summarized here:

Patients needing immediate care (recommended maximum wait to see a physician of less than one minute) waited an average of 28 minutes to be seen by a physician. 73.9% of these patients waited longer than the one-minute recommendation.
Patients with emergent conditions (recommended maximum wait of 14 minutes) waited an average of 37 minutes to see a physician. 50.4% of emergent patients waited longer than 14 minutes.
Patients with urgent complaints (recommended to be seen within 60 minutes) waited an average of 50 minutes, with 20.7% of patients waiting longer than 60 minutes.
Semi-urgent conditions (two-hour maximum wait recommended) had an average wait time of 68 minutes, with 13.3% of patients waiting longer than the maximum recommended timeframe.
Non-urgent patients (24-hour recommended timeframe) had an average wait time of 76 minutes, with no ED reporting wait times to see a physician in excess of 24 hours.
Although national data on patient boarding is limited, the articles reviewed by the GAO and the experts interviewed reported that the practice is a continuing problem due to the lack of access to inpatient beds. In turn, the lack of access to inpatient beds is due to the competition for available beds between hospital admissions from the ED and scheduled admissions, such as elective surgeries, that can be more profitable for the hospital.

While the GAO found that studies on solutions to ED crowding are also limited, strategies have been successfully implemented in isolated cases. One solution found in case studies conducted at several hospitals was to streamline elective surgery schedules, thereby increasing the opportunity for ED admissions. Regarding ambulance diversion, some local communities have established policies that make diversion the last resort for any hospital, as it often leads to critical cases not receiving the immediate care they need. Other strategies include the use of on-call physicians to determine the best ambulance destination for each patient or state policy prohibiting hospitals from going on diversion unless under inoperable conditions.

Strategies to decrease ED wait times included increasing the speed with which laboratory results are available, accelerating care during the triage process by eliminating some of the administrative work associated with patients entering the ED, and implementing a system allowing non-urgent patients to be seen by a medical provider other than a physician. However, none of the strategies to address crowding have been assessed on a state or national level.

The GAO found that there are several other frequently reported causes for ED crowding, including a lack of access to primary care; a shortage of available on-call specialists; and difficulties in transferring, admitting, or discharging psychiatric patients. Less commonly cited causes of ED crowding included an aging population, increasing acuity of patients, staff shortages, hospital processes, and financial factors.

For the full report, go to http://www.gao.gov/new.items/d09347.pdf.
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Hi Everyone!

It is June, 2010. Can you believe it?

Well, Emergency Department crowding is still an issue in 2010 just as it was in 2001.

Here is a post from today.

We will stay in touch.

jc

June 26, 2010
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Hi Everyone,

Well, it is May, 2011. Time flies when you are having a good time.

I posted this article yesterday.

We will stay in touch and thanks for reading.

jc

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Hi Everyone,

Today is June 1, 2011.

I posted this today.

Later,

jc

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Hi Everyone,

Today is October 17, 2011.

I posted this today.

Stay well.

John

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Dear Everyone,

It is December 23, 2011. It is very sunny and clear today. I still need to rake some leaves in the backyard.

Hope you are well.

I posted this today.

Merry Christmas,

John

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May 27, 2012

Dear Everyone,

It is Memorial Day Weekend. Hope you all are well.

I posted this article yesterday. It is from Edmonton and mentions a doctor who notified administrators of his concerns of danger in the ED due to overcrowding in 2008. But his concerns were not addressed.

This sounds familiar to me.

Also, in Peoria, we now have two fire stations that are paramedic. And in the near future all new firefighters in Peoria will have to be paramedic. Please see this post.

So times are changing for the better in Peoria. Change is hard when corruption is deep. And when our local medical leaders who have corrupted the system here for so long are gone, things will be much better for EMS in Peoria.

John

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April 18, 2014
Good Friday


Please read this article from Medscape.

Have a good Easter Sunday.

John

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July 10, 2014

Dear Everyone,

This article was just published in Medscape. Please read the last paragraph first.

Have a great summer.

John


PS: Read this article too about whistleblowers at the VA. It was published yesterday (July 9, 2014). Here are a few paragraphs about what a VA Emergency Medicine physician in Phoenix thought about her VA facility and what happened to her when she spoke up:

The head of the medical inspector’s office retired June 30 following a report by the Office of Special Counsel saying that his office played down whistleblower complaints pointing to “a troubling pattern of deficient patient care” at VA facilities.
“Intimidation or retaliation — not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion or report what may be a violation in law, policy or our core values — is absolutely unacceptable,” Gibson said in a statement. “I will not tolerate it in our organization.”
A doctor at the Phoenix veterans hospital, where dozens of veterans died while on waiting lists for appointments, said she was harassed and humiliated after complaining about problems at the hospital.
Dr. Katherine Mitchell said the hospital’s emergency room was severely understaffed and could not keep up with “the dangerous flood of patients” there. Mitchell, a former co-director of the Phoenix VA hospital’s ER, told the House committee that strokes, heart attacks, internal head bleeding and other serious medical problems were missed by staffers “overwhelmed by the glut of patients.”
Her complaints about staffing problems were ignored, Mitchell said, and she was transferred, suspended and reprimanded.
Mitchell, a 16-year veteran at the Phoenix VA, now directs a program for Iraq and Afghanistan veterans at the hospital. She said problems she pointed out to supervisors put patients’ lives at risk.
“It is a bitter irony that our VA cannot guarantee high-quality health care in the middle of cosmopolitan Phoenix” to veterans who survived wars in Iraq, Afghanistan, Vietnam and Korea, she said.
Scott Davis, a program specialist at the VA’s Health Eligibility Center in Atlanta, said he was placed on involuntary leave after reporting that officials were “wasting millions of dollars” on a direct mail marketing campaign to promote the health care overhaul signed by President Barack Obama. Davis also reported the possible purging and deletion of at least 10,000 veterans’ health records at the Atlanta center. More records and documents could be deleted or manipulated to mask a major backlog and mismanagement, Davis said. Those records would be hard to identify because of computer-system integrity issues, he said.
Rep. Jeff Miller, R-Fla., chairman of the House veterans panel, praised Mitchell and other whistleblowers for coming forward, despite threats of retaliation that included involuntary transfers and suspensions.
“Unlike their supervisors, these whistleblowers have put the interests of veterans before their own,” Miller said. “They understand that metrics and measurements mean nothing without personal responsibility.”
Rather than push whistleblowers out, “it is time that VA embraces their integrity and recommits itself to accomplishing the promise of providing high-quality health care to veterans,” Miller said.
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September 12, 2014

Crowding Kills

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Conversations with Keith Steffen


Conversations with Keith

I spoke with an OSF administrator, Dr. Tim Miller, in early October, 2001, and he stated that I was right and that “OSF had ignored the main campus”. He was referring to my letter to Keith Steffen regarding lack of bed capacity in the hospital for emergency department patients. The focus had been on the Center for Health that OSF had just competed north of the City. It cost 38 million dollars. Some of our patients in the ED didn’t even have pillows on their gurneys to lie on. I thought the ER was quite dysfunctional and our patient satisfactions scores were 33%, the lowest at OSF.

I copied excellent articles from the journal “Society for Academic Emergency Medicine” regarding ER overcrowding for multiple administrators. I heard back from no one in administration at OSF regarding the articles.

My first meeting with Keith was on Oct. 5. I expressed to Keith my concerns with lack of bed capacity at OSF and the long waiting times for patients in the ER, and also discussed the fact that Hevesy had placed me on probation for 6 months on September 28, 2001, the day after I wrote the letter to Keith. Keith told me that things were being done about the bed problem and that he (Administrator of OSF-SFMC) could do nothing about Hevesy putting me on probation.

However, Keith changed the topic of the conversation very quickly. He seemed to be very concerned about a petition that was going around in my support and asked me the names of the nurse or nurses who started the petition. I did not tell him because I feared for their jobs if he found out their names. He repeatedly tried unsuccessfully to get their names from me.

Keith then likened me metaphorically to an uncontrolled hemorrhage in the ED and a cancer in the ED that needs to be “cut out before it metastasizes”. I was quite surprised to hear this. I really didn’t know Keith well but figured out this was going to be tough go.

He also was fixated on the concept of fear. He told me, “Fear is a good thing amongst employees.” Rather strange, I thought.

As the next couple of months went by, very unusual things happened in Keith’s office. During one meeting with him, Keith said, “You know, John, the Apostolic community has a problem with you.”(Keith is an Apostolic Christian). This statement totally caught me off guard. The Apostolic Christians in the area were host families for Haitian kids and very close friends of mine. I couldn’t understand what he was talking about. Keith would look at the carpet, shuffle his feet, smile and say, “You know, John, when this comes out about you, it won’t be good.” I would ask him the same question each time—“When what comes out about me, Keith?” He would never answer but would just shake his head and smile. He went through this same ritual several times with me over the course of a couple of months.

I wasn’t the only one he planted these seeds with.

My brother went in to talk with Keith during the next couple of months and he told Tom, “There is a side of your brother that you don’t know.” This disturbed my brother greatly because there is no side of me that he doesn’t know. What could Keith be doing or thinking with this mantra of his?

On December 5 Keith had a meeting with two Apostolic Christian nurses who had important positions at the medical center to his office and stated the following: “John has done very bad things. People don’t know this side of John.” One of the nurses had helped start another petition on my behalf that really irritated Keith. Keith threatened to sue that nurse even though she had done nothing wrong and cleared it with Human Resources at OSF before she started the petition. Keith wanted to know the status of that petition as well, and the nurse told him that people were very afraid. Keith replied that was good. He then reiterated that the people did not know what they were signing and they did not know the whole story and they did not know the “real John Carroll”. Keith told the nurses there should actually be greater fear in the hospital. Keith went on to tell the nurse that he had spoken to Representative Ray Lahood and Monsignor Rohlfs and that they now understand that I have the problem. I had spoken to both of them and they were quite complimentary towards me. (I heard through the grapevine that Keith had made a very urgent phone call to Rohlfs one day to try and explain his side of things.) Keith even went on to say that “Rick Miller had been right all along.” When I asked the nurse if she meant that Keith was referring to me being frustated in the ER, she said “no”. It appeared that Keith was referring to something else, something much worse than frustration. The other nurse said nothing but was listening to all of Steffens comments about me.

A well known lady in the Peoria community, whose family had hosted a Haitian Hearts child, told me how she went in to Keith’s office and he told her that they had asked me to seek counseling and that if she knew the OSF side of the story she would agree with Keith and OSF. She didn’t know what to think. Keith was definitely doing some damage and spreading seeds of doubt regarding me outside the medical center. She told me this story with her husband present. I could tell they were very apprehensive about what was occuring. Her husband had no idea what to say or do. They both have excellent jobs in the Peoria community and both knew what would happen if they went to bat publically for me.

Another business lady in the community who had never met Keith went in on my behalf after she was told by Sister Judith Ann to do so. Keith talked a lot about the devil with her and stated, “When the devil ensnares someone and pushes him up against the wall, we find out what that person is made of.” This lady was quite scared and wanted to leave Keith’s office at that point. Keith commented to her on the way out that if she talked about their conversation “…maybe we won’t be friends anymore.” (She had never met Keith prior to this.) She couldn’t wait to leave his office. When I asked Sue Wozniak about this a couple of months later she said “ it sounded like a threat”. The business lady thought so too.

Keith talked about my employment at his church in Washington, Il. I know who he talked to. They told me. At one point, Steffen stated, that “each time he (Steffen) sees a Haitian child, it makes me (Steffen) want to puke.” Keith’s inappropriateness knew no bounds.

So there really wasn’t any confidentiality with Keith. OSF attorney, Doug Marshall, would monitor Keith at times in Keith’s office and tell him to watch what he was saying because I was shaking my head and writing everything down. Keith’s mantra to me about “the other side of me will come out and it won’t be good” was never said in front of Marshall, that I know of, so Keith can deny this if he wants. But he will have to deny it a lot if ever questioned under oath because he said it to many people.

Does this sound like the way the CEO of the largest employer in Peoria should act? Doesn’t seem to be great management skills to me. Open and honest communication, one of the Sisters mission statements was absent with Mr. Steffen.

After Keith fired me on December 18, 2001, he distributed a fax to the rest of the medical center (that was written by hospital spokesman Chris Lofgren) as if he was trying to protect me. A lot of people told me about this nonsense. (See post "Conversations with Chris").

Then things got worse.

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Before I met with Keith as described above, I sent him this note pleading for help for the Emergency Room from OSF administration:

Handwritten Note from Dr. John Carroll

10-01-01

Dear Keith,

As you mayor may not know, the ER is in "tough straits" - patient care and waiting time is very lengthy.

I would love to have you or another administrator spend a couple of shifts with me this week in the ER. I work 3-11 and 5-1. You would see patients with me. The objectives of this would be to:

1. See the ER from "ground zero" - this would prompt ideas on how to solve some of these issues. I will tell you how I see the issues and how time could be saved for the patient (from triage to final disposition). There is a huge crisis occurring in our ER now.

2. Your presence would definitely be a "morale improver" for the ED staff and for the patient when he realizes an administrator is personally concerned as well.
I really believe an administrator's presence would be a "win-win" for OSF and ER patients.

Please strongly consider joining me in the ER.

Sincerely,

John

Addendum:

May 22, 2008--Keith refused to come to the ER when I proposed this to him in 2001. He stated that if he came to the ER other hospital departments would want his presence, and he could not be everywhere.

As I look back at it, I doubt the ER had his full attention compared to other big money making departments (like Surgery) and the new Center for Health. The ER and its overcrowding would just have to wait.

In the May 15, 2008 issue of the New England Journal of Medicine is an article written by David J. Shulkin, M.D.

Dr. Shulkin makes late night administrative rounds at the hospital where he is president and chief executive officer. He noted the "stark discrepancy in quality between daytime and nighttime inpatient services."

His goal is to improve his hospital quality of care during the nighttime hours.

Dr. Shulkin writes:

"The consequences of service deficiencies during off-hours include higher mortality and readmission rates, more surgical complications, and more medical errors."

He feels that his midnight rounds were proving a good way to help him understand and address concerns of off-hours staff.

"In order to identify problems and design effective solutions, it is critical to gather such front-line information, and to do so, senior hospital administrators need to see firsthand the working of the "other hospital". I strongly encourage my counterparts else-where to conduct at least 1 week's worth of night rounds each quarter."

"Close attention should be paid to the needs of patients and their families, any procedural and communications issues among staff members, and most important, the quality of dialogue between administration and staff members regarding the organizatiion's inpatient service and safety priorities."

Keith probably needs to read this NEJM article.


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May 14, 2006

In this weeks New England Journal of Medicine, George Annas wrote an article, "The Patients Right to Safety--Improving the Quality of Care through Litigation against Hospitals.

Annas reports, "...safety must be an explicit organizational goal that is demonstrated by clear organizational leadership...This process begins when boards of directors demonstrate their commitment to this objective by regular, close oversight of the safety of the institutuions that they shepherd."

He continues,"...(hospital) safety cannot become an institutional priority without more sustained and powerful pressure on hospital boards and leaders---pressure that must come from outside the health industry. In hospital care the challenge is to reform corporate governance to make hospital boards take their responsibility for patient safety at least as seriously as they take the hospital's financial condition."

“The major safety-related reasons for which hospitals have been successfully sued are inadequate nursing staff and inadequate facilities. Since providing a safe environment for patient care is a corporate responsibility, understaffing is corporate negligence. “

In 1991, for example the Pennsylvania Supreme Court stated simply, “Corporate negligence is a doctrine under which the hospital is liable if it fails to uphold the proper standard of care owed the patient, which is to ensure the patient’s safety and well-being while at the hospital.”

During one of my first conversations with Keith Steffen, I told him I was worried about “institutional malpractice” at OSF. He asked me to define what that meant and I remember replying that he would understand the concept better than I would. He did not reply further. I thought that too many patients were being kept for long periods of time in the ER in 2001 to their detriment. I realize that Mr. Steffen is a small player in the entire scheme and agree with Annas and the New England Journal of Medicine that the Board of Directors at OSF needs to play a bigger role in guaranteeing safety of patients at OSF.