Overstreched in Emerg
The scenes would never make the television series ER. Not enough breathless melodrama. No screaming and scheming and bedlam in the halls. In the real-life emergency rooms of St. Michael’s Hospital in Toronto and The Buffalo General Hospital in upstate New York—two inner-city institutions separated by 160 km and contrasting healthcare systems—the traffic in human misery unfolds at a less frenetic pace. But as the stretchers roll in, the tensions run as high and the behind-the-scenes anguish as deep. On opposite sides of the border, both hospitals are in the throes of an unprecedented crisis, their life-support systems under siege, the terms of their survival in question. If the cause of their maladies are entirely different, many of their symptoms are remarkably the same.
Just past 4.30 p.m. on a recent Tuesday at St. Michael’s,
Leslynne Jones, a 43year-old accounts clerk, lies on a gurney in the emergency department hallway, pale beneath her cornrow braids, an intravenous tube dripping into one intricately manicured hand. The blackboard above the nursing station reports that all 10 of the ward’s urgent-care beds are full—although not so overwhelmed as to start redirecting ambulances to other hospitals, as happens 37 hours a month. The seven cubicles reserved for lesser emergencies are occupied too. Patients like Jones whose complaints are not life-threatening must wait, and increasingly these days that wait is longer. For seven hours, almost since she arrived doubled over with abdominal pain, she has lain in the minor-care corridor, dodged by both patients and staff.
Terrified by hospitals all her life, she had not wanted to come, especially now with daily headlines of government cutbacks that have left Ontario’s $17.5-billion medical system reeling and provoked specialists into open revolt. Nobody knows better than Jones about the tightening of that fiscal tourniquet. Her boss brought her in from her job across the street at the provincial finance ministry, which last fall slashed funding for Ontario’s 213 public hospitals by 18 per cent, or a staggering $1.3 billion, over three years. “There are stories all over,” she worries. “You’re afraid you're not going to get the service you need.”
Groggy from painkillers, Jones waits quietly, but not everybody does. “They yell at us,” says nurse Elaine Laine. “You’ll have
people who will walk out because they have maybe a three-hour wait with a sore throat or a toothache. They use the emergency department like a walk-in clinic, and they’re irate because they’re not getting the care they used to get. But when you’ve got ambulances coming in, you have to prioritize.”
Within 10 minutes of Jones’s arrival at 10.30 a.m., one of the department’s eight certified emergency medicine specialists promptly ruled out a ruptured appendix and she was wheeled out of an examining room into the hall. Two and a half hours later, an ultrasound scan showed she was suffering from massive uterine fibroids—growths, either benign or malignant, which had mushroomed and fragmented. The physician recommended surgery, but she would not be scheduled for two weeks. For now, he has her under observation before sending her home with painkillers. Once, he would have admitted her to a gynecological ward. But with growing government pressure to discourage $806-a-bed overnight stays, a mounting number of procedures, even surgeries, are treated on an outpatient basis. “Obviously, there’s pressure to get patients in and out,” says Dr. Brian Steinhart, medical director of the emergency department, which handled 35,000 visits last year. “But because we’re supported by volume, there’s pressure to see more.”
In fact, while that process keeps costs down for the Ontario Health Insurance Plan and rev-
enues up for the hospital, it is taxing Steinharf s emergency room staff—the front line of medical care. “Now, instead of getting these patients up on the floors, they’re being assessed longer here,” he says. ‘This is having a bottle2 neck effect. You get three of these patients in, § you’re hard-pressed to deal with a cardiac case.” 1 Increasingly, even those cleared for admist sion cannot be moved on to their designated j wards. Already, over the past 10 years, St. £ Michael’s has cut its beds from 701 to 391,
and, during slow seasons like Christmas and the March school break, it closes even more. Administrators boast of an 83-per-cent occupancy rate and an average length of stay reduced from 10 days a decade ago to 6.7—the sort of measures that bureaucrats demand. But vacancies seldom crop up where or when needed. Last month, St. Mike’s was obliged to dispatch one critical case to nearby Mount Sinai Hospital because its own intensive-care unit was jammed. “A lot of times we have people down in the emergency department,” says Laine, “because we can’t get beds.”
One of eight registered nurses on duty during the staggered 12-hour day shift—one of five when she works nights—Laine, 39, finds herself increasingly stretched. “Some nights we work straight through without taking a break,” she says. “People are sicker. In the old days, you didn’t have all the stabbings and shootings. Now, you see a lot more violent crime.” She also sees more of regulars like Pete McMullen, a shaggy 55-year-old in a black tractor cap that reads “Grave digger,” who has just woken up on a stretcher from the alcoholic haze where ambulance attendants found him on his usual turf—the heating vent in front of The King Edward Hotel. “I don’t know how I got here,” he grumbles. “I guess I got busted. I couldn’t even crawl.” Now he pounds the metal arms of his gurney, growling, “I’m hungry, damn it!” Finally, another nurse fetches him a sandwich from a cache kept for the homeless—part of St. Michael’s longstanding mission, set out by the founding Sisters of St. Joseph, to minister to the inner-city indigent. It is a mission the staff still earnestly believes in, but at times it threatens to swamp the department. “Because social workers have been cut, more people are coming in with more social problems,” says Laine. ‘You get a lot of street people, a lot of psychiatric patients and drunks. At night, if we can’t get a bed at the detox centre, we’re a hostel too. It takes a lot of time and the stress level is high.”
But the greatest stress now comes from the scalpel hanging over the staff as a government restructuring commission prepares to announce which of 44 Toronto-area hospitals will live and which die, or merge. St. Mike’s is not on the tentative hit list of 12 recommended to be shut, but it will not survive unscarred. The administration has sheared 3.5 per cent off its annual $ 170-million budget—half that faced by its most-threatened neighbors—and the closures and consolidations could force the elimination of entire departments, including the emergency room. “Stresses have increased,” acknowledges Steinhart. “Job security among the nurses is an issue. It has yet to hit the physicians, but it will with ER closures, and then there’ll be added stresses on those emergency rooms left.”
Already last year, St. Michael’s let 220 employees go, offering early retirement and socalled voluntary exit packages. Now, as part of a radical reorganization, the staff of 2,700 will be trimmed by another 150 over the next three years. Administrators predict that as
many as three-quarters of those remaining will have to be retrained. Some registered nurses like Laine, who earns $25.31 an hour, may be replaced by unlicensed aides, to be called “clinical assistants,” paid half that wage. With two to six weeks of training, they are scheduled to carry out such routine tasks as bathing and feeding patients. But at many American hospitals where the practice has been introduced, the results have been mixed—and in some cases, tragic. Last February, in an investigative series, the Pittsburgh Post-Gazette chronicled a handful of deaths blamed on just such unlicensed staff: in California, one aide accidentally unhooked a cardiac patient from a heart monitor during bathing; and at Pennsylvania’s Allegheny General Hospital, another mistakenly inserted a feeding tube into a patient’s air passage.
The prospect of a similar restaffing at St.
Mike’s has sent rage and rumors skittering through its nursing stations, where RNs struggle to keep patient care beyond reproach while coping with private fears and plummeting morale. “Everybody is kind of on edge,” Laine admits, “because they think: is it my job that’s going to be gone?”
On a Thursday afternoon in the gleaming new emergency room of Buffalo General, a $7.5-million renovation unveiled only four months ago, the facilities are spiffier and more streamlined than at St. Mike’s, but the stresses are almost identical. Opposite the central medical station, nurse Judy Masotti scans the greaseboard that lists every case in the surrounding 26 curtained cubicles: a 350-lb. “frequent flyer” with yet another overdose, a woman with a Q-Tip stuck in her ear, and a rash of assaults and heart attack victims. “Are we yellow yet?” she shouts, referring to the code that warns ambulances of overload, but which cannot, under U.S. law, turn them away. “I’ve got a kid who’s been assaulted and I need a bed.”
But here, too, at upstate New York’s largest medical centre, a private not-for-profit hospital with a staff of 4,487 and an operating budget of $260 million, all the emergency beds are full. Chris Bovenza, a 44-year-old with bone cancer that has spread to her brain, lies on a stretcher in the hallway in red and white Mickey Mouse pyjamas waiting for admission. This morning, she woke up at home, unable to walk. Now, the room booked for her upstairs is not ready and somewhere in the system the voluminous paperwork of her insurance forms has bogged down. But left in the limbo of the emergency room, Bovenza does not blame the nurses for failing to stop by with reassurance. “They don’t have time for that,” she says. Speeding between cases, Masotti ruefully agrees. “I’m like every nurse everywhere,” she says. “Overwhelmed.”
At 33 with 11 years experience, Masotti has no hesitation in fingering the cause. “People are sicker,” she says. Without exception,
Huge U.S. funding organizations are redefining health care
she and her colleagues blame what they call “managed care”— the system instituted by huge U.S. private health maintenance organizations, known as HMOs, which have rapidly replaced traditional insurance companies as the leading force, and funders, in the American medical industry. In return for lower monthly rates, they offer their subscribers the services of a limited list of hospitals and physicians. In a country where privately insured patients have been accustomed to booking appointments with a specialist of their choice at whim, HMOs are suddenly introducing a Canadian-style model, where general practitioners act as gatekeepers who control further consultations and costs—including trying to keep members out of hospital. “They’re going to these places or getting cared for at home longer,” says Masotti. “By the
time they show up here, they’re really sick.” Hooked up to a heart monitor in cubicle 22, James Kulczyk, a 56year-old retired publicschool teacher, can testify to that. Two years ago, he turned up at the suburban clinic of Health Care Plan, a 150,000-member HMO that charges him $350 a month in premiums— $4,200 a year—complaining he felt queasy. The doctor told him nothing was wrong and sent him home. Finally, when Kulczyk went to Buffalo General on his own, an angiogram showed he needed a quintuple bypass—pronto. ‘The last time I was here, I was in deep ca-ca,” he recalls, “and they had me down in the old waiting room for three hours.”
But with the clout of their mammoth subscriber bases, HMOs are setting hospital fees, dictating treatment and approved drugs and, if a hospital proves unco-operative, determining the institution’s fate by threatening to take their business elsewhere. Currently locked in a battle with Community Blue, the regional HMO of the Blue Cross and Blue Shield group, Buffalo General found itself largely banished from the plan’s list, accused of keeping costs too high and patients hospitalized too long. In fact, it had lowered its average length of stay from 8.2 days in 1992 to 6.9 this year, but the pressure is on to get patients out the door in four days. “The HMOs are driving the care here just like the government is driving it in Canada,” says Donna Hosier, the General’s emergency room co-ordinator. ‘The decisions are no longer in the hands of health-care professionals.” Agrees Barbara Allen, vice-president for patient care services: “Every day we are faced with these payers telling us what to do.”
Until now, each procedure has been timed and costed in exacting segments. But in the new year, HMOs can negotiate a blanket fee to treat a set number of their subscribers—pitting hospitals against one another to keep expenses down and profit margins up. For Allen, that will mean more demands on her already overtaxed staff. “Nurses are more frustrated than they are burned out,” she says. ‘They’re being asked to cut corners when they’re already over-stretched and stressed.”
Nor are those stresses likely to ease. Like St. Michael’s, the 782-bed
Buffalo General now faces a major overhaul after a merger with two other city hospitals. Its aim is to stave off a buy-out by one of the mammoth for-profit chains such as Columbia/HCA Health Care Corp. of Nashville, which now runs 347 hospitals across the country. The shareholders of such booming profit centres would not look kindly at the splotch on the General’s books: $4 million last year in writeoffs for treating uninsured cases—which the hospital regards as part of its inner-city mission—and another $7.7 million in bad debts when patients or insurers failed to pay up.
But the merger, which is still being negotiated, will mean cutting staff. In Buffalo, too, registered nurses face the threat of being replaced by unlicensed assistants dubbed, among other things, “personal care aides.” And, as at St. Mike’s, feelings run high. Nursing chief Allen calls it the
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American nursing. “I can get one and a half of these people for the price of an RN,” she says. “I fight with nurses’ unions on this on a daily basis: I say I am not trying to take their jobs away, but the truth is I think they will take their jobs—and they have.”
Now, she warns that nurses must retrain for new roles in the shifting, cost-obsessed healthcare landscape. “They can’t be acute-care nurses any more,” she says.
“They’re going to have to be home-care nurses or do prevention. It will not be easy and it will not be painless. But nursing is in as much flux as American health care.” Nor are nurses alone in fearing that change. At a time when Canadian physicians are threatening to flee
across the border, many U.S. specialists are being declared redundant by HMOs demanding more family practitioners. “I think,” says Allen, “a lot of people in the United States are scared.”
In St. Michael’s emergency room, where Stan Coulthard lies hooked up to a heart monitor, he recoils at the memory of a visit to a Texas hospital five years ago. He couldn’t wait to fly home to St. Mike’s, where he first came as a patient in 1948. At 73, after a triple bypass four months ago, the retired business manager still sings the hospital’s praises. “If I had to live in the American system, I’d be dead now,” he says. “There’d be no way I could pay for it. I just pray U.S.-style health care doesn’t come here.”
But to critics of the new dollar-driven revolution shaking up Canadian hospitals, many aspects have already arrived. Only steps from Coulthard’s bed, St. Mike’s dynamic president, Jeff Lozon, talks of patients as “customers” and brandishes the results of two customer satisfaction surveys performed by a Tennessee firm. “It’s a kind of a mindset change,” Lozon explains. Still, his greatest bow to the U.S. medical mindset has been to hire a New York-based consulting firm called American Practice Management Inc. to choreograph a radical restructuring that will cut costs and redeploy staff. Both he and APM’s Canadian managing director, Michael Decter, a former Ontario deputy minister of health, decline to disclose the fee. But in addition to a lump sum, the corporation gets a percent-
age of the savings it has projected: $21 million over three years.
The downsizing has been sunnily dubbed “the patient care journey”—an official euphemism that even those fearing layoffs now toss around. A handful of St. Mike’s nurses and doctors have been closely involved with APM’s U.S. team of experts in the redesign. But the plan, which remains largely under wraps, already bears the trademark of the corporation’s work at 40 continental hospitals: hiring an outside company to stock medical supplies and replacing registered nurses with unlicensed workers.
Some U.S. hospitals report themselves content with the resulting economies. But three years ago, when APM won a $4-million contract to streamline Winnipeg’s Health Sciences Centre and St. Boniface General Hospital, the outcry forced the Manitoba govm m ernment to abort part
of cutting a projected $45 to $65 million, the province has so far realized only $25 million in savings. And although assistant deputy health minister Tim Duprey has no complaints against APM, he admits it cost the government public support. Says Duprey: “People thought we were Americanizing the healthcare system.”
In St. Mike’s emergency room, the only evidence yet of the patient care journey in progress is the department’s new computer-controlled drug vending machine, the Pyxis Med Station System 2000—rechristened “Beckers” in dubious recognition of its resemblance to a convenience store fridge. With a drastically scaled-down inventory of drugs, as well as every Tylenol and Gravol locked inside, it is projected to trim $40,000 off the department’s pharmaceutical bill. But within weeks of its arrival, it earned the wrath of some nurses. Twice during a hectic weekend shift, its computerized drawers jammed, paralyzing drug supplies and prompting a quick sprint to the trauma room to unlock the Fentanyl. “It’s a lot of time wasted,” worries nurse Jennifer Price, “especially if you’re in a hurry or you have a cardiac arrest.”
For Price and many of her colleagues, some of APM’s other prescriptions are equally troubling. “If I feel I’m not giving the kind of care I expect from myself or the setting is unsafe,” she says, “then I'd have to take some time and really question nursing.” But Michael Decter argues that hospitals may have no choice. “The big question I get asked is: are we destroying medicare?” he says. “I think actually the opposite—that these changes are necessary if we want to continue to have medicare in this country.”
Brian Steinhart too remains determinedly upbeat about the surgery that the government has enforced on his department. “It’s made us look inward at what we’re doing,” he says, “and be a little inventive about maintaining our standards.” Still, as he tracks readmission rates and nursing workloads, he is reserving final judgment. And at a time when both Canadian and U.S. health systems are under economic assault, he sounds a cautionary note that could well apply in either country. “My only apprehension,” he says, “is that we lose sight of why we’re here.” □