OHSU TALKS BACK
In response to the June 24 Willamette Week story ("Barely Managed Care") about alleged nurse staffing problems in OHSU's Emergency Department, we would like to correct several factual errors. We want to thank reporter Josh Feit for interviewing OHSU management about staffing and managed care challenges.

We do wonder, however, why Mr. Feit did not query the physicians and other ED personnel who cared for the patient mentioned to check the accuracy of information he received from the nurses.

Below are the factual errors or problems we found in the story:

1. The elderly patient had medical personnel in attendance. Although the triage nurse may have left the room, two physicians and a medical student were with the patient the moment his condition changed. The patient had a history of cardiac disease and received prompt resuscitation. Given his clinical scenario, having a nurse in the room with him continuously would not have saved his life.

2. It was irresponsible and possibly inaccurate to have named the alleged patient. OHSU as an institution has strict policies that honor patient confidentiality and did not give Willamette Week a patient name. Your newspaper, in fact, admitted it did not have confirmation of the name and therefore should not have speculated and printed the name anyway.

3. The story incorrectly implied that an Oregon Health Division report criticized staffing issues surrounding the alleged elderly patient. The report, in fact, had nothing to do with that specific patient but referred to general staff improvements that needed to be made while OHSU was transitioning from its old ED facility to its new one. Those improvements have since been made.

4. The story stated that the ED budget has decreased 3 percent from last year. The truth is that last year's ED budget was $2.8 million and that this year's budget increased by 20 percent.

5. The story said that wages and benefits at OHSU Hospital dropped by 3 percent between 1996 and 1997. In reality, there was a 6 percent increase in wages and benefits during that time frame.

6. It is misleading to compare the increased patient capacity in the new ED with the increase in nursing staff. The new ED is vastly superior in size and technology to the old facility but in fact does not operate at capacity. It was designed to allow OHSU the flexibility to "grow" into using more ED beds as needed by patient usage. The number of ED visits has grown by 2.8 percent this year, while nursing staff has been beefed up by 17 percent (a total of 10 positions).

7. The article said a new nursing schedule in the ED cuts nursing care by five hours per week. The new schedule, in fact, includes the same number of nursing hours per week but changes some employees' work schedule to include evening hours when there are more patients in the ED.

8. There are more than 50 RNs who work in the Emergency Department at OHSU. Willamette Week interviewed only about half a dozen of them and implied that their views were shared by all the nurses in the ED.

9. The Oregon Association of Hospitals provided the reporter with staff comparisons that showed OHSU has more health care personnel per patient than any other hospital in Oregon. That was a critical piece of information, which the reporter chose to omit.

Finally, we want to reassure patients who come to the Emergency Department at OHSU that they will continue to receive the finest care in the state. We have a dedicated team of physicians and nurses who care deeply about their patients and are extremely conscientious about their role in saving lives. Please do not let the voices of a few outshine the work of the many.

Jerris Hedges, MD, chief,
Department of Emergency Medicine

Pat Southard, RN, JD,
associate director, OHSU Hospital

Josh Feit responds: My story was based on a state investigation into staffing shortages at OHSU's emergency room. It raised questions about the quality of health care at OHSU and the effects of budget cutting in the era of managed care. Jerris Hedges and Pat Southard's letter to the editor raises questions about the veracity of my reporting. I will respond to each point.

1. The state investigation reports that no staff members were present when the patient's condition changed. The report explains that staff weren't aware of the patient's condition until the patient's family "alerted them of his collapse." Nurses on the scene told WW that no medical staff members were with the patient for 20 minutes. It is impossible to say whether the presence of staff would have saved his life.

2. I respect OHSU's institutional policy to honor patient confidentiality. As a reporter, I believe the name of the man described in the state report is relevant. In the article I explained that emergency room nurses filed a complaint partly in response to the death of an elderly Russian patient on Aug. 4, 1997. Multnomah County Medical Examiner records show only one similar death--that of 85-year-old Vasyl Zhylin. No one has claimed that we named the wrong patient.

3. In order to illustrate its finding that there were "deficiencies" in OHSU's emergency department, the state report cited several instances related to understaffing, including the death of the elderly patient we reported in our story. The man's collapse is reported on page 6 of the state report under the heading "Summary Statement of Deficiencies." The report, which is filed with the Oregon Health Division (number 97-41) finds that "the hospital failed to assure that the nursing staff level met the minimum requirements of the emergency department staffing policies." As I reported, an emergency department nurse listed several planned improvements that have not happened, including failure to fill an extra backup position and failure to implement an emergency on-call system for high-acuity situations.

4. OHSU emergency department director Dick Cates provided me with the emergency room budget numbers. He characterized the difference between fiscal years '97-'98 and '98-'99 as a "slight drop." I compared the numbers he gave me ($4.17 million and $4.15 million) and adjusted for inflation. In real dollars there is a 3 percent drop in funding. Upon receiving OHSU's letter and reading the hospital's report of a 20 percent increase, I called OHSU spokeswoman Lisa Godwin to ask for an explanation. Godwin could not explain the discrepancy.

5. The state office of Oregon Health Plan Policy and Research provided me with information regarding OHSU's salaries, wages and benefits. The difference between '96 ($155.6 million) and '97 ($150.9 million) is a 3 percent drop. OHSU has since explained that the $4.7 million difference resulted from shifting computer-support personnel out of the hospital budget.

6. Hedges and Southard are correct that our numbers compared the increase in total capacity with the increase of nursing staff and that the hospital is not yet operating at full capacity. However, as we reported, as late as mid-June 1998, formal staffing-shortage complaints continued to be filed by emergency room RNs.

7. According to a copy of the new emergency room schedule, obtained from an employee of OHSU's emergency department, nurse staffing has been cut from 107 hours each week to an average of 102 hours each week.

8. Hedges and Southard are correct that I interviewed "about half a dozen" nurses. I knew of at least 10 others who wanted to talk but said they feared repercussions from management. OHSU, in fact, specifically instructed nurses not to talk to WW for this story. After the story was published I received e-mails and phone calls from six more OHSU nurses and staffers who said the story reflected their concerns. I did not receive any responses from ED nurses objecting to the story.

9. The Oregon Association of Hospitals and Health Care Systems provided me with data on full-time equivalent employees per occupied bed. The number of full-time employees per occupied bed at OHSU is higher than the Portland average. Our story, however, made no claims that OHSU's service was worse than that of any other Portland emergency rooms. The story had to do with cutbacks and how those cutbacks fit into a trend. As I reported, the number of full-time-equivalent employees per occupied bed at OHSU dropped 3.6 percent between '95 and '97. The Portland average of full-time employees per bed has dropped as well--by 2.4 percent in the last year.

As The Wall Street Journal reported on July 16, managed care has "gone too far in imposing cost controls on hospitals that too often result in downsizing nursing staffs or using technical assistants to do what well-trained nurses used to do." Our story portrayed a local version of this serious problem.

 

THE TRUTH IS OUT THERE...
Willamette Week recently printed a story about an 87-year-old patient who passed away at OHSU ["Barely Managed Care," WW, June 24, 1998].

My colleagues and I were the physicians who resuscitated and treated the patient. The article contained significant inaccuracies.

The article stated, "The man, whom the nurses believe had a heart attack, went unattended for 20 minutes in the emergency department before dying." The author later in the article stated, "The triage nurse entered his name into the computer and labeled him emergent, which means he needed to be attended to within 5 to 10 minutes. The man died 20 minutes after arriving at OHSU's emergency room. With a line of emergencies queuing up at the front desk, no one ever got to him."

As one of the physicians in attendance, I would like to explain what really happened.

The gentleman came to OHSU with abdominal pain. He was accompanied by his extended family and spoke only Russian. The triage nurse performed a timely evaluation and immediately moved the patient to the main emergency care area in direct sight of most of the ED personnel.

The triage nurse suspected acute disease (emergent). The patient was placed immediately on a cardiac monitor and attended to by two emergency physicians and a senior medical student. During their assessment of the patient's condition, he became unconscious and lost blood pressure. Despite prompt resuscitation and temporary improvement, the patient could not maintain his blood pressure.

It is always incredibly sad to lose a patient, but I want to assure your readers that the patient was receiving the best possible care during his visit.

Jonathan Jui, M.D.
Associate professor of emergency medicine, OHSU

Josh Feit responds: I refer readers to page 6 of Complaint Investigation Report 97-41 filed with the Oregon Health Division's Office of Health Care Licensure and Certification. In the report's "Summary Statement of Deficiencies," state investigators maintain that bedside care was not immediately available because of the high volume and acuity of patients already in the department when the patient was admitted. The state found that there was a delay in care and that "staff intervened when the patient's family alerted them of the patient's collapse."

My account of the patient's death was taken from the state report and interviews with nurses on the scene. I should have interviewed Dr. Jui as well.

 

IT'S WORSE THAN YOU THINK
Thank you for an informative and uncharacteristically restrained article on the impact of managed medical care on the staffing of registered nurses in the OHSU emergency department ["Barely Managed Care," WW, June 24, 1998]. One thing the article didn't do, and rightly so within the scope of the topic, was examine some of the dynamics that further degrade the ability of RNs to deliver safe and effective care under the auspices of bottom-line-driven health care. If I may:

1. The cost of nursing care is a huge budget item and an obvious target for policies designed to increase bottom line under the guise of making health care delivery more efficient. Along with an adversarial collective bargaining system, these policies put RNs directly under the gun of both labor issues and delivery-of-care issues, two stressors which adversely affect the morale of registered nurses.

2. In a facility such as OHSU, the battle for RN bodies and patient beds between nursing department managers, charge nurses and attending physicians is continuous and distracting in the extreme. Staffing shortages have a cascade effect: the goal of the emergency department is to move patients out: to home, to surgery, to floors and to specialized care units. A shortage of staff or beds (usually staff) on any of these nursing units creates a logjam in the emergency department. This is one significant reason why patients end up in observation areas with inadequate supervision and why all nursing units can be affected by staffing shortages anywhere in house.

3. Nursing has become specialized. In order to increase their own levels of efficiency and comfort, most RNs gravitate to a specific area: emergency, intensive care, medical-surgical, coronary care and so on. And while hospitals try to work with this trend, nursing management also pushes very hard to make any RN available to any given nursing department depending on staffing needs. This is fine to the degree that the capabilities of a given RN are properly matched to a given unit, but very often, especially when the crunch is on, an RN can find himself or herself ordered to take a patient assignment which they are not adequately trained to carry out. And unfortunately, the vast majority of RNs will accept such an assignment rather than refuse it on grounds of patient safety and incur the wrath of their supervisors.

4. Finally, I am compelled to comment directly on a statement made by the nurse manager of the emergency department at OHSU, to wit, "I'm not counting beans, I'm counting patients." I beg to differ. Under managed care, nursing department heads are under enormous pressure to stay not only within staffing budget constraints, which can be unrealistic in the first place, but to reduce costs wherever possible; and again, the easiest target for cost reduction is nursing staff. To be fair, the nurse manager is in an untenable position, but he is more likely to respond to pressure from the bean counters than pressure from the staff RNs.

Realistically, there is no economically viable way for a facility such as OHSU to keep enough RNs on staff to eliminate shortages that will inevitably result in bad outcomes. The use of unlicensed personnel is effective only when used as an adjunct to existing adequate RN staff, particularly in specialized nursing departments where RNs are expected to routinely and safely manage the complex needs of critically ill patients. The truly amazing thing about this entire situation is the fact that the system works as well as it does, and that there aren't more people languishing in emergency rooms for lack of adequate staffing. My own opinion, based on eight incredible years of working as a registered nurse in various critical care areas in two Portland hospitals, is that a nurse who becomes a bean counter is no longer the most effective advocate for the needs of the ill and injured. I find it very disturbing that managed care seems to be devaluing registered nurses rather than making their presence a priority within the health care system.

Robert A. Knapp, RN
Northeast Tillamook Street

JUDICIAL ACTIVISM IS JUDICIAL ACTIVISM
Although I would be among the last to question Willamette Week's expertise in knowing a whine when it hears it, your position that the Oregon Supreme Court acted on valid constitutional grounds in voiding Measure 40, the Victims' Rights Initiative, is as specious as it is ironic ["Oregon Justices United," 500 Words, WW, July 1, 1998].

In order to void 40, the court read new meaning into a section of the Oregon Constitution that has never before been used to void an initiative in our state's history. As Jim Westwood, about as big a member of Oregon's legal "establishment" as you can find, admitted with refreshing candor, "This is a very activist decision by the Supreme Court. They seem to be taking the bit in their teeth and running. It's the court almost making new law."

Indeed, prior to the Supreme Court's ruling, this attack on 40 was so farfetched that--to the knowledge of the attorney general's office--not a single judge who considered the issue, and dozens did, had ruled in this way.

No, this was judicial activism at its worst. The irony is that it was exactly this type of legislating from the bench that Willamette Week decried--dare we say whined about--when the court struck down the campaign-finance limitations voters approved.

What some people don't have the intellectual honesty to admit is that judicial activism is judicial activism whether it's upholding slavery, striking down New Deal legislation, creating new "rights" for criminal defendants, or voiding victims' rights and campaign-finance reform.

Additionally, contrary to your editorial, I do not approve of the Judicial Election Reform Act as written, but I have warned that the judiciary is encouraging it and the politicization of judicial campaigns by its actions.

Norman W. Frink
Multnomah County Chief Deputy
District Attorney

 

originally published July 22, 1998