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911 call from emergency department shows the need for response teams
Family calling for help in ED was a last straw for troubled hospital
Many risk managers struggle to maintain high standards in overcrowded, understaffed emergency departments (EDs), and a recent case in California illustrates just how bad things can get when the system can't cope with the volume of patients. When a 43-year-old woman's family and a bystander had to call 911 to seek help for her as she was lying on the floor in the ED at Martin Luther King Jr. — Harbor Hospital in Los Angeles, it was the beginning of the end for the troubled hospital.
What happened to Edith Rodriquez may have been an aberration, an extreme case of a patient falling through the cracks, but risk managers say the incident holds lessons about how patient safety can spiral downward when a system is overburdened.
Rodriquez was on the floor throwing up blood when family members called 911 and told the dispatcher that the ED staff was ignoring her. According to a report in the Los Angeles Times, the 911 operator questioned why the ED staff was not helping her. Speaking from a pay phone outside the ED at 1:43 a.m. May 9, the woman's boyfriend, Jose Prado, responded by saying, "They're watching her, and they're not doing anything. Just watching her."
Eight minutes later, a bystander unrelated to Rodriquez called 911 with the same report. The 911 operator refused to send an ambulance to the ED and instead urged the caller to seek help from hospital staff. A half-hour after the first call, Rodriquez died of a perforated bowel, according to a report from the county coroner. Hospital security video shows the woman lying on the floor for 45 minutes, with staffers standing around and a janitor cleaning the floor around her.
The incident proved to be a final straw for the hospital. County supervisors recently voted unanimously to close the hospital. They released a 124-page report by federal inspectors that detailed dozens of significant problems found during a comprehensive review in July. Over the past four years, the hospital has been cited more than a dozen times for patient care lapses and blamed for a series of patient deaths. Inspectors concluded that there was no functioning quality improvement plan at the hospital.
Response teams can save the day
Grena Porto, RN, MS, ARM, CPHRM, senior vice president with Marsh, a consulting firm in Philadelphia, and past president of the American Society for Healthcare Risk Management (ASHRM), has heard of similar instances at other hospitals. Patients and family members have called 911 from inpatient units as well as EDs, she says. Wherever the call originates, it suggests a systemic problem in the health care organization, Porto says.
Rapid response teams (RRTs) may be one solution to the problem, Porto suggests. With RRTs, patients, family members, or even staff can call a designated phone number within the health care system when they think the immediate caregivers are not responding appropriately. The RRT is a team of clinicians who will respond to the patient immediately and intervene as necessary.
"Anyone can call the number when they're desperate. That doesn't make it OK to neglect patients just because you have a response team as a backup, but it gives people a productive option when they really need help," she says. "I don't think what happened in Los Angeles is an isolated event, and calling the rapid response team is a far better option than calling 911."
A last-chance backup
The RRT is a fail-safe mechanism, a last chance backup when a patient may be near crisis, Porto says. When there is no such option, people may believe they have no choice but to call 911. "Calling 911 is a bad option for the patient because they're in a facility where the best help is somewhere down the hall, if only they can get the right person's attention. 911 probably isn't going to send help at all," she says. "And when the incident becomes public, it's extremely embarrassing for the hospital that the patient felt that desperate for help."
The RRT system must be structured so that it is not seen as a replacement for quality care, and the criteria for calling the RRT must be explained to people well enough that the team is not called out for less-than-urgent needs, Porto says. Ideally, a RRT should be called upon infrequently. Frequent use of an RRT can signal systemic problems within the organization that must be addressed, she says.
Porto also suggests that the Rodriquez case should make risk managers wonder if their ED staff check on patients frequently enough to spot those who are suddenly getting worse.
Resource allocation is important
A situation such as the one in Los Angeles can be the result of poor resource allocation in the ED and a staff that are focused on the wrong goals, says Maurice A. Ramirez, DO, BCEM, CNS, CMRO, an emergency physician at Pascoe Regional Medical Center and president of the consulting firm High Alert, both in Kissimmee, FL. Especially in an overcrowded, understaffed, and underfunded ED, he says, staff members can lose sight of their primary goal of providing the highest-quality care.
"If you don't plan for situations like the one in which a woman is lying on the floor dying, you get what happened in Los Angeles, where life-sustaining care took a back seat to some other objective," Ramirez says. "What was that other objective? We'll probably never know because it will end up in a sealed settlement, but some other objective ended up at the top of the list in that institutional culture."
Losing focus can be insidious, Ramirez warns. Even in a badly overstressed hospital ED, if you asked staff members what their primary objective is, they probably will say the right thing: providing quality care to patients. But in the heat of the moment, they may act quite differently, Ramirez says. "But if you went back and looked at how patients actually moved through the system, the goals probably were to move the highest number of patients through as quickly as possible, and that's not necessarily the same as providing the best care," he says. "The patients who are seriously ill get seen right away, and the ones who can be treated in five minutes might be moved through pretty quickly. But those who are in the middle might wait and wait."
Those patients aren't intentionally singled out for long waits, but competing interests and goals end up having that effect, Ramirez explains.
Watch for lost focus
ED management is tricky, and keeping patients moving is a valid goal, Ramirez says. But the way people are triaged is one indicator of what is really motivating ED staff, he says. Patients who are repeat visitors and known to be time-consuming also might be kept waiting too long, he says.
"When you're trying to get patients through your ED, sometimes it just seems to make sense to go ahead with these five other patients instead of spending time with that one patient you know is going to take up space for hours," he says. "You get so you can justify that decision in your head."
Ramirez suggests risk managers meet with ED managers, physicians, and staff to discuss some of these possible outcomes when they are pulled in too many directions. Be prepared to open a can of worms if you ask them to vent about all the competing priorities, but simply discussing the conflicts can help ED staff be more aware of the risks, he says.
"It seems obvious sometimes, but these people are being pulled in a lot of directions at once, so it can be good to remind them that true triage has to take precedence over moving bodies through the ED," he says. "No one wants someone to die of a hemorrhage in the waiting room while they're putting a [bandage] on a cut finger, so sometimes it is worthwhile to just remind them that they can practice good medicine, which is what they really want to do anyway."
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