Friday, July 27, 2012

Charles C. Anderson Shares--Safety Vs. Money...with Offer for Free Copy...

"On the far side of the couch on the floor of the room where
 she had been raped was her own purse and overcoat.
The work scrubs on the floor meant that she
 had been abducted on her way to or from work
in the emergency department, where she was
an attending physician. She guessed that it 
had happened in the parking deck as she was leaving,
although she had no recollection of this. 
"Walking to and from the car in the parking deck was 
the most vulnerable time for any female employee
 at Parkview Hospital. The Plagues specialized in preying
 on nurses and other female employees coming and going 
for the night shift.They were smart enough to disable
the security cameras before acting. She recalled that an 
emergency department nurse named Janice Green had
 been abducted from the second level of the
 parking deck and raped about six months earlier." 
Want to learn more, BRH has been authorized to give a PDF copy of The First to Say No...just leave a comment that you are interested. You can comment each day an article runs at BRH.
If you have already read The First to Say No, ask for The Farm...both by Charles C. Anderson. Let us know what you think about this issue!

The Reality Behind the Book...


I have had a close working relationship with six hospital administrators, close enough to figure out some of the things that make them tick. The easiest administrator to deal with is not the CEO of a hospital that is part of a large hospital corporation. The corporate administrator is a puppet. He wants only two things from the ED– happy patients and getting paid. After all, this is a big part of how he is judged by his corporation.

The administrator in an independent hospital is more likely to care about his employees, to institute policies that protect them, and stand behind the ED staff. He is accountable only to a local board, to which he can justify measures to protect employees. Let’s examine a couple of examples where administrators undermine their own ED.

Corporate CEOs in hospital chains are competing with their colleagues in other hospitals. In their race to keep their Press Ganey scores up, increase revenue, and capture as much market share as possible, the corporate administrator often makes promises to the public that the staff in their ED cannot keep. Have you noticed the battle of the billboards, where each hospital administrator tries to outdo his competitors by promising that a patient will be seen in his ED even before he take his clothes off. They have reduced themselves to competing over the number of minutes before a patient is greeted by a physician. Somebody forgot that our mission is to provide the best care possible for each patient and to concentrate on the sickest people first.

The ED is not a cattle drive or a theme park. Its purpose is not to entertain you or make you happy. Its purpose is not to leave you satisfied. Its purpose is to deliver the most appropriate care to each patient, as quickly as possible given the overall requirements of the sickest patients. When patients are given impossible promises and told that they are entitled to satisfaction they frequently become angry when they find that the waiting room is packed and they have to wait a half hour. The average ED patient is not known for his patience. He is noted for being demanding. Guess who is teaching him this? So the administrator sets up a confrontation between the ED staff, who are working as fast as they can, and the patient and family, who actually believe the billboards.

The best solutions to most ED problems have been known for decades. They are just trampled by the desire to make more money. One good answer to diffusing potential violence is a dedicated concierge whose only job is to advise patients and families about the progress of their relative or how long it will be until they are seen and why. Hospital administrators do not want to waste money on concierges any more than they do on adequate security. It’s always about money.

I was so happy when Virginia developed the first prescription monitoring program. At last doctors could track drug seekers from pharmacy to pharmacy. We did not have to make an educated guess who was a drug seeker. We could have the data in front of us before we confronted the patient. Guess what? Administrators have no interest whatsoever in the fight against prescription drug abuse, even though more people kill themselves from prescription drugs than heroin and cocaine combined. Remember, they want happy patients who pay their bills. The administrator does not care if you give the drug seeker 40 tablets of Dilaudid as long as he leaves happy with a smile on his face. He will be given a survey as he leaves and a follow up call later to make sure he was satisfied with the service from his pusher. Press Ganey calls this measuring quality of care.

I always take a nurse into the room with me when I talk to someone about their overuse of drugs, usually narcotics. I want double documentation that the patient was properly informed, that he was referred to a pain management specialist, or to his private doctor, or to drug rehab. It doesn’t matter where he is referred. He will be angry. He was promised a happy visit to the theme park and now he has to leave without the prescription he came for. He is not satisfied.

Again, the administrator has promised a service that I cannot deliver. I have a moral obligation to do the right thing for each patient, even if he doesn’t like my treatment. Thus, the ED physician has a difficult choice. He can generate great Press Ganey scores and turn out happy patients with no personal concern for the harm he is doing, or he can stand his ground, be branded as a trouble maker by the administrator, and generate confrontations where he is the most at risk. Are you beginning to understand why we are not making any progress in the prescription drug epidemic? Ideally, the uniformed police officer should accompany the ED physician into the room and escort the patient off of the premises. When a patient is in withdrawal and wants only one thing, he can turn violent in a heartbeat. The officer by your side is an effective tool. But the real culprit is the administrator. He is the one who is inviting the drug seeker to keep coming and to expect to go away happy. If these drug seekers were disappointed regularly, and the administrator stood behind you and what you were trying to do, they would not come back.

I have some more bad news for those of you who thought the administrator cared about best practices for common diseases. You know, all that stuff you spend hours learning in CME courses. If you have a determined mom who wants antibiotics for her kid’s cold, it is not in your best interest to try to educate the mother. Mom’s own doctor and other ED physicians have so thoroughly indoctrinated her that all URIs require a visit to the doctor and an antibiotic that your attempts at education will only produce another unhappy patient. And, of course, producing happy paying patients is the administrator’s priority, not providing care based on best practices.

Press Ganey scores have proven that doctors who pass out more drugs get higher scores. The administrator and the patient want you to order as many tests and X-rays as possible. It doesn’t matter that the patient doesn’t need them. Press Ganey measures satisfaction, not quality of care. If mom thinks junior needs an X-ray, and that is why she came, then you, the physician, are trapped. The hospital makes money on the tests you order. This is why it does not bother the administrator that the same alcoholic gets 25 head CTs per month for evaluation of altered mental status. Each physician is judged by the amount of money he can generate per patient and the number of patients he can satisfy. What does this have to do with quality of care?

Many of the basic safety measures that are unavailable in many EDs are missing simply because they cost money. Three uniformed off-duty cops per day cost money. Metal detectors cost money. Your safety as an ED employee is not as important to Mr. Administrator as saving that money. Having officers interferes with the administrator’s view of the ED as a theme park. So do metal detectors. One of the problems with the average administrator is that he has never experienced the emotional trauma of a sudden, unexpected shooting or stabbing of a real person, someone he cared about, right in front of him. He is under the same illusion as the administration at Virginia Tech—“That couldn’t happen here.”

I have been in the ED or trauma center on six occasions when bullets were flying. I have seen five people killed in the ED with guns and two shot in their beds on floors upstairs. I have seen a nurse stabbed in the parking lot and a physician’s brain turned to hamburger with a baseball bat just outside the ambulance entrance. Let me tell you what I have learned. If your uniformed officer is not in the ED when these events start, he is useless. If he is not armed, in some fashion, he is useless. Having a team that responds to “Code Atlas” is too little, too late for the type of patients that EMTALA has herded into our EDs. The pen on all those policies for response to violence has not been mightier than the sword in my 38 years of experience. You can write all of the policies you want, but if you do not have a weapon that you can access in a few seconds, you have no chance to prevent further tragedy.

Think about it. The average fight is over in less than 30 seconds, usually in half that time. It doesn’t take long to pull a knife or shoot a gun. If you believe that no one in your waiting room has a loaded gun or a knife, you are a fool. Sociopaths and deranged schizophrenics do not care about policies. They can clear out your waiting room for no other reason than they are tired of waiting. I guarantee that you will never forget it.

I spent the greater part of my career working the night shift in large hospitals. That is one of the reasons that I am more attuned to the potential for sudden violence. Most of the very worst tragedies I have seen occurred at night. The only good thing about nights is that the administrator is not around to babble on about satisfaction surveys from a group of patients who are intoxicated, psychotic, drug seeking, and drug abusing. I have never figured out how those comatose, septic nursing home patients filled out their surveys, but I appreciated them.

What is the point of having uniformed guards, or any security guards, or any action team, if no one is allowed to touch the patient? In a subsequent post, I will discuss the effect of fear of litigation on violence in the ED and how this constant over-concern with being sued prevents us from giving any useful guidelines to our own employees. Many employees feel that anything they do to help a colleague who is under attack will result in being fired. They are often right.

I just finished reading the position statement of the Emergency Nurses Association on violence in the emergency setting. I was shocked at the list of generic recommendations. Even the ENA does not demand uniformed, armed (in some fashion) officers. They do not specify concierges. They do not ask for relief from charges of assault if they are forced to come to the aid of a colleague. They do not ask to be able to defend themselves without fear of being charged with a crime. They do not provide the specifics that are necessary to take to the legislature.

I still contend that it is better to prevent an assault than respond to one. Preventing assaults requires a constant show of credible force. Administrators are standing in the way of this with their emphasis on satisfaction, speed, and theme park environments.

In summary, hospital administrators are one of the chief barriers to having a safe workplace in the ED. They put their money into television sets, security cameras, lights, and policies. Happy patients and paying patients. These are some of the reasons you are being assaulted. I pray that no nurse ever has to look down at her dead colleague in the floor of the ED before insisting on protection in specific terms.
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