What are the issues, and what’s being done about them?

Emergency room doctors at Haywood Regional Medical Center have been on a collision course with hospital administration since a brand-new $5 million emergency room opened in December 2004.


Hospital CEO David Rice said the ER doctors have not cooperated with numerous hospital initiatives aimed at improving efficiency of the new emergency department, from a new computer system to reducing patient wait time.

Emergency room doctors claim they are a scapegoat for bad decisions and cost-cutting measures by the hospital administration that are beyond their control. Dr. Mark Jaben, an ER doctor, said Rice misled the hospital board with an incomplete set of facts.

The hospital board has been caught in the middle of the argument. To address concerns on both sides, an emergency department oversight committee was formed 18 months ago in an attempt to solve some of the issues. The committee included a cross-section of the many sectors working within the emergency department.

Rice said he had reached a stalemate with the doctors over several long-standing issues, prompting the hospital board’s decision two weeks ago to hand ER operations over to a new entity at the end of the month.

ER doctors claim the hospital board never articulated these issues to them in the context of contract talks. The ER doctors had only one meeting with the hospital board on the subject of their contract before the board voted to cancel it. During that meeting, the ER doctors asked repeatedly why the hospital board wanted to cancel their contract. The board said it had nothing to do with quality of care. The only reason the board cited was the doctors’ poor relationship with hospital administration.

Dr. Nancy Freeman, chairman of the hospital board, said that while the board did not enumerate specific issues in the context of the contract discussions, the ER doctors knew these issues were out there.

“These are issues that have been articulated time and time again,” Freeman said. “We are asking them to give up some of their autonomy for the greater good, and the greater good is treatment of the patient. I wish I could say the outcome would have been better. That’s the sadness of it. These guys do provide decent patient care.”

In an interview, Rice and Freeman described some of the issues that have led to the stalemate. Jaben, who was appointed by Haywood Emergency Physicians to serve as spokesman for the group, responded on their behalf.


Issue: Turnover time

The amount of time it takes to move a patient through the ER.

Hospital administration:

The hospital constantly receives complaints from the community about patient wait time in the ER. It is the top issue the ER oversight committee has addressed. To improve patient wait time, the hospital measures and tracks every step of the patient: from when they walk in to when a nurse takes their symptoms, when they move into a room, how long it takes to get their X-rays done, their lab work back, etc.

“We have every segment of that measured,” Freeman said. Timeliness of care is crucial to patient satisfaction.

ER doctors:

The ER oversight committee set time goals for every department within the ER. None of the departments have met their goal.

“You cannot hold the doctors accountable for aspects of turnaround time for which they have no control,” Jaben said.

One example is the amount of time it takes for a patient to be moved out of the ER and into ICU or the main hospital after an ER doctor has stabilized the patient. Once a doctor has made a decision to admit a patient to the hospital, it takes a little more than two hours on average to get that patient transferred out of the ER into the main hospital wing.

“That’s a bed that for those two-plus hours we cannot use to see someone else that is waiting,” Jaben said. “That’s where the big backups are.” But that problem lies with hospital administration, not the doctors.

Jaben said he sometimes see patients in the waiting room or the in-take room when all the ER rooms are full.

Another hold-up is the wait-time for patients with non-life threatening issues to be interviewed by a nurse about their symptoms. Nurses then prioritize the patients in the line-up. It takes 30 minutes on average for a patient to get that first interview barring an emergency condition. That wait time has nothing to do with the doctors, but is handled by the hospital’s nursing staff.

Hospital administration:

Hospital administration wanted the ER doctors to identify a trigger point that would justify calling another ER doctor in, but they refused.

“We were trying to get them to step up to the plate and identify when they thought it would be reasonable to bring another person in,” Rice said. “We knew a trend was there. All we were asking is for them to respond to that, to get a commitment that when we reach a certain range that second or third physician will come in. We wanted to define in this contract some way we could ensure we have coverage. We absolutely could not get to first base on that.”

ER doctors:

The ER is staffed with two doctors from 11 a.m. to 1 a.m., which is the busiest period, and one doctor the rest of the time.

The biggest problem is a nursing shortage, not doctor shortage, but Rice won’t pay to hire more nurses, Jaben said. The administration is cutting corners by paying nurses too little to retain the ones they have, and isn’t hiring enough to do the job.

Due to a lack of nurses, the ER doctors only use 14 of the 17 rooms in the new ER. The other three are kept closed due to lack of staff. The old ER had 11 rooms and three stretchers in hallways to treat patients. The new ER is seeing 20 percent more patients, but has the same number of functioning beds to accommodate patients as the old ER, according to Jaben.

Hospital administration:

“There is no shortage in nursing,” Rice said.

ER doctors:

“I believe Mr. Rice is using the physicians as a scapegoat because the new emergency department is not performing as he promised the community it would,” Jaben said.

For example, the ER was intended to have a paperless medical record system where nurses could do charts at computer portals in the hallway and in patient rooms instead of congregating around a central nurses station. As a result, only 9 of the 17 emergency rooms were designed to have a direct line-of-sight with the nurses station.

But the computer system Rice selected and installed doesn’t work well and nurses can’t do their charts and paper work on the computer but have to mill around the nurses station anyway. As a result, operations are no more efficient in a new $5 million ER than they were in the old one, Jaben said.


Issue: Protocols

Kind of like an instruction manual, protocols are written guidelines that lay out the course of action for a given a slate of symptoms.

Hospital administration:

A written set of protocols would help nurses know what care should be administered immediately to patients who are exhibiting certain symptoms. For example, someone with chest pains is instantly given aspirin during in-take.

“These are things that can be done swiftly. Even if the doctor is taking care of some other patient, these are things the nurses can go ahead and take care of,” said Nancy Freeman, chairman of the hospital board.

ER doctors:

Jaben said he was very confused by this complaint. He said ER doctors have had a set of written protocols for 10 years. The problem was providing the nurses with proper training on administering the protocols.

“You can’t just hand someone a piece of and say ‘Here’s what the protocols are. Now do it,’” Jaben said.

The nurses work for the hospital, not Haywood Emergency Physicians. Jaben said the ER doctors have volunteered for three years to do protocol training with the nurses. The hospital finally took the doctors up on the offer this summer. The protocols now work. For example, when a patient came in this weekend with a clearly broken arm, the nurse who conducted the in-take interview made the call to order an X-ray. Before the protocol training, some nurses would have waited for a doctor to see the patient.

As for patients with chest pain, it’s always been standard procedure for nurses to administer aspirin immediately.

Hospital administration:

The group drug its feet on developing written protocols. Some things still aren’t addressed in the protocols.

“We wanted protocols to streamline the care and to reduce the turnover time. It may be something different than what you were doing 10 years ago, but they are necessary standards,” Freeman said. “There was dissention among the (Haywood Emergency Physicians) group. Some were OK with it, some were not OK with it.”

ER doctors:

Jaben said not every set of symptoms has a clear protocol, such as abdominal pain.

“You’re talking about something with a list of potential causes two pages long. If everyone who comes in with abdominal pain has a standard set of tests ordered for them before the doctor sees them, they will get things that aren’t appropriate to their situation at whose cost and what risk?” Jaben said. “I think it is an example of Mr. Rice not understanding the practice of medicine. If he doesn’t even understand the issue how he can he reliably articulate that to the board?”

Issue: Inserting central lines in patients when there is a risk of sepsis

Central lines are lines inserted into a patient’s neck and fed into their body to monitor things like oxygen levels in a patient’s blood. The issue is who should insert central lines and when.

Hospital administration:

Central lines can determine whether a patient is succumbing to sepsis, the tenth leading cause of death and a major risk for emergency patients.

“Protocols across the county stipulate that for any emergency patient to have the best outcome because they are so incredibly sick, the emergency room physician should insert central lines that give data back regarding oxygenation and blood levels,” Freeman said.

Hospital administration wanted a written protocol for inserting central lines.

“They didn’t want to do it,” Freeman said of the ER doctors.

ER doctors:

Jaben called inserting a central line a “blind stick” that carries a risk of complications and should only be done when necessary, not based on a carte blanche protocol. It takes about 45 minutes to put the line in and is often better suited once the patient has been transferred to ICU or surgery.

“This is a case of Mr. Rice dictating the practice of medicine,” Jaben said.

Hospital administration:

Freeman said the hospital wanted a central line policy as part of its Medicare quality control improvements.

“If it is a national standard, we don’t want it to be their discretion,” Freeman said. When other doctors are called in to insert the lines, or the patient is transferred to ICU first, “that’s critical time that is being lost,” she said.

ER doctors:

This issue is currently being addressed by the medical executive committee, a committee of half a dozen doctors from various disciplines that meet monthly to discuss hospital-wide issues.

“This is an institutional issue under discussion among a large segment of the medical staff,” Jaben said.

A member of the medical executive committee confirmed that the medical executive committee has addressed central lines and said it was inappropriate for hospital administration to cite central lines as an issue with the ER doctors.


Issue: Completing patient records in timely fashion

Hospital administration:

Haywood Emergency Physicians gives doctors in their group month-long sabbaticals, or vacations. Some physicians did not complete patient records before leaving on their sabbatical.

“We expect those records to be up to date before they leave to go on vacation,” Rice said. “There is no reason for a record to be delinquent.”

ER doctors:

The hospital’s medical records department has serious internal flaws that Jaben described as dysfunctional. The medical executive committee has attempted to address the issue with the hospital in the past.

“The hospital wants to blame the doctors for not signing things on time but that’s because we can’t get things to sign,” Jaben said.

Jaben said he could go by the medical records department tomorrow and ask them to pull all his patient records to sign.

“A week later I could go by and there would be stuff from two months ago that they didn’t pull for me. How can we be up to date?” Jaben asked.

Issue: Computer system.

When the hospital built the new ER, it purchased a new computer system that it hoped to eventually implement throughout the hospital. It was selected against the wishes of doctors and medical staff, including Jaben, who served on a search committee assigned to research and recommend a computer system. Conflicts and accusations between the ER doctors and hospital administration over the Meditech system are too numerous to mention, so here is just one example.

Hospital administration:

The hospital wants to use a computer system called Meditech throughout the hospital. The new system was launched in the ER. The ER doctors fought the new system every step of the way.

“We have almost a year delay now because we cannot come to any satisfactory resolution on the physician piece of the electronic medical record,” Rice said.

ER doctors:

ER doctors used a computer program called PAIGE to type up instructions for patients to take home. The program provided templates that doctors could customize for individual patients, from how frequently bandages should be changed to how frequently they should apply cold packs.

ER doctors were told they would have to stop using their program and use a Meditech version instead. Doctors didn’t like the Meditech version because they couldn’t customize the instruction templates. They had to type up the instructions from scratch if they didn’t like something in the template.

Instead of taking one minute to do patient instructions for a broken ankle, it could take three or four. Multiply that over 20 patients during the day and it could really add up, Jaben said.

“This is a patient care issue. What I want to say to a patient should be what I want to say to a patient, not some canned thing put in by Meditech,” Jaben said.

The Paige program put all the instructions on a single sheet of paper. But the Meditech version prints each instruction on a separate piece of paper. Patients are less likely to read a stack of paper with a single line of instructions on each one.

“We saw this as a matter of physician-patient relationship,” Jaben said.

Hospital administration:

To accommodate the ER doctors, the hospital bought a license for the Paige program and mimicked as much of the program as possible in the Meditech system. But the doctors could not keep using the Paige program within the Meditech system. The program was not compatible with Meditech.

Rice said Meditech is used in hospitals and emergency departments all over the country.

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