Internal Bleeding

St. John's Mercy Medical Center alienated their RNs when they turned to less experienced caregivers to save money. Now they're paying for it.

Jody Miller, an ER nurse who's since left St. John's, says "after the first wave, we started noticing that we couldn't get our patients out of ER because there was no one upstairs to accept them. Meanwhile, the hospital was starting to ask us to draw blood, do EKGs and give respiratory treatments, because they were getting rid of the respiratory therapists."

Today, conditions vary dramatically, depending on the area of the hospital and how smoothly its teams function. Kerry Thacker, who's worked at St. John's almost 24 years, heard two patients saying, "This is just the worst floor!" and wanted to tell them, "'I'm sorry. You are getting the thrift treatment.' We're a medicine floor, and the average age of the patients is 70. They have multisystem breakdowns -- kidneys, lungs, heart, diabetes. They are on Medicare, so the hospital gets reimbursed less for their care. And each PCA has 10 patients to take care of."

St. John's chief nursing executive, Christine Crain, still insists that patient-focused care was a necessary improvement.

"The history of it is that we were getting feedback from our patients and from the physicians about the lack of continuity, that they would see as many as 50 or 70 different faces of people coming in to provide some element of care for them," says Crain.

So this wasn't a cost-cutting effort? "Let me -- " she blurts, determined to tell the story in a certain order. "So as we were looking at that information in terms of how to meet their needs with more consistent caregivers," she resumes deliberately, "we were exploring how we could do that better, and at the same time, health care was being faced with some significant challenges in terms of economics, managed care, decreased reimbursement. The public was telling us that health care was too expensive. So we came up with a system of care delivery that's team-based."

What, specifically, might that mean? Joan Kretschmer, who's been at St. John's for 15 years, says that before patient-focused care, her 24-bed ambulatory-care unit had four nurses on days, four on evenings and three on the night shift. Now they have three nurses on days, three on evenings and two on nights. They used to have at least one nursing assistant around the clock, with a second overlapping in heavy times. Now there's no overlap, and no PCA at night. The unit secretary's hours have been reduced, too, forcing the RNs to enter doctors' orders into the computer and answer phones, as well as respond to call lights all night. "We also no longer have lab techs coming in to draw blood, central service stocking the supplies for us twice a week, or an efficient housekeeping system that cleans the bed stat if you need it," adds Kretschmer. "Everything has shifted onto nursing. We're expected to clean the room, empty the trash and strip the bed before housekeeping even comes in to sanitize it, and you might wait an hour for a 'stat' bed to be sanitized."

Crain admits, "There is a challenge with housekeeping. We have experienced some vacancies. Nurses do pitch in. And I know that sometimes that can be a burden." But Kretschmer's concerns don't end there: "The ER is backing up with patients. And doctors are skipping the ER because it's so crowded, so we do a lot of triaging.

"I come home beat up," she finishes. "Sometimes it's 1 a.m. before I get out of there" (she's supposed to leave at 11:30 p.m.) "because I won't go off and leave the night shift if they're in obvious distress. Some nights I just pray, 'Don't let anybody go bad on me, because I am stretched so far I will miss it.'"

Last April, Dr. Farrin Manian, an expert in infectious diseases on staff at St. John's Mercy Medical Center, published an article in the New England Journal of Medicine asking, "Should We Accept Mediocrity?" He didn't mention his hospital by name, but he did enumerate consequences of patient-focused care: "Experience in basic health care services such as drawing blood and starting intravenous lines doesn't seem to matter much anymore, and in fact may be detrimental to one's future job security.... Important information such as vital signs, medications, and status of the intravenous site is no longer predictably documented in the patients' charts.... Changes in patients' clinical status (e.g., new onset of chills or changes in mental status) are not necessarily recognized by the nurse's assistants, nor are additional vital signs measured."

Manian summarized the problem neatly: "Those who hire non-nurse patient care workers to do nurses' jobs at lower wages seem to have underestimated the importance of the basic nursing skills required for recognizing when something is wrong. These skills cannot be acquired overnight, and yet miraculously anyone interested in taking vital signs and working in the health care field seems to have become qualified."

Have managed care and other economic pressures done as much damage as administrators anticipated? "Yes, absolutely," says Crain. "It has been a significant challenge to provide for the care of patients with decreasing reimbursements."

Yet according to a June 29, 1998, article in Modern Healthcare ("Market Pressures? Say What?"), hospitals in St. Louis "expected to have to defend against healthcare reform, managed care, cutbacks in federal reimbursements and declines in utilization. So they cut costs internally.... But healthcare reform never happened, and managed-care penetration stalled at about 25 percent of the market." Meanwhile, the hospitals had learned to negotiate en bloc, and they were so well-connected with the religious and corporate communities that there weren't "too many outsiders or bit players stirring up trouble or asking rude questions."

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