Thursday, March 15, 2007

Homicide in the ER?

Homicide in the ER?
January 14th, 2007
by Dr. John A. Carroll

On July 28, 2006, a 49-year-old lady went into the Vista Medical Center East Emergency Department in Waukegan, Illinois. She was experiencing chest pain, nausea, and shortness of breath. Apparently she was triaged to the ED waiting room.
She sat there for 2 hours and when the nurse called her for treatment, she didn’t answer and was found unconscious in the chair. CPR and advanced cardiac life support were given but were unsuccessful.

Less than two months later a coroner’s jury ruled she died of an acute myocardial infarction and her death was ruled a homicide.

Emergency Medicine News stated, “Years after years, prediction after prediction has warned that the emergency care system in the U.S. was on the verge of complete collapse.”

Lake county coroner Richard Keller, MD, who sent the case to the coroner’s jury, agreed that Vista Medical Center East suffered from the same system problems afflicting other hospitals. Dr. Keller commented, “It is a failure of the system”. He did not dwell on human error. Dr. Keller also stated that he “did not expect a criminal indictment to come from the ruling.”
On September 26, 2001, I worked the 3-11 shift in the ER at OSF. I had elderly patients as usual and several signed out and went home when they realized how long they were going to have to wait for a bed in the hospital. They were sick and I intended to admit them, but they just couldn’t take lying on a stretcher for many hours, and so they politely told me that they “needed to go home”.

The OSF-ER had an administrator on call every night to call at home if there were problems. These calls usually did not help at the time the call was made.
On September 27, 2001 I decided that Keith Steffen, CEO at OSF-SFMC, should at least know of my concerns and so I wrote him a letter and copied it to all of my colleagues in the ER and to other OSF administrators. (See letter below.) Someone seriously warned me that I might get fired if I sent the letter. I knew that could be true, but thought the letter needed to be written based on how dysfunctional the OSF-ER had become.

I did not hear back from Mr. Steffen but did hear the next day from Dr. George Hevesy who had been promoted to ED Director on August 1 to replace Dr. Rick Miller. His secretary handed me his letter as I was starting to resuscitate a man in the ER who had a cardiac arrest and was brought in by ambulance.

Dr. Hevesy’s letter stated that he was putting me on probation for six months from the main ER for writing the letter.

Letter to Keith Steffen:
September 27,2001

Keith Steffen, Administrator
OSF Saint Francis Medical Center
Peoria, Illinois 61637

Dear Keith:

I started working at OSF-SFMC in 1971 as an orderly on 8B. Most of my last 30 years have been spent inside this building. OSF-SFMC means everything to me. Please interpret the following knowing my heart and spirit are with St. Francis and always will be.

I worked 3-11 last night in the main ER. The ER mayhem and disarray that usually exists was actually somewhat manageable. However, patient waiting time from disposition to arrival on the floor was unbearable. Two sick patients of mine, rather than staying in the ER all night, politely decided to sign out, go home, and hope for the best.

Giving appropriate care in the ER can be challenging but having no room upstairs to admit the patient can be life threatening to the patient. Should I call other medical centers around the area/state for their admission and subsequent care before I see the patient or after? Studies have shown increasing time spent in the ER increases patient morbidity. Obviously, I don’t want to do this.

Please tell me what to do.

An ER crisis has been occurring for many years in our ER. But last night with “home diversion” of patients we have reached an all time low. This cannot continue.
I need an immediate answer from you today as to how I should approach these sick patients and their families. I will meet with you any time today or tonight.

My pager is always on (679-1980.)


John A. Carroll, MD

cc: Sue Wozniak, Chief Operating Officer, Tim Miller,MD, Director of Medical Affairs, Susan Ehlers, Assistant Admimstrator Patient Care Delivery Systems, Paul Kramer, Executive Director of Children’s Hospital of Illinois, Lynn Gillespie, Assistant Administrator Organizational Development, Emergency Department Attendings———————————
When I wrote the letter to Mr. Steffen and copied the people mentioned above (including all of the ED attending physicians), the OSF-ER had the lowest patient satisfaction of any department in the Medical Center and a very low employee patient satisfaction. There was a high turnover of nurses. Patients were boarded in the hallways, waiting for hours to be admitted. Many of the patient gurneys didn’t have pillows. The problems were both intrinsic and extrinsic to the ER. When there were no beds upstairs, we couldn’t move patients. That made other people in the waiting room wait longer. And diversion of patients occurred in the pre-hospital setting.

Patients, families, and staff were very frustrated.

Administration needs to be involved in the ER of a hospital. If the hospital doesn’t work well, neither will the ER. That is why I wrote Mr. Steffen.

When I spoke with Dr. Tim Miller, Director of Medical Affairs a few days later, he stated that he had read my letter and agreed. He stated that the “main campus” had been ignored with the construction of the OSF-Center for Health.

The Annals of Emergency Medicine headlined an article in the January, 2000 issue “Overcrowding in the Nation’s Emergency Departments: Complex Causes and Disturbing Effects”. During the 90’s, overcrowding in emergency departments became a national issue. It didn’t just involve OSF in Peoria.

The article stated:

“ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence….Unless the problem is solved in the near future, the general public may no longer be able to rely on ED’s for quality and timely emergency care, placing the people of this country at risk.”

In my opinion, this described OSF-ER almost perfectly. Thus, when I wrote Mr. Steffen my concerns and then met with him for the first time in early October, I had no idea that he would metaphorically refer to me in that meeting as a “cancer in the ER that needs to be cut out before it metastasizes” as well as a “hemorrhage that needs to be stopped before the bleeding gets out of control”. How his medical descriptions of me as a cancer and a hemorrhage related to bed capacity and overcrowding at OSF, remained a mystery to me.

In fact Mr. Steffen didn’t seem to be focused on the important issues for OSF. He seemed to be focused on the concept of fear among employees. He told me that fear among OSF employees was a good thing. Something more than the ER seemed to be wrong here…

Almost a year later an article appeared in the journal Academic Emergency Medicine–”The Elusive Nature of Quality”. It discussed that systems need to change, just like Dr. Keller, the coroner in Lake County said about the Waukegan incident, before emergency rooms can change for the better:

“Front line care providers (doctors working in the ER) are the frequent targets of criticism regarding the quality of care, and are often the recipients of the metrics we use to measure quality. These dedicated, skilled, and talented clinicians are often powerless when systems changes are needed, but they are held accountable for their actions within a SYSTEM THAT CANNOT ALLOW SUCCESS.

“The true route to achieving quality begins with an enduring commitment from the highest leaders of the organization, willing to exercise their authority for productive benefit. If the board of trustees and the CEO do not actively support excellence in the ED, enduring improvements are unlikely.

“If the messasge is not loud and clear that the patients in the ED must be served optimally by every service with impact, then mediocrity will be the norm. Responsibility must be properly allocated, which is a task of the leaders. No system is successfull without effective leadership.

“If we accept that the formula for quality begins with leadershhip, then the top of the hospital administration must set the expectations for all critical congributors to the ED.

“The essential element of leadership is strong principle.”

These paragraphs define the situation perfectly, in my opinion. And both Mr. Steffen and Dr. Hevesy told me that they were serious problems with leadership in the OSF-ER.———————–

Five years later, in April, 2006 when OSF announced its new 234 million dollar campus renovation, Keith Steffen stated that this would include a “much needed” improvement in the Emergency Room which was built for 32,000 patients but was expected to have 62,000 visits in 2006.

Why did Mr. Steffen refer to me as a “cancer in the Emergency Department” when I brought the OSF bed capacity problem to his attention in 2001?

April 6, 2006

An Eight-Story, Concrete and Glass Addition to OSF Saint Francis Medical Center

The expansion is needed because the hospital is out of space,administrators said.
St. Francis had to divert patients to other hospitals Wednesday, and it hasbeen that way much of the past month because there aren’t enough beds, CEO Keith Steffen said. Just last year, more than 200 patients had to be sentto other locations.
But when the $234 million construction project is completed, that no longerwill be a problem, Steffen said.

“We’ve seen significant growth over the past few years,” Steffen said. “We’d be remise . . . if we didn’t respond.”

The new building will be 440,000 square feet, almost twice the size of thehospital’s Gerlach Building, which houses surgery, the emergencydepartment, most of medical imaging and five intensive care units.

The project also will include a “much needed” emergency department expansion. The current emergency room was constructed to serve 32,000patients annually, but this year it will surpass 62,000, Steffen said.

This Journal Star Editorial followed several days later:
April 10, 2006

When Keith Steffen, OSF Saint Francis Medical Center CEO, got to work Wednesday morning, he was greeted with familiar news: the intensive care unit was full. Because of overcrowding, St. Francis annually diverts 200 patients to other hospitals, 100 of them children. That space crunch is precisely why Steffen would announce later in the day a $234 million expansion of St. Francis.
The largest medical center in downstate Illinois isn’t big enough.

The single biggest private building project in Peoria’s history, if approved by state regulators, will shoehorn an eight-story building onto the Downtown campus and position St. Francis to meet the medical needs of central Illinois and beyond for the next 25 years. Once the so-called Milestone Project is done, St. Francis will have three new floors for the Children’s Hospital of Illinois, three more for diagnostic services and surgery, one for adult cardiac patients and a new and bigger emergency room.

With the expansion, all of the hospital’s 616 rooms - it has 560 now - will be private, which has health and customer satisfaction advantages. New surgery rooms will be large enough to accommodate robotics and other technology, some $47 million worth. A larger ER will no longer have to operate at twice capacity.

Finally, after many years, it was stated that the ER at OSF was operating at twice its capacity. Even Mr. Steffen stated that they would be “remiss” if changes weren’t made. OSF has been “remiss” for many years now regarding excessive patients in the ER and inadequate bed capacity in the main house.

In the April, 2006 issue of Academic Emergency Medicine an article regarding overcrowding in the emergency department describes the problem very clearly. The journal reports:

“The phenomenon of emergency department crowding has become recognized across the globe as a serious public health threat. …experts widely agree that crowding in the emergency department (ED) is a system-wide problem, not one that results solely from problems in the ED or one that can be addressed using only ED based solutions. Crowding has become a shared burden for emergency providers. Each of us has a collection of stories to tell about how crowding has affected our patients, their families, our co-workers, and our own professional satisfaction.”

On June 15, 2006 USA TODAY had the headline “Emergency System Called Very Ill” on the front page:

“The nation’s emergency medical system is in a dangerous state of crisis, says a new series of landmark reports. The Institute of Medicine (IOM) recently released extensive reports which were prepared by a 40-member board after a two-year investigation. The IOM report states that the U.S. life saving system is failing. (The IOM report can be seen at

“The IOM reports detail how hundreds of thousands of lives are affected every year by EMS deficiencies that are not obvious. The chair of the panel, Gail Warden, stated that “in most communities, there is a crisis under the surface.”

“Many emergency rooms barely can handle their daily patient loads, children don’t always get good care, and the quality of rescue services is erratic, the report says. A USA TODAY probe found a 10-fold difference between major cities in cardiac arrest survival rates.”

Arthur Kellermann, M.D., M.P.H. published an article in the September 28, 2006 New England Journal of Medicine. He is chairman of the Emergency Department at Emory University School of Medicine. He sat on the IOM committee regarding Emergency Medical Systems.

Dr. Kellermann stated that the problem with hospital bed capacity slows the emergency department admission of sick patients and more patients are diverted to other hospitals. In every minute of every day, an ambulance carrying a patient is turned away “diverted” when an emergency room says it is too full to take patients.
Collectively, the committees describe an over burdened emergency system that is rapidly approaching its limits. Dr. Kellermann states, “With more patients needing care and fewer resources to care for them, emergency department crowding was inevitable.”

Dr. Kellermann writes about “boarding patients in exam rooms or hallways who need inpatient care”. He notes the very negative and dark side of ambulance diversion and that cities may experience the “health care equivalent of a “rolling blackout”. Everyone’s care is affected…”

Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) in 1986 which allowed everyone in the United States to acquire legal rights to emergency care. However, Dr. Kellermann argues that because this mandate (EMTALA) was unfunded, it created a perverse incentive for hospitals such as OSF-SFMC to tolerate Emergency Department overcrowding and divert ambulances while continuing to accept elective admissions.

My letter to OSF CEO Keith Steffen in September, 2001 was asking for his leadership and help for problems in Peoria that were very similar to problems addressed by the IOM in 2006.

I communicated with Dr. Kellermann and spoke to the Project Medical Director of another city with 5 million people regarding the unfortunate EMS situation in Peoria. The Project Medical Director asked me what would happen in Peoria if there was a mass casualty with the Peoria Fire Department at a Basic level and nontransport. Good question, but I doubt this will be answered in Peoria, until after the problem occurs. Peoria will be in for a cruel awakening.

Dr. Kellermann stated in the article that the “IOM committee calls on hospitals to end the boarding of admitted patients in emergency rooms and the diversion of ambulances, except in extreme cases, such as community wide disasters”.
He concludes that the IOM envisions a “coordinated, regionalized, and accountable emergency care system that is capable of delivering lifesaving treatment to all in need”.———————-

The IOM report sounds very much like the problems in Peoria. I have questioned the monopoly of paramedic transport care in Peoria. The IOM report mentions, crowding and ambulance diversion also occur because of lack of coordination among emergency medical response teams and hospitals…as well as entrenched professional interests. With regards to Peoria, I would say the “entrenched professional interests” are centered around the medical centers and their relationship with Advanced Medical Transport.

There is a “crisis under the surface” in Peoria.

In the meantime, my advice would be to go to the ER with your family member and speak up for them when they are too sick to advocate for themselves. And the unfortunate lady’s death in Waukegan was not a homicide. Human errors will continue, because we are all human. But the systematic errors need to be recognized and eliminated as much as possible.

John A. Carroll, M.D.

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