Cookies for dinner

Cookies for dinner

April 2, 2007 - Today The New York Times published a story by Reed Abelson about whether small, physician-owned specialty hospitals are able to handle health emergencies. "Some Hospitals Call 911 to Save Their Patients" raises some important questions. It discusses specific cases in which post-surgical patients have died after specialty hospital staff called emergency services to have the patients taken to full-service community hospitals. And it presents the arguments of critics that the specialty hospitals represent efforts to cherry-pick the most lucrative procedures without taking responsibility for possible complications--in effect, skipping right to the dessert of health care profits. But the piece ignores nursing almost completely, and repeatedly suggests that the main if not the only issue is whether the specialty hospitals have physicians on the premises. This suggests that nurses play no critical role in handling such emergencies--unless you count calling the physicians. In fact, skilled nurses are at least as important as physicians in emergency care, and pieces like this should focus as much attention on the quality of nursing care available at specialty hospitals.

The piece explains that there are now about 140 small, physician-owned specialty hospitals in the U.S., with some two dozen more under development. The hospitals specialize in procedures like heart surgery, back operations, and hip replacements. Critics say physician-owners have an incentive to send patients to these facilities even when they may be better off at one of the nation's 4,500 full-service hospitals. Tragic cases are drawing attention from Congress and Medicare regulators. In one recent Texas case, a man who had had spine surgery at one such hospital developed breathing problems. "Staff" called 911, and although the patient was taken to a full-service hospital, the man died soon after. In another case two years ago, another post-spine surgery patient received too much pain medication; staff again called 911, but the patient died.

The problem is that to the extent the piece discusses what emergency care such hospitals ought to be required to provide in any specific way, the focus is entirely on the presence of a physician. There is no mention whatsoever of the necessity of skilled nursing care. Even if the assumption is that the small specialty hospitals do have qualified emergency nurses--though we have no reason to think that is the case--and simply lack emergency physicians, the impression most readers will get is that physicians save lives in emergencies and nurses are of no importance.

The "only physicians matter" theme runs throughout the piece. In describing the Texas case, the piece says that "[n]o physician was working there when the staff first recognized [the patient] was in trouble." The piece later notes that such small hospitals may not have "a doctor on site at all times during a patient's recovery." Still later the piece reports that "staff grew alarmed by [the patient's] breathing difficulties and called the surgeon back to the hospital. Ill-equipped to handle a medical emergency, the West Texas staff phoned 911," according to the lawyer for the patient's family. The piece adds that "[w]hen the paramedics arrived, they inserted a breathing tube before taking him to a nearby full-service hospital where he was pronounced dead a short time later." The upshot is that the only relevant factor is whether a physician was present; indeed, the only reference to who was present is "staff." There is no mention whatsoever of what nurses (if any) were there, or what their skills were. If paramedics were required to insert a breathing tube, it would seem that no qualified emergency nurses were present.

The theme continues in the article's broader discussion of the specialty hospital trend and possible regulatory changes. The piece reports that the chairman of one 18-bed physician-owned hospital in Texas says his facility "has an emergency department and a doctor present around the clock, and is also building an intensive-care unit." Later, the piece reports that Dr. Mark V. Williams of Emory University says (in the reporter's words) that "[w]ithout a doctor on premises, a nurse must call a physician for help if there is an emergency...but there is evidence that nurses are often reluctant to do that." The final paragraph says Texas "is considering requiring any hospital in a county with 100,000 or more residents to have a doctor on the premises around the clock and to have certain emergency medical equipment on hand." There you have it: emergency care = physicians + equipment. There is no mention of nurses, anywhere.

Back in the real world, critical patients would not live long with just physicians and equipment. Skilled nurses are essential to adequate emergency and critical care, and any legislation requiring only physicians and machines would be of limited use. The statement that nurses must call physicians for help in an emergency but are often reluctant to do so is very misleading. Of course nurses may require the help of physicians in an emergency, and some are reluctant to ask for it when a physician is off-site, in large part because of the abuse they may experience when doing so. However, this is actually the model pursued in most hospital settings; it is not unique to specialty hospitals. The recent trend toward hospitalists (physicians who follow patients in the hospital on a shift basis) is driven in part by a broader recognition of how problematic this system is. More importantly, the phrasing here suggests that when there is an emergency, nurses simply call physicians--they can do nothing significant by themselves, and would have nothing important to contribute if a physician was present.

The question we have--one that is just as important as what physicians are available--is what nurses are available at these specialty hospitals? Assuming the facilities even have registered nurses, are they certified in emergency nursing or Advanced Cardiac Life Support? Do they know how to insert an endotracheal tube? Do they know how to give emergency medications such as dopamine drips and epinephrine? Have they been trained to operate emergency care technology? How many clinical nurse specialists are on staff? What is the nurse to patient ratio? In the cases where patients have died, did the nurses--whose job it is to monitor patients for complications 24/7--miss vital clues, perhaps because they were overwhelmed with a high patient load?

The piece quotes the chairman of the 18-bed Texas hospital as saying that the physician-owned specialty hospitals are "really about the physicians getting back in control." In an environment that is designed to address physicians' woeful lack of power in the ordinary hospital setting (LOL), do nurses have adequate authority to resist care plans and systems that are not in patients' best interests? And getting back to the one nursing issue the piece does raise--reluctance to call off-site physicians in an emergency--do nurses in these boutique settings feel more reluctant than other hospital nurses to bother the "physician owners," at least before a situation becomes an indisputable emergency? Lives can be lost because of poor communication before a patient has declined to the point where her life is in immediate danger.

Unfortunately, for the most part, the above questions do not seem to occur to those responsible for major media articles like this one. So they do not occur to New York Times readers, or to other readers, or to health care decision-makers. Thus, nursing care is undervalued, and ultimately underfunded--perhaps even by some of those who run small specialty hospitals that confront patient emergencies.

See the article "Some Hospitals Call 911 to Save Their Patients" by Reed Abelson in the April 2, 2007 edition of the New York Times.

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