I had a phone conversation yesterday with an emergency medicine physician after her shift at an unnamed hospital in an undisclosed state.
She had a number of frustrations to share and she doesn't really have an outlet (and doesn't want her name out there for fear of retaliation). More importantly, this isn't about one institution. She works in a well respected system. So this lack of preparedness and leadership could be widespread. When I posted my concerns about hospital preparedness for Covid-19, I guess they weren't unfounded.
I'm sharing these concerns in a public way because I think it's important to try to inspire other healthcare professionals and improvement specialists who CAN be on site to drive improvements.
I also hope it serves as a reminder to the public to NOT GO to the hospital unless it's a life-or-death emergency right now. “When should I go to the hospital?” and more questions were be covered in a webinar that was done on Wednesday. Listen, watch, or read a synopsis here.
Note: The doctor reviewed this post for accuracy before I published it. I am not a journalist, so I did not reach out to the hospital for their view or for confirmation of the reality. But, I have every reason to believe that this is all true. I'll add the disclaimer that this post is based on the input of ONE doctor and she is not speaking on behalf of her medical group or the hospital.
I'm not in the hospital “gemba” (workplace) anymore because of restrictions on contractors (and the general need for people to stay out of circulation). Healthcare workers have no choice but to be out there trying to help people. But hospitals DO have a choice about better preparing for the sake of doctors, nurses, and patients (and anybody else who comes into contact with them… like security guards).
Security Guards as “Cannon Fodder”
After the call, I asked my wife (who was working from home) this question: “Who would you expect to be out in the front of the emergency department as 1st contact with patients??”
She said, “A nurse.”
Well, the answer at this hospital was “A security guard.”
The guard was handing out surveys to patients (in what languages?) with four questions meant to risk stratify them for Covid-19.
The guard had no Personal Protective Equipment (PPE) like a mask and yet was constantly being put at risk of exposure to an infected patient.
“It's not overdramatic to say they're cannon fodder,” said the doctor.
She also explained that the guard was working a 12-hour shift and “apparently, nobody planned for meals or bathroom breaks.” The guard had to ask somebody to call the supervisor because he “had to pee and couldn't leave.”
So, the charge nurse from the E.R. was sent out to fill in. That wasn't ideal, because now if she had an exposure, she'd be running around the E.R. spreading it for the rest of her shift.
Mark's thought: Organizations need to anticipate things like this… think through your staffing and your process design. Once issues are identified, work to correct them… don't repeat the same mistakes every day.
Shifting Standards on PPE
Speaking of masks, the doctor was originally told to wear N95 masks… until there was a shortage. Now, apparently, blue surgical masks are OK (unless they are swabbing or intubating a patient).
Mark's note: I have trouble tying those masks because I don't wear them often.
But now the doctors and nurses are slowed down (by the tying) and “our hands are near our faces more,” which increases risk.
Back to Screening Patients
The doctor said that IF the security guard (who is NOT a clinician) has a patient who meets the four survey criteria in front of them, then a nurse is called and the patient is immediately brought back to an appropriately isolated exam room.
Mark's note: If we're supposed to maintain six-foot distancing, I'm not sure the guard handing a survey card to every patient is a good strategy.
But, if the patient answers “no” to just one of the four criteria (so can still have fever and cough), that patient is placed in a surgical mask and allowed to proceed into the waiting room and general triage area.
“This patient who could have Covid-19 is now sitting next to a elderly person who has chest pain or a child with a broken arm.”
The doctor points out that even in a pediatrician's office there are two waiting rooms, one for “sick” and one for “not sick.” These are lessons learned from prior outbreaks such as measles.
“Why can't the hospital see this triage plan is a really bad idea for patients and providers?”
As early as last Sunday, clinicians working in the ER suggested moving triage outside the front door under an already covered area (there are apparently no tents available at this facility).
This would allow patients to be directed to a specific, less centralized area if they have respiratory symptoms before contaminating the entire ER.
The explanation for why this wasn't being entertained was a lack of staff to support this model. To which the doctors asked, “Why not use the telemedicine cart?” which MD's have been previously trained to use. No response was offered. What about adding shifts? Or simply moving the entire triage process outside? There has got to be a better solution that simply throwing up our hands and saying, “OK, the virus wins.”
The clinicians were assured that their concerns would be addressed at a Monday C-suite/administration meeting, but as of Tuesday afternoon, no changes have been made to the triage process. Nothing had been communicated as a follow up and the staff and patients remain in limbo.
Getting Testy About Tests
The doctor was frustrated by the current state of Covid-19 testing (or a lack thereof). For one, she knows of at least one ER doctor with fever and cough with a suspected exposure who couldn't get a test that would have allowed her to return to work ASAP… instead she has been forced to self quarantine for two weeks causing other MD's to step in and cover shifts during an already stressful time. We are just at the beginning of this.
She said there was a “lack of direction on testing” in terms of “who gets tested and who is making the call — the treating MD, the health department or a hospital administrator.” She said, “Who decides changes each day.” She complained that requests for a consistent top-down algorithm for deciding who to test is ambiguous at best.
Although the directive to ER doctors has been that they CAN use their own discretion to determine who needs to be tested, it's not unusual for a “chart audit” by someone not seeing the patient to determine later that the test will not in fact be run.
It's “crippling” she says, as they “don't know how to message this to patients.” Who calls the patient after they've left the ER, directed to quarantine until called with their Covid-19 result, to reveal that in fact the test will never be run? Talk about not meeting patient satisfaction expectations.
While test kits have become more available, the state laboratory is now “overcapacity and is closed to accepting new tests.” Even at the most efficient, this labor-intensive lab test “takes 3 to 5 days to result.”
With the state lab overloaded, private labs are stepping in but at what cost to the hospitals? She suspects this added cost (state lab vs private) is at least partially driving the hesitation to more liberally test patients.
Elective Means “Elective”???
She was also frustrated that the hospital was still doing elective surgeries and procedures like knee replacements and colonoscopies. All of the protective equipment being used will be VITAL in about 1-2 weeks when supplies run out. Hey, another idea. What about redirecting those staff to help out with the new triage process that needs to be enacted?
“Why are they being so cavalier?” she asked.
As this article says,
“The nation's largest hospital associations are pushing back against a recommendation from U.S. Surgeon General Jerome Adams that providers “consider stopping elective surgeries” until the coronavirus threat subsides.
“Our ability to respond to patients must not be prevented by arbitrary directives,” the American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, and the Children's Hospital Association said in a joint letter to Adams on Sunday.
Some hospitals ARE stopping elective procedures and appointments, with the goal of saving capacity for those who really need it.
But, the AHA seems to be hung up on technicalities, as they complain that there's not a clear definition of “elective” being given.
Canceling elective surgeries means a financial hit to the hospitals. But, why don't the hospitals do the right thing for public health and then do what the airlines and other industries do? They could ask for a federal bailout. They're too important to fail.
Again, she implores you to “stop doing elective procedures and use those resources and mind-share to start problem solving this minute on the more concerning problem.
“Does the image of moving deck chairs on a certain ship come to mind or is it just me?”
I sincerely hope these problems are isolated. I hope other hospitals are able to avoid these situations — or quickly improve once they find them.
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