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Wednesday, 25 April 2007 00:00

Haywood nurses frustrated by changes

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Editor’s note: A group of nurses who work at the Haywood Regional Medical Center Emergency Room recently contacted The Smoky Mountain News. They said that during the controversy over the firing of Haywood Emergency Physicians, which took place last December, their opinions had never been sought by hospital administrators and never publicized in the media. A group of several nurses spoke to us about their concerns. Since their jobs could be jeopardized for speaking to us, we agreed to grant them anonymity. HRMC Administrator David Rice was asked to respond the allegations, but he said a pending lawsuit by fomer emergency room doctors prevented him from doing so. Since this story is presented from just nurse’s side, we are printing it in the opinions section.

Sitting around the kitchen table of a modest Haywood County home after a day on the job, the emergency room nurses said they just wanted their opinions on the matter heard. Throughout the controversy surrounding Haywood Emergency Physicians and Hospital Administrator David Rice, the nurses said no one had sought out their opinion.

 

The nurses said they were reluctant to speak up, fearing their jobs would be at risk for doing so, but thought the issue was important enough to the public’s interest for their voice to be heard.

“In the past we have fought very hard for the reputation of Haywood Regional Medical Center. We have told our friends, our family, our patients that we had lots of confidence in the hospital,” said one nurse. “I don’t think there is a one of us now that would want our critically ill family member to go there.”

“If I had an MI (myocardial infarction) tonight, I would want them to take me to Mission,” said another.

•••

To begin with, the nurses said that Rice had wrongly portrayed the relationship between the nurses and old emergency room doctors in order to cast a bad light on those doctors. Rice contended that the doctors treated the nurses poorly. Hospital administration propagated the notion that there was nearly a “nurse-doctor war” in the ER, according to the nurses interviewed.

That is far from the truth, the nurses said. In fact, to a person they said they loved working with the former ER doctors.

“We had such a good working relationship with them,” said one nurse.

The nurses said they were helpless to rebut the claim of hospital administrators for fear of being fired.

“That’s one thing that pissed us off so bad, that they put out in the community we didn’t like the ER doctors. That’s lies,” said another nurse.

Hospital administration would tell the nurses that the ER doctors were bad-mouthing the nurses behind their backs at meetings.

“Rice has been trying to put a wedge between us and the doctors,” said one nurse.

The nurses also said they were asked by their superior to spy on the doctors and report anything they thought the doctors were doing wrong to help administration build its case.

•••

The emergency room nurses also said hospital administrators mischaracterized the treatment patients received in the ER. Rice publicly claimed that the ER doctors refused to implement protocols that guide the treatment of patients upon entry to the ER. Protocols are like an instruction manual that tells nurses what course of action to take when a patient shows certain symptoms.

For example, if a patient with a clearly broken wrist came in, the nurse can order an X-ray without waiting for the doctor. Rice claimed publicly the ER doctors resisted the implementation of such protocols. The ER doctors insisted otherwise — that they already had such protocols in place. The nurses shared the same story.

“We’ve always had protocols,” said one nurse.

“If somebody came in with a fracture you would order the X-rays. If we ever had a question we just went to the doctor and said ‘Here’s what it is. Should I do this or that?’” said another nurse.

The nurses said protocols also dictated everything from when to go ahead and start IVs or administer aspirin in the case of a suspected heart attack.

•••

The nurses said they miss the trust they had with the old doctors. They said the old doctors valued their opinions about patients.

“With our old doctors, I could walk up to anyone of them and say ‘I think we need to do whatever’ and they would say ‘Now why do you think so?’ and (Dr. Mark) Jaben, for example, would make you explain it and if you could explain your case he would do it,” said one nurse.

“They respected us,” said another.

The nurses said they miss their old doctors and are tired of all the new faces on a daily basis.

“For a lot of us this has been one of the most stressful awful things that has happened. It’s been like a death,” said one nurse.

There have been 22 different doctors rotating through the ER in the past two months.

“We are having a revolving door of doctors,” a nurse said.

The nurses never know who will be there.

“I had a patient ask me the other day what his doctors’ name was and I didn’t know,” another nurse said.

While Rice would not comment to The Smoky Mountain News on the hospital’s progress lining up a group of permanent doctors, Rice told The Mountaineer in March that five permanent, full-time doctors have already been recruited and would be in place by summer.

•••

The nurses said the transition to the new emergency room group has been rocky. For starters, the new doctors don’t use digital patient records. Instead, they do everything with paper charts, which makes patient care more cumbersome. The nurses were never given a crash course on the paper charts used by the new doctors, but instead were expected to pick it up on the job.

“The day they came, everything was new that day,” one nurse said.

The paper charts make the nurses’ work more difficult and slow down patient care, they said. The paper charts also provide far less information about patients.

The old ER doctors dictated all their observations about a patient into a dictaphone: symptoms, labs and X-ray results, diagnosis, treatments, medications, etc. A hospital transcriptionist typed it into the computer for everyone to access.

“I had everything the doctor knew. You saw a whole picture of the patient in a story form,” one nurse said.

In comparison, the paper charts used by the new ER doctors offer bare bones information.

“Nowadays we don’t know nothing,” another nurse said.

Detailed records are particularly important for critical patients being transferred to Mission Hospital in Asheville, nurses said. In the old days, nurses could access the doctors’ detailed notes on the patient from the computer, print them out and send them with the patient.

“Now I have to actually go talk to the doctor and say, ‘OK I know this is an aneurism. Is it dissected or not? Where is it?’ You have to go hunt them down and say ‘Tell me about this,’” a nurse said.

“It’s more work for us,” another said.

Paper-less medical records have been touted as a top goal by hospital administration. In one of the numerous justifications for getting rid of the old ER doctors, Rice claimed they were uncooperative in the hospital’s goal toward digital medical records. According to the nurses, the new ER doctors have moved the hospital backward in that goal.

“Way back,” said one nurse.

“Our paperless system now creates more paper than ever before,” another said.

•••

The paper charts used by the new ER doctors are proving frustrating for other doctors in the county. Patients seen in the ER often see a specialist for a follow-up visit the next day or later in the week. Any doctor in the county can access the hospital’s computer system and pull the patient’s file from their ER visit, including all the notes the doctor made on the patient’s condition.

But since the new ER doctors started using paper charts, that’s no longer possible. Instead, specialists seeing an ER patient for a follow-up visit have to call the ER and get the patient’s charts faxed over. The nurses are then bogged down pulling the charts and faxing them to doctor’s offices all over the county.

The new doctors also don’t enter prescriptions into the computer. They simply write the patient a prescription. If the pharmacy calls the next day with questions — they can’t read the doctor’s hand writing on a prescription a patient brings in, for example — the nurses have no record of the prescription in question.

“We had to say ‘We can’t help you. We don’t know who that is. We don’t have a record of it,’” one nurse explained.

To fix the problem, nurses started making photocopies of the prescriptions.

“One more step in our paperless system,” a nurse said.

So when a pharmacist or another doctor seeing the patient for a follow-up visit calls with a question about the patient’s prescription, the nurses once again have to track down the paper file and pull out the photocopy they made of the prescription. Under the old doctors, prescriptions were included in the computer system.

The nurses said workflow and protocols are constantly changing, but without formal communication from their manager. So some nurses use one system and others use another. Eventually, a change in protocol will filter through the staff, but the nurses feel like they never know what’s going on.

“It changes on a daily basis,” said one nurse.

“I felt like we had just entered the twilight zone,” said another.

•••

One reason Rice cited for wanting the old ER doctors gone was their resistance to using the hospital’s new computer program called Meditech.

Rice said the old ER doctors were uncooperative in using Meditech, and it was said that the new doctors would use the system. The spokesperson for the new group even said their doctors were already familiar with it and would be able to pick it right up.

That couldn’t be further from the truth, the nurses said.

“They came in here not even knowing how to use Meditech and expected us to teach them how to use it and print their stuff out for them,” one nurse said.

While Rice would not comment on this issue for The Smoky Mountain News, in an article that appeared in The Mountaineer in March, Rice said when the permanent group of ER doctors is on board, they would be trained on Meditech. It did not make sense to train the temporary doctors who were rotating through.

•••

Since the new doctors came, the hospital has opened three additional rooms in the ER without enough nursing staff to cover the rooms, according to the nurses.

The three additional rooms were a source of controversy between the old ER doctors and hospital administration, and were part of the ammunition Rice used in terminating the old ER doctors.

The ER has 17 rooms, but the old ER doctors were only allowed to use 14 of them. The old ER doctors wanted to open the extra three rooms, but nurses insisted they would be stretched too thin. The hospital refused to hire more nurses, citing the cost, and instead decided to keep the extra three rooms closed.

In making the case for getting rid of the ER doctors, hospital administrators blamed the ER doctors for not wanting to open the extra three rooms, when in fact it was hospital administration that was keeping those rooms closed by not adding the necessary nursing staff, according to the nurses.

When the new doctors came, the hospital administration promptly opened the extra three rooms.

“The old doctors asked for that and were told ‘no,’ we were not to open those rooms because we did not have the staff,” one nurse explained.

•••

Another argument Rice made for dismissing the ER doctors was that it would improve coverage in the ER. He said the old doctors refused to establish a protocol for when to call in an extra doctor — a trigger point when wait times reached a critical mass that another doctor would come in for back-up. The new doctors are actually providing less coverage than the old doctors, however. The new doctors are providing fewer hours of care a day than the old doctors were.

The new team has one doctor working from 7 a.m. to 7 p.m., one from 7 p.m. to 7 a.m. and a third doctor overlap from noon to 10 a.m. That’s a total of 34 man hours a day. The old doctors worked a total of 39.5 hours a day.

•••

According to the nurses, another lie that was propagated about the old ER doctors was that they walked out when their shift was over regardless of whether there were patients backed up. Rice told the hospital board this and the public.

When asked whether that was true, the nurses seated around the table answered no, emphatically shaking their heads in unison.

“That was just a bald-faced lie,” one nurse said.

“They hardly ever left right on time,” said another.

•••

Other concerns include:

• The nurses say far more tests — some of them unnecessary — are being ordered now than under the previous doctors.

• Patient wait times are being manipulated to make it look like the new doctors are moving patients through the emergency room faster than the old group, nurses say. To accomplish this, patients are being logged into the tracking system while still in the waiting room even though they haven’t been seen by a doctor, according to the nurses. Improving wait times was one reason cited by hospital administration for getting rid of the old ER doctors. Wait times are no better, if not worse, than before, the nurses said.

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