August 9, 2006

After 24 years at Haywood Regional Medical Center I have decided to resign from Haywood Emergency Physicians. I have done so, in part, because the Emergency Department has many serious problems which make it unsafe by any reasonable standards of care. I have a lot invested in the institution and so over the course of the last couple of years I have tried to have these problems addressed, using the established channels of authority. I am bringing my concerns to you in this manner because the established channels were ineffective.

When I say “by the established channels of authority,” I mean that these issues were brought up at meetings of Emergency Department Committee and the ED Practice Committee (now the ED Oversight Committee). I also brought them to the attention of HRMC’s Medical Director, the Vice President of Nursing, the ED Nursing Director, the Chairman of the Department of Emergency Medicine, the President and the current Chairman of the Board.

There is inadequate ED nurse staffing and many of the newer individuals are insufficiently trained in emergency nursing.

Emergency Department nurses have been charged with performing duties that were previously the responsibility of lab and special medicine technicians. It will be impossible for them to meet this expectation. It ‘s hard to see the value in using a more expensive resources (i.e., RN’s time) to accomplish tasks that technicians, by virtue of training and experience, can accomplish more quickly and at a lower cost. This radical departure from previous staffing patterns invites failure and poses unacceptable risks.

The nurses are over burdened by documentation requirements: The ED nurses spend more of their time documenting care than actually providing care. This fact that is not lost on the ED patients. An electronic record should reduce duplication of effort, yet as the system now functions important documentation must sometimes be recorded twice: (once for the Electronic Medical Records and another time by hand). Important information can’t be retrieved rapidly and reliably from the EMR.

The current Emergency Department Information System is, in fact, not functionally adequate in numerous ways and will never meet the needs of the department. No one doubts that all medical records will need to be paperless in the near future, nor that EMRs will be more efficient than paper. Unfortunately, despite a year of tinkering (which I suspect cost more than the system itself) the Meditech EDIS has introduced more sources of medical errors than solutions to them. No hospital has been able to fully implement the Meditech EDIS. A number of the problems listed here are a direct result of this archaic software.

Clinical information that is essential for patient safety is often erroneous or completely missing from ED patients’ charts, the most common omission being “Medication Allergies.” This poses enormous medical risks for the patients as well as legal risks for the physicians and the hospital. I can cite numerous specific examples of this documentation problem.

The Meditech EDIS time stamping function provides information that is susceptible to manipulation and falsification.

Dictation and conference rooms, built with funds that were raised during the Foundation’s “Campaign for Life,” have been assigned to other departments and serve functions unrelated to the legitimate needs of the ED. I have objected to this because:

1. The need for more than three dictation spaces (for the ED physicians, the hospitalists, and consulting physicains) still exists. Nevertheless the room that was built to accommodate that need is not available for use by any physicians. No justification has been offered.

2. The Emergency Department has long suffered from lack of space, within the department itself, for meetings and training sessions that can easily be attended by a majority of the nursing staff. Unfortunately the conference room in the ED built for this purpose has been ceded to the Radiology Department, again without justification.

3. As a long time supporter of HRMC’s Foundation, I believe that funds raised for a specific project should be used for that project. Doing otherwise amounts to a breach of public trust.

A 60-inch plasma TV screen that displays patient information can not be more important than having enough nurses, to any reasonable person
The citizens of Haywood County rely on the ER at HRMC to provide them with emergency care for life-threatening illness and injury. Depriving the professionals that work there of the resources needed to provide such care is a mistake for the hospital and the community it serves.

Even as new clinical pathways are being developed, existing approved departmental policies that give practical directions for the ED staff are ignored. In an institution with a high rate of staff turnover these standard operating procedures are vital to the task of reducing medical errors. They offer a practical guide which should be updated and made readily available to the staff. They may not improve the hospital’s health grade but they will help get the job done.

Decisions relating to the manner in which ED physicians provide medical care have been inappropriately assumed by administrative and nursing personnel. Some examples include:

Ready availability of basic supplies and equipment. Often surgical supplies are not at hand for life-threatening traumatic situations.

Medications available for treatment of patients in the department. Appropriate emergency medicines are not always readily available in situations of cardiac arrest and other life-threatening problems.

Patient discharge instructions. These are important to any physician’s ability to assure appropriate aftercare. Mr. Rice believes that he should decide what instructions are available, rather than the ED physicians themselves.

Despite expectations to the contrary, the number of patients per hour that can be treated in the Emergency Department has not improved significantly since startup at the new facility. This is not a safety issue but certainly reduces patient satisfaction. It’s hard to imagine how this could possibly happen. The department went from 11 beds to 14 beds and the ED nursing director asserts that the number of nursing FTEs was increased at least enough to cover three more beds. The ED physician coverage was increased soon after the move into the renovated facility (with longer shifts that overlap at the busiest times of day). Leaving the question: “how can the same people, doing the same job, in a bigger place, get less done?”

It should be clear to the reader by now that it is my opinion that the Emergency Department isn’t really getting the resources that needed for it to accomplish it’s mission.

As things stand, the Emergency Department is an accident waiting to happen, and the board has not lived up to its responsibility to oversee the way that an important part of the institution has been managed. As a result, patients will come to harm. Whether the hospital wishes to acknowledge it or not, the Meditech EDIS is worse than useless, ED nurse staffing is pitifully inadequate, and the current leadership, at every level, lacks either the will or the ability to turn things around. I would not have left if I thought otherwise.

Sincerely,
Michael T. Rey, MD