[golfing eagles]

And one more criticism----ALL of this should be explained to the patient. There is a lot less confusion when the patient knows what is going on and why. Unfortunately, this tends not to happen.

[Challenger]

Originally Posted by golfing eagles

I apologize for the length of this post in advance, but having read most of the threads concerning TVRH over the last year, I think we need to put some perspective on the issues.

First of all, if I were a lay person, my impression of TVRH would be horrible. Many of the stories, IF they occurred as posted, would be open and closed malpractice if there was any injury to the patient. But as you know, there are always 2 sides to any story. No one has to be lying, they just relate the story as they remember it, or as they heard it second hand. Just ask any LEO what they get when interviewing "eyewitnesses" and it's really the same thing. Also, someone who feels they had a "bad" experience is probably ten times more likely to post than those who had a "good" experience

Next, please remember that it is NOT the ER doctors and nurses who are creating a jammed ER and a long wait, it is the volume of patients. The nature of ER medicine is that you can be twiddling your thumbs one minute and overwhelmed the next. Someone above posted that no ER should be allowed to operate if they cannot handle the load. Ridiculous. No ER can staff for peak volume any more than a restaurant or grocery store. All ERs get stuck with 30-40% of patients showing up with non-emergent and non-urgent problems. Those patients will be triaged and have the longest wait. Everyone feels that THEIR problem is the most important case in the ER, but that is most certainly not true

Here are the top 5 patient complaints to hospital administration in Central NY:

1) too long a wait in the ER
2) too long to get a bed if admitted
3) too long a wait for the nurse to answer the call bell
4) the nurse/aide/MD was discourteous
5) the food is bad/cold

Sound familiar? Seen it on TOTV regarding TVRH?
I hope no one thinks that the purpose of opening TVRH was to provide the worst patient experience and the most sub-standard care imaginable?


When I evaluate a post with a complaint, I'm looking at it differently. Was the evaluation appropriate to the complaint? Were the correct tests ordered and correct treatments rendered? Was the standard of care followed? If something went wrong, then why? And what was the medical thinking?
This is called quality assurance, and every hospital has a QA committee. I know something about it having chaired one for many years.

The QA committee get tons of information to evaluate. ER wait times are tracked, so is the wait time for a bed, both in the context of # of patients signed into the ER and # of beds available. All medication "errors" are tracked, all patient complaints are evaluated, even the temperature of food leaving the kitchen and on arrival at the room is looked at. Now, you may get a letter that says something along the lines of "We're sorry to hear you were dissatisfied with your recent hospital experience and we are continually looking at problems and ways to improve them", but behind the scenes these complaints are taken seriously. The QA committee is responsible to report this information and suggestions for improvement to the Executive Committee--which by the way I have also chaired---and the Executive Committee along with the Board of Governors --which I also been a member of---is legally responsible to the State Health Department. All hospitals undergo a periodic review either by JCAHO or the State Health Department or both, and trust me, these are VERY SERIOUS evaluations.

So, to look a little closer at the post I quoted. As posted, this is unacceptable, but I would have many follow up questions, since it is impossible to evaluate the quality of care from the information given:

1) How long were the symptoms present before going to the ER?--if they were constant for 3 days, and the EKG was normal, it is highly unlikely to be cardiac in origin. More likely to be digestive in nature, Did they do pancreatic enzymes?, or a RUQ ultrasound? On the other hand, if the symptoms started within the hour, this is ACS (acute coronary syndrome) until proven otherwise

2) what did the EKG show, and was it looked at immediately by the doctor?

3) Did they run immediate Troponin I (cardiac enzymes), and since the patient was there 24 hours, 2 more sets and serial EKGs?

4) Did they give the patient an aspirin to chew on arrival. Did they give NTG? MSO4-?

5) I am a little confused by a cardiac unit admission after 24 hours. Everything that would be done in the CCU in the first 24 hours should have been done, then a determination of whether the patient is stable for a stress test or needs cardiac cath would be made. So, did it turn out to be cardiac, or was it cholelithiasis, or pancreatitis, or gastritis? Was it a kidney stone? Was it a herniated disc?

As you can see, there's a lot more that goes into this than the waiting time

In a perfect world, we all could walk into an ER, or urgent care, or a doctor's office and they would be waiting for us to arrive and instantly diagnose and treat us. Not happening, not in this world

Lastly, as far as never going to the TVRH ER again, beware of absolutes. If you have a life threatening injury or medical event at Spanish Springs, guess where you'll be happy to go, and be happy that it's there

Thanks Doc for this post. Unfortunately it will be forgotten by tomorrow and the next rant. I was on the board of a 300 bed community hospital for 17 years and Chairman for 4. The complaints about our ER were so similar to TVRH so that you could substitute the hospital name and not recognize which was which.
Hope you stay with TOTV so as to add some intelligent input to this forum that is so filled with less than accurate posts.

[dbussone]

Originally Posted by golfing eagles

And one more criticism----ALL of this should be explained to the patient. There is a lot less confusion when the patient knows what is going on and why. Unfortunately, this tends not to happen.

GE - I've selected this post rather than your longer and very detailed post several posts earlier. Just to save some space.

You comments are on target with two exceptions. You note that ER physicians and nurses are not the cause of jammed ERs. Generally this is true. However, if physician and nurse staffing is not altered to deal with higher volumes, they do become bottle necks. For example, if a hospital staffs the ER physicians at certain level during summer, and maintains that level in season, there is a high possibility of the docs becoming a cause of the waits and log jam. The same with ER nurses, lab and X-ray techs, etc.

Now this is not necessarily the fault of these professionals. It is more likely caused by management's failure to plan and staff properly. Having said that, management may well understand the problem, but may not be able to find sufficient staff in season to deal with the volume. Florida is a staffing nightmare for most hospitals when 50% of beds may be filled in summer, and the census might be 110% in season.

[Polar Bear]

I really don't know how TV Hospital's efficiency would stack up against others. But related to any single experience...

Don't forget about the possibility that it was simply a bad night. Nobody can predict bad accidents or sudden health issues. There might be a long stretch with very few bad occurrences. Then all you-know-what might break loose. That's the nature of random events.

Nothing can eliminate the possibility of unforeseeable events on a given night resulting in backups and delays...regardless of planning and staffing levels.

[golfing eagles]

Originally Posted by dbussone

GE - I've selected this post rather than your longer and very detailed post several posts earlier. Just to save some space.

You comments are on target with two exceptions. You note that ER physicians and nurses are not the cause of jammed ERs. Generally this is true. However, if physician and nurse staffing is not altered to deal with higher volumes, they do become bottle necks. For example, if a hospital staffs the ER physicians at certain level during summer, and maintains that level in season, there is a high possibility of the docs becoming a cause of the waits and log jam. The same with ER nurses, lab and X-ray techs, etc.

Now this is not necessarily the fault of these professionals. It is more likely caused by management's failure to plan and staff properly. Having said that, management may well understand the problem, but may not be able to find sufficient staff in season to deal with the volume. Florida is a staffing nightmare for most hospitals when 50% of beds may be filled in summer, and the census might be 110% in season.

I think staffing/recruiting might be a bigger problem given a large number of seasonal residents. But then management should bite the bullet--there are plenty of locum tenens ER docs, but the cost is higher. The other problem that can develop, although rarely, is a culture of negativism. The aides take their clues from the nurses and the nurses take their clues from the doctors. If the doctors feel overwhelmed and helpless to change the situation, it will tend to filter throughout the ER.

A tale of two ERs:

Beth Israel in Boston and Albany Med in NY---
The staff and doctors at Beth Israel were grumpy, slow to react, and overall lacked courtesy, even though it is acknowledged as one of the best hospitals in the world. Albany Med is just as busy, but everyone is cheerful and helpful. It's not a reflection on the abilities of either staff, but rather on the culture that developed, and apparently is allowed to continue

[ConnieNonnie]

hi from recent experience with my mom and dad, I think if
you arrive in an ambulance you definitely get top priority.
I have several experiences with our Village Regional Hospital,
and I am so relieved that they are here. You just need to
be persistant and say what you mean, but don't say it mean.

[rubicon]

Originally Posted by dbussone

GE - I've selected this post rather than your longer and very detailed post several posts earlier. Just to save some space.

You comments are on target with two exceptions. You note that ER physicians and nurses are not the cause of jammed ERs. Generally this is true. However, if physician and nurse staffing is not altered to deal with higher volumes, they do become bottle necks. For example, if a hospital staffs the ER physicians at certain level during summer, and maintains that level in season, there is a high possibility of the docs becoming a cause of the waits and log jam. The same with ER nurses, lab and X-ray techs, etc.

Now this is not necessarily the fault of these professionals. It is more likely caused by management's failure to plan and staff properly. Having said that, management may well understand the problem, but may not be able to find sufficient staff in season to deal with the volume. Florida is a staffing nightmare for most hospitals when 50% of beds may be filled in summer, and the census might be 110% in season.

dbussone; You referenced some of my thinking. Again I said that any business not ready to make reasonable accommodations for its customers/patients should not be allowed to operate. I am sticking to my belief and believe this is especially essential for a medical facility whose first rule is "FIRST DO NO HARM"

Overcrowded chaotic emergency rooms are legendary so much so that for years they have been portrayed in movies and TV sitcoms. One would believe that this would have been enough for medical providers to invent a newer and better model by now? Historical statistical data can provide valuable information for optimum staffing and newer yet safe protocols, etc. Short of a catastrophic event every emergency room should be able to reasonable accommodate patients

Indeed the Rashamon Effect may be an element of story telling but when you are placed in a corner in an uncomfortable chair with cramping belly pains dry heaves and continuing retching you can throw that theory out the window.

As you sit there you watch other patients who can barely hold themselves in their chairs expecting anyone of them to drop to the floor. And when you are the one in such pain and understand that triage is necessary, it however affords little comfort.

And while a medical person does and must remain somewhat callous concerning pain and suffering I do not believe they are barrier to a better and more responsive emergency room.

I lay the blame at the feet of bureaucrats medical, insurance government.


Hospital management , insurance interested in profit margins and government interested in controlling 1/6th of our economy. Some medical providers do cash only business because they do not want to deal with the red tape and I can't blame them.

I was asked to manage a facility that was a complete disaster..there go to guy. I negotiated a great transfer package and said I would accept provided they granted me the freedom in which to act and the essential funds to get the job done. With this clear understanding I accepted. When I assumed that position my customers told me to my face that we were the last place they would do business. when I left these same customers were telling me we were the first place they go to. The fix was easy the problem or would be problem is always the bureaucracy.

Personal Best Regards:

[graciegirl]

Originally Posted by ConnieNonnie

hi from recent experience with my mom and dad, I think if
you arrive in an ambulance you definitely get top priority.
I have several experiences with our Village Regional Hospital,
and I am so relieved that they are here. You just need to
be persistant and say what you mean, but don't say it mean.

I am stealing that very nice line.

[dbussone]

Originally Posted by rubicon

dbussone; You referenced some of my thinking. Again I said that any business not ready to make reasonable accommodations for its customers/patients should not be allowed to operate. I am sticking to my belief and believe this is especially essential for a medical facility whose first rule is "FIRST DO NO HARM"

Overcrowded chaotic emergency rooms are legendary so much so that for years they have been portrayed in movies and TV sitcoms. One would believe that this would have been enough for medical providers to invent a newer and better model by now? Historical statistical data can provide valuable information for optimum staffing and newer yet safe protocols, etc. Short of a catastrophic event every emergency room should be able to reasonable accommodate patients

Indeed the Rashamon Effect may be an element of story telling but when you are placed in a corner in an uncomfortable chair with cramping belly pains dry heaves and continuing retching you can throw that theory out the window.

As you sit there you watch other patients who can barely hold themselves in their chairs expecting anyone of them to drop to the floor. And when you are the one in such pain and understand that triage is necessary, it however affords little comfort.

And while a medical person does and must remain somewhat callous concerning pain and suffering I do not believe they are barrier to a better and more responsive emergency room.

I lay the blame at the feet of bureaucrats medical, insurance government.


Hospital management , insurance interested in profit margins and government interested in controlling 1/6th of our economy. Some medical providers do cash only business because they do not want to deal with the red tape and I can't blame them.

I was asked to manage a facility that was a complete disaster..there go to guy. I negotiated a great transfer package and said I would accept provided they granted me the freedom in which to act and the essential funds to get the job done. With this clear understanding I accepted. When I assumed that position my customers told me to my face that we were the last place they would do business. when I left these same customers were telling me we were the first place they go to. The fix was easy the problem or would be problem is always the bureaucracy.

Personal Best Regards:

Your last sentence is completely accurate. And on top of that, the bureaucracy never likes change.

At one time I was responsible for 4 hospitals in Las Vegas. We built a fifth and used its newness to try and improve processes that were creating bottlenecks to care. One of our fixes in the ER was to put a highly competent RN or PA right out in the ER waiting room. That RN was the first person to greet an incoming (non ambulance) patient. He/she made decisions about prioritizing care and told the patient/family where they were in the queue. All waiting room patients were updated by the RN frequently.

It seldom took more than 30 minutes for a patient to be seen by a doc. If the wait was expected to take longer, a non-emergency patient was told they might want to consider going to an urgent care center and given a printed list of alternative care locations.

The process worked so well we moved it into the other hospitals. Some ERs took it well and ran with it. Two ERs had to be dragged kicking and screaming into the future. All the ERs significantly improved throughput, handled increased volume easily, reduced door to door time, and patient satisfaction increased.

Compare that to the TVRH ER. A volunteer with no authority or medical knowledge is the only person whom a patient may see for hours in the waiting room. Rather than take patient data sheets back to the triage nurse (who is hidden in a room where he/she can't see the waiting room) as the patients complete them, the volunteer takes them back after gathering a few. The patient sheets are put in a pile in the triage room without regard to priority- because the volunteer can't make medical decisions.

One experience with the TVRH ER went something like this. My wife fell in the shower, badly fractured her ankle, and went to the ER by ambulance. Inside the ER she was held in a hall on a stretcher because the treatment rooms were all full. I was not allowed to stay with her, so I was in the waiting room. About two hours after arrival she was brought out to the waiting room in a wheelchair. She had not as yet received any tests or treatment and her ankle was not properly protected when she was moved to the wheelchair from the stretcher. After several more hours she still had not been seen so I insisted that the triage nurse come out to talk with me. More time passed before that conversation took place. As I recall it was about five or six hours before she finally had an X-ray. Still no pain med and not seen for that entire time by a doc. Finally she was admitted and moved to an inpatient room. It took several plates and numerous screws to repair her ankle in surgery a day or two later.

Now I know TVRH has built a larger ER, but architecture seldom corrects bad processes. Unless they make some significant changes in the way the ER is operated, things cannot improve.

[NYGUY]

Originally Posted by dbussone

Your last sentence is completely accurate. And on top of that, the bureaucracy never likes change.

At one time I was responsible for 4 hospitals in Las Vegas. We built a fifth and used its newness to try and improve processes that were creating bottlenecks to care. One of our fixes in the ER was to put a highly competent RN or PA right out in the ER waiting room. That RN was the first person to greet an incoming (non ambulance) patient. He/she made decisions about prioritizing care and told the patient/family where they were in the queue. All waiting room patients were updated by the RN frequently.

It seldom took more than 30 minutes for a patient to be seen by a doc. If the wait was expected to take longer, a non-emergency patient was told they might want to consider going to an urgent care center and given a printed list of alternative care locations.

The process worked so well we moved it into the other hospitals. Some ERs took it well and ran with it. Two ERs had to be dragged kicking and screaming into the future. All the ERs significantly improved throughput, handled increased volume easily, reduced door to door time, and patient satisfaction increased.

Compare that to the TVRH ER. A volunteer with no authority or medical knowledge is the only person whom a patient may see for hours in the waiting room. Rather than take patient data sheets back to the triage nurse (who is hidden in a room where he/she can't see the waiting room) as the patients complete them, the volunteer takes them back after gathering a few. The patient sheets are put in a pile in the triage room without regard to priority- because the volunteer can't make medical decisions.

One experience with the TVRH ER went something like this. My wife fell in the shower, badly fractured her ankle, and went to the ER by ambulance. Inside the ER she was held in a hall on a stretcher because the treatment rooms were all full. I was not allowed to stay with her, so I was in the waiting room. About two hours after arrival she was brought out to the waiting room in a wheelchair. She had not as yet received any tests or treatment and her ankle was not properly protected when she was moved to the wheelchair from the stretcher. After several more hours she still had not been seen so I insisted that the triage nurse come out to talk with me. More time passed before that conversation took place. As I recall it was about five or six hours before she finally had an X-ray. Still no pain med and not seen for that entire time by a doc. Finally she was admitted and moved to an inpatient room. It took several plates and numerous screws to repair her ankle in surgery a day or two later.

Now I know TVRH has built a larger ER, but architecture seldom corrects bad processes. Unless they make some significant changes in the way the ER is operated, things cannot improve.

Great post..

[patoonya]

I have experienced the same waiting three years ago and I see nothing has improved.

[JoMar]

I believe any expansion must be government approved and there are demographics that must be met. Requests and funding must be started years before approvals are granted. I would think, based on the growth curve of TV, the approvals are always behind that curve.

[dbussone]

Originally Posted by JoMar

I believe any expansion must be government approved and there are demographics that must be met. Requests and funding must be started years before approvals are granted. I would think, based on the growth curve of TV, the approvals are always behind that curve.

In FL, we have a partial CoN (Certificate of Need) program. Bed expansions must be approved but Outpatient facilities are exempt:

AHCA:CON FA

[rubicon]

Originally Posted by dbussone

Your last sentence is completely accurate. And on top of that, the bureaucracy never likes change.

At one time I was responsible for 4 hospitals in Las Vegas. We built a fifth and used its newness to try and improve processes that were creating bottlenecks to care. One of our fixes in the ER was to put a highly competent RN or PA right out in the ER waiting room. That RN was the first person to greet an incoming (non ambulance) patient. He/she made decisions about prioritizing care and told the patient/family where they were in the queue. All waiting room patients were updated by the RN frequently.

It seldom took more than 30 minutes for a patient to be seen by a doc. If the wait was expected to take longer, a non-emergency patient was told they might want to consider going to an urgent care center and given a printed list of alternative care locations.

The process worked so well we moved it into the other hospitals. Some ERs took it well and ran with it. Two ERs had to be dragged kicking and screaming into the future. All the ERs significantly improved throughput, handled increased volume easily, reduced door to door time, and patient satisfaction increased.

Compare that to the TVRH ER. A volunteer with no authority or medical knowledge is the only person whom a patient may see for hours in the waiting room. Rather than take patient data sheets back to the triage nurse (who is hidden in a room where he/she can't see the waiting room) as the patients complete them, the volunteer takes them back after gathering a few. The patient sheets are put in a pile in the triage room without regard to priority- because the volunteer can't make medical decisions.

One experience with the TVRH ER went something like this. My wife fell in the shower, badly fractured her ankle, and went to the ER by ambulance. Inside the ER she was held in a hall on a stretcher because the treatment rooms were all full. I was not allowed to stay with her, so I was in the waiting room. About two hours after arrival she was brought out to the waiting room in a wheelchair. She had not as yet received any tests or treatment and her ankle was not properly protected when she was moved to the wheelchair from the stretcher. After several more hours she still had not been seen so I insisted that the triage nurse come out to talk with me. More time passed before that conversation took place. As I recall it was about five or six hours before she finally had an X-ray. Still no pain med and not seen for that entire time by a doc. Finally she was admitted and moved to an inpatient room. It took several plates and numerous screws to repair her ankle in surgery a day or two later.

Now I know TVRH has built a larger ER, but architecture seldom corrects bad processes. Unless they make some significant changes in the way the ER is operated, things cannot improve.

dbussone:

Medicine is a science of uncertainty and an art of probability (William Osler)

The precursory comment every time a doctor is deposed or sworn in at a trial is "within a medical certainty"does.... Its an known unknown by many that medicine is not precise. Diagnostic testing are measured by their predictive values and likelihood...what I am leading to is that because of these uncertainties its all the more reason that administrative people need to get the heck out of the way between the relationship of doctor-patient.

To employees who work in such chaos day after day it soon becomes normal, "I am paid to do my job and I do my job". To patients in the waiting room its a mystery that these employees can't see what they see?

But administrative people ( medical insurance, government)maintain control for profit, bonuses, , power.

Let's us not forget those heroes who would be honor to handle your claim who force medical people to practice defensive medicine What a waste of resources and time. Clearly the tort laws need to be changed and given that medicine is imprecise its that much more important because many doctors may be held to a higher standard then is realistic

[dbussone]

Originally Posted by rubicon

dbussone:



Medicine is a science of uncertainty and an art of probability (William Osler)



The precursory comment every time a doctor is deposed or sworn in at a trial is "within a medical certainty"does.... Its an known unknown by many that medicine is not precise. Diagnostic testing are measured by their predictive values and likelihood...what I am leading to is that because of these uncertainties its all the more reason that administrative people need to get the heck out of the way between the relationship of doctor-patient.



To employees who work in such chaos day after day it soon becomes normal, "I am paid to do my job and I do my job". To patients in the waiting room its a mystery that these employees can't see what they see?



But administrative people ( medical insurance, government)maintain control for profit, bonuses, , power.



Let's us not forget those heroes who would be honor to handle your claim who force medical people to practice defensive medicine What a waste of resources and time. Clearly the tort laws need to be changed and given that medicine is imprecise its that much more important because many doctors may be held to a higher standard then is realistic

We agree.