Dear Karen, some thoughts on nursing

Home Health Columnist / Guide · Jan 2, 2002

oramar:

Please post articles name and I'll chek it.

Did you also see articles re UPMC selling it's HMO and Shadyside getting $20 million windfall?? i'll post later if interested.

oramar · Jan 2, 2002

The name of article on healthleaders is ... Arbitration cases reveal lapses in Kaiser emergency care, it is listed under LEGAL. I would love to see that article about UPMC, how did I miss that one?

Home Health Columnist / Guide · Jan 2, 2002

Cases Reveal Lapses in Kaiser Emergency Care

Health: Nine arbitration proceedings offer a rare look into HMO. It denies any pattern of negligence.

By CHARLES ORNSTEIN, TIMES HEALTH WRITER

http://www.latimes.com/news/printedition/front/la-000000280jan02.story?coll=la%2Dheadlines%2Dfrontpage

The Kaiser Permanente doctor who examined Harun Antwine had worked at least 10 hours that day, seeing 25 patients in his office and 15 more that evening at the HMO's Fontana urgent care center.

The swamped physician didn't spot Antwine's serious bacterial infection, and the 29-year-old patient left urgent care without antibiotics, Antwine's family lawyer says. The father of three young children died two days later.

"It was a classic case of failing to treat a patient [who] really needed it," said lawyer Gregory Patton, who won an $848,000 arbitration award from Kaiser stemming from Antwine's 1998 death. "Their doctors are really, really overworked." In justifying a $1.1-million fine against Kaiser, state regulators cited three patient deaths and said the cases demonstrated a pattern of problems in emergency care that has put the HMO's 6 million California members at risk.

Similar problems showed up in at least nine other cases since 1995--including Antwine's--in which arbitrators found Kaiser liable for patient injuries or deaths.

Although the number of arbitration awards is small, and Kaiser calls the cases anomalies, critics say they illustrate the same dangers identified by state officials: not enough staff and overcrowded facilities.

Kaiser, the state's largest HMO, denies that it has systemic problems and argues that the state's HMO czar, Daniel Zingale, has overstepped his authority. It is challenging the fine, which was imposed in 2000 and was increased last year.

Moreover, Kaiser said the arbitration awards reviewed by The Times should not be considered a pattern, given the millions of patients who seek care through the HMO.

"These cases are obviously things that everybody wants to pay attention to," Kaiser spokesman Jim Anderson said. "But to suggest anything other than that they represent [nine] individual medical malpractice cases is stretching a long way, we think."

Arbitration awards, though relatively rare, are among the few public avenues available for examining patient complaints against Kaiser. Dissatisfied Kaiser patients seeking damages must go through arbitration, because the HMO requires enrollees to waive their right to sue.

According to the nine arbitration summaries, Kaiser has been ordered to pay more than $3.5 million for lapses in emergency or urgent care since 1995.

That amount represents only a fraction of what Kaiser has paid out in cases that were settled and sealed from the view of the public and HMO regulators, patients' lawyers say. Kaiser has settled nearly half of its recent arbitration cases, records show.

The nine cases reviewed by The Times include those of:

* A 39-year-old diabetic woman who died after her chemical imbalance went undetected by an urgent care doctor in Lancaster.

* A 6-year-old boy who died in the hospital after the Kaiser urgent care center in Panorama City failed to diagnose a heart ailment.

* A 64-year-old man who died of an undiagnosed ruptured abdominal aortic aneurysm at the Woodland Hills urgent care center.

* A 41-year-old man who went to Kaiser's Panorama City emergency room, where his chest pain was attributed to yardwork. The man visited Kaiser facilities twice more before dying five days later of a heart attack.

Anderson said the nine arbitration awards involved different facilities, different patient symptoms and different outcomes. He said Kaiser has 11 emergency rooms in Southern California that see 800,000 patients a year and that many more people visit urgent care centers.

The arbitration cases also span a significant period of time, Anderson said. Though all were decided since 1995 and most involved incidents in the last decade, one dates to 1987. Arbitration cases can take years to resolve.

Kaiser argues that even if everyone does their best, patients sometimes die.

That, Kaiser claims, is what happened in the case of Antwine, the 29-year-old who died of a bacterial infection.

When the patient arrived at the urgent care center, arbitration filings say, he wasn't exhibiting typical symptoms of a strep bacterial infection. Even if he had been given antibiotics, the HMO said, Antwine would have died.

Critics say such cases should not be viewed in isolation. In fact, the state findings and the arbitration claims are, in some instances, remarkably similar.

Two of the cases won in arbitration involved patients who died of undiagnosed abdominal aortic aneurysms, the problem also found by the state in its investigation.

In their fine, state regulators cited the case of Wolfgang Spunbarg, a 72-year-old enrollee who went to the Woodland Hills emergency room in April 2000 complaining of severe pain in his abdomen and testicles.

According to the hearing testimony of Spunbarg's wife, Edith, she pleaded with the ER receptionist to have someone examine her husband immediately but was told that the ER was too busy and that she would have to wait.

About 15 minutes after arriving, she burst into the examination area of the ER and demanded that a doctor see her husband. Moments later, he fell unconscious; he died within two hours of an undiagnosed abdominal aortic aneurysm.

According to filings in a separate arbitration case, Gery Lichtig, 64, had gone to the urgent care center at the same hospital 13 months earlier, complaining of serious abdominal and back pain. As in the Spunbarg case, Lichtig's wife, Temah, pleaded with the receptionist to call a physician.

After being seen by a nurse, Lichtig waited 45 minutes, retching in pain, according to the arbitration filings.

On his way back from having X-rays taken, the documents state, Lichtig leaned back in his wheelchair and screamed, "The pain, the pain!" His eyes then rolled back, and he fell unconscious. He died less than three hours later, also of a ruptured aneurysm.

Temah Lichtig said the state's findings were like a horrible echo of her own experience with Kaiser.

"The state is so accurate in everything that they're saying," she said. "They're just calling it like it is."

Kaiser is challenging the $1.1-million fine before an administrative law judge, claiming that Zingale does not have the authority to regulate care provided by its hospitals and doctors. Testimony resumes this month in Oakland.

Defending the fine, Zingale said the California Department of Managed Health Care found that Kaiser doctors and nurses failed "to communicate . . . the seriousness of a patient's condition and the need for a rapid response."

He said some of the claims raised in the arbitration cases reviewed by The Times seem "of a similar nature to what we're looking at." But the cases were not cited in support of the fine because they alleged individual instances of medical malpractice, not systemic problems.

Several patients' lawyers said they did not allege systemic problems, because winning individual malpractice cases does not require proof of widespread flaws.

The plaintiffs' lawyers say Kaiser's problems are more extensive--and the real toll paid by the HMO is far higher--than the public record suggests. The awards obtained through arbitration reflect only those cases in which a verdict was reached, not those settled confidentially.

Kaiser declined to discuss the number of cases that it has settled or their amounts.

"There's systemic problems with everything they do," said Bruce Levenson, a Beverly Hills lawyer who represented the family of the diabetic woman who died. "I think they give you as little care as they possibly can. . . . They cut corners."

Anderson, however, said Kaiser is more likely than other HMOs to be targeted by arbitration complaints because it owns its hospitals and works primarily with one doctors group. As a result, patients associate quality of care with the HMO itself.

Kaiser is also more likely to face action related to the quality of patient care from state HMO regulators, as Zingale himself acknowledges.

But some lawyers and family members who have won arbitration awards against Kaiser say they only wish its flaws had come to light sooner.

"I want to help bring this awareness to other people so Gery's death will not have been in vain," Temah Lichtig said. "This man did not have to die."

Kaiser argues that he could not have been saved.

"People can do their very best and do everything right and do superhuman efforts, and the patient will still suffer a bad outcome," Anderson said. "That's just a sad fact of medical life."

Times researchers John Tyrrell and Scott Wilson contributed to this report.

MollyJ · Jan 2, 2002

Enjoyed this article much. However, I saw the articles right before Christmas about the Nurse Reinvestment Act, bills now in congress that are designed to recruit people into nursing and help with ed cost. I would be, of course, in favor of these bills, but I feel that these bills ignore the greater problems and that is that hopsital environments are becoming untenable, burn out factories where DOCTORS AND NURSES ALIKE have more data, more duties to process than is humanly possible. I thought about putting THAT in a letter to my legislators, one of which is a co-sponsor to the Nurse Reinvestment Acts.

Home Health Columnist / Guide · Jan 3, 2002

I feel that these bills ignore the greater problems and that is that hopsital environments are becoming untenable, burn out factories where DOCTORS AND NURSES ALIKE have more data, more duties to process than is humanly possible.

Molly, really like the way you phrased it above. tah's the problem in a nutshell. SO much more info to digest and regurg these days...sometimes we forget to LOOK at the patient. Got out of Critical care just when Swan + PA lines coming into vogue.

One of the reasons gave up wearing my nurses cap was so much equipment/IV lines around a vented patient, kept getting knocked off!

Numbers only tell so much. Told resident that patient didn't look right, thought he was dying by demeanor/pallor. VS normal and lab work drawn 30 min before was WNL. He scoffed at me. Sure enough he coded and didn't survive....that's when I learned numbers can be perfect but you can still die.

fiestynurse · Jan 3, 2002

"People can do their very best and do everything right and do superhuman efforts, and the patient will still suffer a bad outcome," Anderson said. "That's just a sad fact of medical life."

The point is that people can NOT do their very best when they are taking care of too many patients and are overworked and stressed-out! Sometimes I wonder if Kaiser worries about outcomes at all?!

MollyJ · Jan 5, 2002

FiestyNurse said:

Sometimes I wonder if Kaiser worries about outcomes at all?!

ONLY ON THEIR BALANCE SHEET!

Mijourney · Jan 5, 2002

Hi. Looks to me as if the "work smarter not harder mantra" doesn't apply in these cases. I think the fact is that this cliche only applies when you have ample staff to delegate to and of course, you're in a position and have the authority to delegate.

I agree with all the previous comments especially yours, oramar, in which you seem to imply that there has been tremendous difficulty in making a good marriage between providing quality patient care and applying business principles to that patient care.

We now have clear evidence of how severely complex it is to work from both ends. We try to work to excellence in patient care yet we have to constantly keep on our toes with health care business and politics. The way we're having to work through these relationships is indeed a recipe for disaster.

prmenrs, RN · Jan 5, 2002

I think that all of the things you've said are absolutely true--but don't you think that the root of ALL EVILS is the insurance industry?

Who's responsible for shrinking compensation? When I first started, we counted on the paying customers to balance out the freeloaders. No longer.

Patients could stay long enough to get WELL, not just long enought to get the IV out--if they don't go home WITH the IV! Not any more.

Between the insurance companies and the regulatory agencies, it's just not even fun.

Getting more nurses into the system would help if they didn't have too much to do, and too little time in which to do it, and all to keep the beaurocrats[sp] and CEOs happy! I'd like to keep the pats and their families happy instead.

What can be done to put some brakes on the REAL bottom line?

Mijourney · Jan 8, 2002

Hi. I don't think the roots of all evil is the insurance industry. I do think they have a big hand in the problem though. I think the fact that health care was last to the table in terms of conforming to the industrial mode has a great deal to do with the difficulties we're going through. It doesn't help our industry that many of us, including your's truly, have alot of difficulty conforming to the industrial or business mentality. As I pointed out earlier, it's been very difficult for many of us who entered health care before it officially became an industry to marry our bottom line with the bottom line of business. This may be true for those who came into health care the last 10 or 15 years. The largest percentage of people in health care I believe are still health care practitioners like nurses and doctors. But we're being hard hit from all sides by insurance companies and other members of the business community, the government, the legal industry, and the increased demands of the public. For obvious reasons, this explains why many of us have decided to pull out of health care or reduce our participation.

My opinion on people staying in the hospital long enough to get well is this. Hospitals are responsible for exposing patients and families to alot of germs as well as alot of impositions on personal liberties. I think that hospitals and other settings responsible for direct patient care should have enough staff so that patients and/or their family and friends could be educated on how to properly do self-care once back in the home. There's not enough staff in hospitals, in ambulatory care centers, in home care, in community health to ensure adequate safety, security, and care of the patient and family. That's just my two cents.