"Hallway admissions" at overcrowded ED, and professional risks of RNs talking to press

[klone]

Saw this article in Becker's this morning. As I was reading it, I was quite surprised to read this quote:

Kate Pugh, RN, a Montefiore ER nurse for five years, told the publication that on the busiest days, she typically treats up to 15 patients in the ER at one time.

"These are sick people," Ms. Pugh said. "Basically you're just running around putting out fires instead of giving quality care. This is not an easy fix. We just don't have space."

City Councilman Ritchie Torres sent a letter to the New York City Department of Investigation in August, urging the agency to "probe Montefiore's practice of placing Medicaid recipients in crowded hallways that neglect patient care," the report states. However, the prompt failed to change patient care techniques at the hospital.

Wonder if Miss Kate Pugh still has a job. Why would anyone besides the hospital spokesperson think it would EVER be a good idea to be quoted in the press, particularly about a shortcoming of the facility for which they work?

'Hallway admissions' abound at overcrowded Montefiore ER, nurses say

[Neats, BSN]

This hospital is one of the top 50 largest employers in the state of New York. This hospital was founded in 1884. Was known as a hospital for chronic diseases for many decades. The hospital has greater than 85000 inpatient admissions annually. In 2007 it received a 20 million dollar shared grant for arts and social services (donated from Bloomberg). The resident doctors there are usually 3/4th year students and actually run an internship/residency to serve underserved people.

In 2017 it opened a new outpatient medical complex (nearby) that is a 12 story medical center (same day surgeries available) but alas no inpatient overnight beds. It does however serve some of the most nations poorest communities in the US with their chronic care issues who have traditionally used the hospital as their doctor office...out of necessity, and perhaps not knowing what is available to them as far as healthcare services

.

In 2011 Nurses at this hospital agreed to a union settlement related to overstaffing and wages-the nurses received a $750.00 bonus, pay raise of 7.5 percent over a 4-year period. Nurses do not have to pay for their premiums for healthcare. (I would have demanded way more)

Boarding patients who cannot go home, moved to any area you can place them safely, who are too unstable to be discharged is an issue at a lot of hospitals in the US. Many hospitals fail to make significant changes to ensure a collaborative patient approach is being made across all departments, it usually is the ED calling department looking for a bed.... The days of round discharges should be made from the admit and units should be able to bridge orders based on patient presentation and if anything could have follow-up at an outpatient basis in lieu of staying one more day to get all things completed, the patient should be discharged with appointments already made at the hospital--their new state of the art outpatient medical complex. This way of thinking needs to change for faster patient access.

I applaud this hospital for taking care of some of the sickest we could ever see in an environment that has such high patient turnover and patient usage of using this hospital as their family provider again maybe out of necessity or not knowing healthcare access. Clearly there is a need for additional inpatient beds but until this happens we need to collect the hard data that "proves" what changes need to occur.

As an Administrator I do not think this nurse should lose her job because she spoke out this is how change happens. It just needs to be done in a more analytical way so the decision makers have the accurate data to move forward. When you see this rich hospital history I can only imagine the piece meal hospital renovations that has occur over the last 100 years and imagine they do the best they can. I am not siding with Administration nor the nurses...I think instead of reacting to the current day there should be some forward thinking on planner's part as to what really needs to change and if it includes diversions then so be it.

Lastly about Hospital calling Diversion status: When a hospital calls a diversion status it means the hospital is currently unable to provide care in an emergency-- ambulances are then asked to divert to other hospitals. It does not mean the hospital emergency room is closed, it is notification the current patient load is being exceeded to treat the patient in a timely fashion. The hospital may not refuse care if a patient is brought there (and many of these patient are brought in by cab/family or walk ins). With many hospitals in the past 5 years' diversions have been on the increase some rightfully so some not. Again diversion is mostly related to ambulances and then triage really kicks in. There really is no penalty and the Diversion is usually time limited.

We can all complain but what we need to do is join together and make some real vocal significant concerns about healthcare changes that are needed, directed to the right people who make those healthcare decisions, in a manner that is "civil" and provide real solutions. We should be able to decide what we need after all we are the ones in the trenches and our history of support has not been a good ride.

[klone, MSN, RN]

Whistle blower laws would clearly protect her. Just being quiet, drinking the management Kool-Aid and taking **** when your administration runs a facility in a way that makes it dangerous is not a way to change it. You know that, right?

Yes, I know that, thanks.

Whistleblower laws generally do not apply to talking to the press. They're meant to protect workers from filing complaints with regulatory agencies, CMS, etc.

[angeloublue22, BSN, RN]

This is why the system keeps getting away with it for fear of retaliation. Maybe more of us should be doing this, more people would be aware and try to make changes. Keeping quiet about system break downs and patient and staff safety doesn't seem to be helping in any way. Although, I probably would have done it anonymously. That is one brave woman.

[TriciaJ, RN]

Whistle blower laws would clearly protect her. Just being quiet, drinking the management Kool-Aid and taking **** when your administration runs a facility in a way that makes it dangerous is not a way to change it. You know that, right?

I don't have great faith in whistle blower protection. Remember the 2 nurses in Texas some years ago? Texas has whistle blower protection but that didn't mean the hospital couldn't try to retaliate. Just that the nurses eventually were vindicated - after a whole lot of stress and hassle.

[rearviewmirror, BSN, RN]

I remeber hearing about some nurse in my early career, that she was fired after whistle blowing. I questioned my preceptor if that was possible due to protection and she scoffed and said administration came up with couple of things like not writing her name on all the boards or something of those caliber to let her go. Not sure how true that was but saw plenty of times admin throws people under the bus, which is why I never trust the whistleblower protection, and yes if you must, do anonymously. Some people tend to think their hospital is on their side.... pfff not. They give me money, and I give labor.

[traumaRUs, MSN, APRN]

Interesting info. I do agree talking to the press carries risk. However, caring for 15 patients in a busy ED is risky too.

So....should we keep silent for fear of losing our jobs?

[klone, MSN, RN]

Interesting info. I do agree talking to the press carries risk. However, caring for 15 patients in a busy ED is risky too.

So....should we keep silent for fear of losing our jobs?

I think there are definitely less risky ways to go about whistleblowing or effecting change that would protect one's job. Unless of course that particular nurse didn't care about the repercussions of being quoted by name in the press, and had reached her personal "**** it" point, which I totally get.

[LibraSunCNM, BSN, MSN, CNM]

I think there are definitely less risky ways to go about whistleblowing or effecting change that would protect one's job. Unless of course that particular nurse didn't care about the repercussions of being quoted by name in the press, and had reached her personal "**** it" point, which I totally get.

I'm guessing that's probably what it was. Sort of a "what are they going to do, fire me and be even more short staffed?" kind of thing. But I agree it's unusual!

[JKL33]

She is a 2015 NOTY at her place. I can't help but find it somewhat admirable that someone being encouraged along the primrose path would speak out. Due solely to the enraged responses that can be readily observed when nurses press an issue such as this (or any real, actual safety issues) through internal means, I think our COE is a little light on reality in laying out the metered steps nurses should take in attempt to "promote resolution" of serious safety issues. In fact the chain of command itself sets individuals up to be targeted/pinpointed: By the time you're "allowed" to make a huge whopping stink through whistle-blower-type reporting, you're supposed to have already pressed the issue through multiple other (internal) routes. By then it would be well-known who is causing trouble. These issues appear to be very easy to squelch - that individual will lose their job in the process of going through the chain of command about something like this. So each person recognizing a bonafide safety issue (a truly big one that can't be fixed by ordering nurses to do x, y, z and pretending the problem is fixed) always has to make their decisions within these contexts.

We mostly think her action is crazy (or admirable) because we have been conditioned that this is wrong and that if we only comport ourselves professionally and take the right steps according to our COE, these types of problems get solved in a timely manner. I don't know why a staff nurse working in this situation would have any reason to believe that to be true, though. We have to remember that these issues were not unknown, this didn't crop up yesterday, and they aren't one wayward employee's perception. Everyone remotely familiar with this setting already knew of this issue - - and we can tell solely from this short article that there are obvious ways to at least temper/mitigate the problem that are not being undertaken. Easy example: The article focuses on the crowding and the obstacle courses. But the crowding is a separate issue from staffing. When working in a chaotic physical setting like they describe, one of the very first responses should be "all [more] hands on deck" - that's a no-brainer. That's why we are set up to mass text all ED employees to respond for any level of disaster, even relatively small. Well - - this situation is it, every day. And the response has been to apparently not take the big steps required to attempt to maintain safety.

Alternatives to what she did are not realistic from the standpoint of individual professional survival. If she gets fired now, everyone who knows of her action will know precisely why she was fired. There will be no making up BS about how this NOTY has suddenly been discovered diverting or has mysteriously become one of the worst nurses on the unit and thus needed to be fired or maybe just decided to resign in order to "pursue other interests."

Maybe we should inform/involve regulatory agencies more often and individually feel empowered to do so rather than reacting in a way that could be seen as a stunt - and maybe the reason we don't think those channels are effective is because very few individuals ever use them; I'll concede that possibility. But, as it stands right now, instances of individual reporting are, for various reasons, unlikely to change anything like this and it comes with professional risk that, although perhaps not as well-known, is quite real.

[Wuzzie]

True story, one time at the ED I worked we had so many patients in hall beds that someone called the fire marshal and reported a hazard. He was obligated to respond. Once there he determined that all of the cots in the hall impacted egress and administration was forced to find rooms for all the patients. Patient rooms that had been converted for other uses (like offices) were reverted back to their original purpose, dirty rooms were magically cleaned, administrative nursing staff had to remove their pristine white coats, don scrubs and actually be nurses. It was hilarious!!!

[Guest219794]

A couple thoughts-

his nurse is probably going to make out fine. For one thing, she is part of a union. For another, if they don't like the poor publicity from her speaking out, they really won't like what will happen if they fire her for that, or try some other sneaky nonsense to force her out.

"In August, Torres sent a letter to the city Department of Investigation urging the agency to "probe Montefiore's practice of placing Medicaid recipients in crowded hallways that neglect patient care.""

I think that the implication that this is done because these are Medicaid recipients is probably unfair.

[LibraSunCNM, BSN, MSN, CNM]

A couple thoughts-

his nurse is probably going to make out fine. For one thing, she is part of a union. For another, if they don't like the poor publicity from her speaking out, they really won't like what will happen if they fire her for that, or try some other sneaky nonsense to force her out.

"In August, Torres sent a letter to the city Department of Investigation urging the agency to "probe Montefiore's practice of placing Medicaid recipients in crowded hallways that neglect patient care.""

I think that the implication that this is done because these are Medicaid recipients is probably unfair.

Correct. A huge portion of patients at Montefiore (and at any other hospital in the Bronx) are on some form of Medicaid. It's a general overcrowding issue, not a private vs. public insurance issue.