Emergency and health care system challenges in our midst

Debra L. Glasser, M.D.

PHOTO BY GLORIA TOWNE

To focus on the state of emergency medical care in Thurston County, I have met with a member of the state House of Representatives and the top area leadership for Providence Swedish.

It is sadly clear that our healthcare system is broken on many levels. The problems, which are deep and wide, affect emergency access and timely care.

It is apparent to me and nearly everyone I have connected with since writing and recruiting readers this weekend that:

Healthcare challenges are inextricably related to societal challenges

>The corporatization of businesses has left us bereft of the kind of personal and caring service we knew 50 years ago when businesses were small.

Private medical practices succeeded when patients were treated with quality care and felt they mattered to those caring for them. Employees stayed for the same reasons. In those days (before monopolies and corporatization), there were also more choices.

Everything in business and healthcare was more personal (high touch vs. high tech).  

>Technology has further eroded personal service and caring. People need to be touched, seen, and made to feel they matter. That is respectful and humane. My 80-year-old friend was recently handed an iPad to sign in to her new doctor. The young receptionist was (at best) naively unaware that such a device was bewildering to her elder patient. Someone in charge of that clinic came up with this ‘resource-saving’ process that discounted the practice’s real resource, the patients.

>Staffing issues are universal (restaurants, clerks in stores, everywhere). Morale and personal appreciation are not like they were when businesses were small and employees felt integral to the business’s success.

>Lack of planning

Our society and institutions did not plan for the influx of baby boomers who are now senior citizens and as such, have the highest need for healthcare. Caring for our elderly challenges every aspect of the system, from staff to beds, from nursing homes to hospitals.  Short-term bottom-line thinking is what got us here.  It will not get us out. Solutions need to look at the big picture and the long range.

>Our culture has not invested resources for our sick, elderly, and those suffering from mental illness.  The healthcare system is strained as a result.  

I appreciate that Darin Goss, CEO of South Puget Sound Providence Swedish, and the Director of Nursing Suzie Scott took the time to meet with me in person. I learned a lot.

>The Providence Emergency Department (ED) is a bottleneck

Providence St. Peter Hospital ED sees an average of 200 patients/day. I was astounded to learn that 22% of patients coming to their ED require hospital admission. The availability of Urgent Care Clinics in the last 8 years has increased the acuity (i.e., severity) of those coming to the ED. 

Finding beds for those patients is the bottleneck.  Why? On an average day, there are ~35 hospital beds being taken up by “difficult discharges.” It is not uncommon for up to 10 of the ‘admitted’ patients to be housed in the ED ‘hallway’ for days up to a week.

Mr. Goss explained that the ED backup (long triage and waits to be seen) is a thru-bed problem due to difficult discharges and transfers, like a conveyor belt backed up.

Difficult discharges are in part, a result of the shortage of beds for the elderly and chronically ill to go to for rehabilitation (e.g., skilled nursing facilities) and long-term care.  

>Mental illness has always been the poor stepchild of medicine.

The mentally ill are waiting both to be cared for and as well as discharged safely.  The Providence ED sees 10-20 mental health patients per day, many of whom require hospital admission, some too complex for their 14-bed psychiatric unit that is always full, and the South Sound Behavioral Health Hospital in Lacey.

Our society and those suffering are paying for this neglect now. Addiction, depression, psychosis, and anxiety are equally as life-threatening and life-depreciating conditions as physical illness and affect a disproportionate share of our young people. Some of these patients are admitted to a hallway holding zone in the ED, not a comforting environment to say the least. Others lay dying in the ICU as a result of addictions.

>Healthcare staff are overwhelmed, overworked, underappreciated, and feel they have no voice in the delivery of care. The wage of staff RNs compared to that of traveling RNs poses a huge challenge worthy of a column. Many doctors and nurses retired or left their careers early after the additional overwhelm of COVID-19.  Morale and resilience in current staff are strained, as I witnessed the night I spent in the ED with my son.  

The Administrators shared that their current RN staff is young (and thus inexperienced) with a lack of mentors. Recruiting RNs and retaining the ones they have has been challenging, compounded by the national nurse shortage. Nurses’ aides could offload some of the RN’s responsibilities, but are hard to come by as they are in demand in all care situations.

Mr. Goss shared that Providence Swedish leadership is working on solutions:

1 - They support a Medic 1 team (ambulance EMTs) to oversee care for up to 4 ambulance patients in the breezeway of the ED waiting to be triaged and assigned to an ED care team.

2 - Providence has partnered with Interfaith Works and Thurston County Public Health to support four beds in the REST program for the homeless (along with two beds supported by MultiCare) being discharged from the hospital.

3 - St. Peter’s Hospital at Home program is a temporarily funded federal program that has allowed 200 patients to receive hospital-level care in their homes in the last two years. This has freed up hospital beds. They hope the federal government’s current one-year mandate for this successful program will be extended indefinitely.

I was privileged to have a conversation with State Representative Jessica Bateman and learn what the legislature is doing to improve medical care.

It turns out they are doing a lot.

They are dealing with ways to improve the healthcare workforce through training incentives and salary improvement. The legislature is exploring a myriad of ways to fill the need for nursing instructors, nurses’ aides, and all levels of nurses. (As is Providence with their nurse’s aide to RN incentive program).   Recruiting nursing instructors has been challenging for reasons being addressed, impairing efforts to replenish the nursing workforce.

She and colleagues have introduced legislation to increase Medicaid payment rates to adult care homes to reflect the true costs so they can both stay open and hire caregivers at a living wage.

A Work Group is collaborating with the Departments of Health and Human Services and the Healthcare Authority focused on the “Difficult to Discharge.” The state Office of Financial Management is currently in the process of assessing our state’s need for hospital beds. Ms. Bateman was distressed to learn that the Department of Health has not completed its rules process to take trauma center applications.

Kudos to Representative Bateman and her colleagues on the Healthcare Committee and all collaborating WA state departments for their efforts!

No longer is the ED a place for the acutely ill and injured to obtain care promptly.

Like Rep Bateman, I am interested in “Innovative near-term (i.e., ASAP) solutions” for emergency care in our community.

Even after learning all that I have, I still believe that innovations to improve TRIAGE, PAIN MANAGEMENT, and TIMELY access to care are possible even while tackling deeper and broader problems that will involve lag times of different lengths.

I am in touch with nurses who work in a variety of Providence departments who feel that successful STAFF RETENTION strategies have not been prioritized. It was my experience working for Providence that top-down business-focused management did not enhance staff satisfaction, retention, and resilience. I feel this strategy neglects a wealth of ideas for potential solutions from the many dedicated and wise professionals they employ and work ‘on the ground.’ Feedback from the community about the challenges they have faced in this busy ED could offer much as well.

Meanwhile, we wait with some hope for the improvements coming down the pike

AND I re-iterate to my readers:  

Advocate for yourself and your loved ones while navigating the healthcare system. Please take care of yourself, keep your balance, do your best to avoid falling, and stay clear of the ED if possible!

Debra L. Glasser, M.D., is a retired internal medicine physician in Olympia. Got a question for her? Write drdebra@theJOLTnews.com