Sunday, Nov. 14, 2010 | 2 a.m.
Do No Harm: Hospital Care in Las Vegas, Part 4
- Why we suffer
- Flesh wound was so much more
- After sugery, an injury uncured
- Missouri family loses its rock
- Leaving hospital saved her life
- Where I Stand: Hospitals should examine what ails them, seek cure
- Overview of the Sun’s series on health care
- How to file a complaint
- Why Nevada’s nurses quit
Share your stories
Mediocre hospital care in the Las Vegas Valley, evidenced by thousands of preventable injuries, infections and deaths, can be traced to a few fundamental causes.
Based on a two-year examination of 2.9 million hospital billing records and interviews with more than 170 health care insiders and scores of harmed patients, the Sun found:
• The corporate push for profits sometimes trumps patient care and can create an environment where best practices give way to risky shortcuts. Nevada and Clark County have the highest concentration of for-profit hospitals of any state or urban county in the nation.
• Academic medical centers elevate a city’s health care because of their focus on excellence, innovation and research. Las Vegas is the only U.S. city of its size or larger with no such center.
• Hospitals suffer from staffing problems, both in numbers and quality. At one hospital, each nursing assistant was required to care for up to 26 patients at a time, an unmanageable number, and administrators were unresponsive to complaints by employees for months.
• Oversight agencies are either controlled by the hospital industry or inconsistent in their findings. One accrediting agency, for instance, praised a hospital for its transplant program even though the federal government disciplined the same program for an excessive number of deaths.
• Hospitals are required to report unexpected harmful events and to then learn from those mistakes. But hospitals sometimes cover up harmful incidents, in part because of fear of lawsuits.
The blame can be shared among hospital leadership, elected officials, regulators, doctors and nurses — all of whom, combined, have created a health care system that too often has turned patients into victims.
The most common complaint by patients is that they feel dismissed, disrespected or ignored. Too often hospital care lacks, of all things, the caring they expect.
The shortcomings help explain the findings in the Sun’s two-year investigation, which identified 3,689 cases in 2008 and 2009 where patients suffered preventable harm while under a hospital’s care.
The mishaps included patients being infected with lethal bacteria, falling and breaking bones, acquiring gaping bedsores and being injured during surgery, including one patient who suffered serious burns after catching on fire on the operating table.
In 356 of the incidents, patients died in the facilities.
In Nevada’s frontier mining days, the abundance of single men and high transiency contributed to a cultural ethic of independence, where people looked out for themselves, not the larger community.
A century and a half later, Nevada’s demographics have changed but not its libertarian foundation. As Las Vegas became the fastest-growing metropolitan area in the country, little philanthropic or public investment in health care occurred, and no one agency or organization assumed responsibility for developing a coordinated system of health care.
As a result, patient services are provided by a fragmented collection of special interests — doctors, nurses, competing hospitals, insurance companies and government payers. There is no overarching assessment of community needs and no integrated planning.
Instead, hospital care in Nevada is shaped by market forces — entrepreneurship, cutthroat competition and what’s best for the bottom line — says Larry Matheis, executive director of the Nevada State Medical Association and a former health division administrator. There is no real hospital system here, but rather an industry.
The hospitals were developed during the rise of corporate medicine in the United States. Out-of-state for-profit hospital chains entered Nevada, proliferated and reaped enormous profits. Twelve of the 13 acute-care hospitals in the Las Vegas Valley are privately owned, and nine are for profit.
According to federal records, 52 percent of admission days in Nevada in 2008 were at investor-owned hospitals, compared with a national average of 13 percent. State records show that for-profit corporations control 70 percent of acute-care beds in Las Vegas hospitals.
The out-of-state for-profit chains are responsible to shareholders, and their profits have been the stuff of legend. Former administrators, requesting anonymity for professional reasons, told the Sun that profit margins were as high as 25 percent at Sunrise and Valley hospitals in the 1980s.
In 1987, legislation required hospitals with profit margins exceeding 17 percent — Desert Springs, Valley and Sunrise at the time — to reduce billed charges. (These cost-containment efforts led the state to collect hospital billing data used by the Sun for its analysis.)
The legislation expired after several years and, a Sun analysis of state records has found, some Las Vegas hospitals have reaped robust profits in the past decade — 16 percent profit at Desert Springs and 11 percent at St. Rose Dominican Hospitals – Siena Campus in 2008 — although all the chains have struggled during the recession.
Although for-profit hospitals are criticized for prizing profit above patient care, others argue that the community should be thankful for their presence.
“There would be almost no hospitals here if not for the for-profit hospitals,” said Mike Walsh, a former administrator at Valley Hospital Medical Center as well as the county’s public hospital, University Medical Center. “They’ve invested a great deal of money to provide service for the community, and the taxpayers didn’t have to pay for the hospitals.”
The reliance on for-profit hospitals has, by some accounting, undermined any initiative to build academic medical centers in Las Vegas. (Some teaching occurs at UMC, but there is little research — a hallmark of academic medicine.)
The underfunded University of Nevada School of Medicine’s academic center is in Reno. Promises to develop a health sciences center in Las Vegas, pitched in 2006, have faded with the recession. There are not enough residency and fellowship programs to keep locally trained doctors in Nevada, and the best doctors in the country are not attracted to Las Vegas, in part because it lacks a reputation for cutting-edge health care.
Kathy Silver, CEO of UMC, said private hospitals are not “mission driven as it relates to research and academics. There is no room for that in the for-profit world.”
Most U.S. medical communities are more mature and have a deeper mix of public and private teaching facilities, Silver said, adding that such facilities exert peer pressure.
“It steps up the pace for everybody,” said Silver, the only Las Vegas hospital CEO who agreed to be interviewed by the Sun. “We seem to lack that here. In part that’s because there’s been a lot of dedication to building infrastructure that generates money.”
Ron Serino suffers with a bedsore he acquired in April at a Las Vegas hospital. Serino, 60, a retired Army captain, said there were not enough nurses and aides to shift his body to prevent the bedsore.
“I would ring the buzzer, and they wouldn’t answer it, up to hours at a time,” he said.
Although patients claim they were neglected, nurses say the problem is poor staffing, and they point the finger at budget-conscious administrators.
As is the case in most states, there are no specific nurse-to-patient ratios in Nevada. Staffing is flexible, depending on the number of patients and the severity of their conditions. Hospitals, however, are required by law to provide the individual attention that each patient needs.
But that doesn’t always happen. In 2008, state regulators cited Valley Hospital managers for having no system to staff nurses based on individual patient needs.
Indeed, when UNLV surveyed recent nursing graduates about what it was like on the job, at least three in four respondents said staffing levels were inadequate and they had no time to spend with patients. And 65 percent said the conditions were not conducive to safe patient care.
Thirty percent quit their jobs in the first year and 57 percent quit within two years, many complaining that administrators did not staff enough nurses to care for patients. Patient safety issues were cited in the UNLV study as the most negative aspect of the job and the most common reason for leaving.
A nurse who cared for up to eight patients at a time said on the survey: “The outcome for patient care was poor. I witnessed so many frightening events that I decided to quit after one year and transfer to another hospital.”
Another nurse noted, “The patients were wonderful, but I had so many I felt I wasn’t giving them the care they deserved.”
Academic studies cite poor nurse-to-patient ratios as a contributing factor in patient deaths and nursing burnout. A 2007 study published in the journal Medical Care linked insufficient staffing levels to patient bedsores, infections and deaths.
In 2009, eight of the 13 Las Vegas hospitals had high rates of postoperative blood clots, ranging from 40 percent higher than expected at Spring Valley to 95 percent higher than expected at UMC, the Sun found.
Nurses told the Sun that helping patients get out of bed to move around — which helps prevent blood clots and bedsores — is usually the first task lost when they are overworked.
Staffing problems prompted a state investigation of a January 2009 incident involving a patient on a ventilator at Centennial Hills Hospital. When a relative found the woman sitting in diarrhea, her feeding tube leaking onto the bed, she hit the call button to no avail. After waiting more than 20 minutes, the relative walked down the hallway, yelling into each room that she needed a nurse.
In the ensuing investigation, Centennial Hills employees said staffing levels were unsafe, with certified nursing assistants — who take vital signs, feed patients and take care of basic hygiene — responsible for up to 26 patients.
The chief nursing officer told the state inspector that employees had complained for three months about unsafe staffing levels, and a group of nurses met with administrators in March 2009 to discuss the problem. They were told the current staffing would continue, the state investigation found.
Clark County Commissioner Lawrence Weekly was the chairman of the UMC board of trustees when he told the Sun that he was uncertain if it was illegal for a hospital employee to leak private patient information to outsiders.
It is illegal.
Silver acknowledged that it’s difficult for lay people to understand the complexities of hospital care.
But that’s precisely where the Nevada Administrative Code places responsibility for providing quality care: with a hospital’s board. The boards are made up of physicians, administrators and community members who may sit on the board for political, philanthropic or business reasons, but have little knowledge of the intricacies of running a hospital.
A businessperson who sat on a hospital board in Las Vegas told the Sun that the boards provide the appearance of oversight but fall short. Community board members understand little about medicine, and the information they receive is carefully controlled by the CEO, the director of nursing and the chief of staff, the former board member said.
“The boards are soft, just soft,” the former board member said. “They’re just community people who don’t challenge the system, do their own homework or get immersed in the things they’re asked to decide on.”
Boards are just one part of the fragmented structure of hospital oversight. State, federal and accrediting agencies have jurisdiction over various aspects of patient care, but there is little coordination among them and no uniform standards or controls, sometimes resulting in conflicting findings.
Improving patient safety is also hampered by conflicts of interest. The federal government’s Centers for Medicare & Medicaid Services, for instance, contracts in Nevada with HealthInsight, a nonprofit consulting organization, to improve quality of care, transparency and other initiatives. But HealthInsight’s board is largely made up of hospital administrators and lobbyists. The board’s “consumer representative” is a physician, former assemblyman and newly elected state Sen. Joe Hardy, who favors limiting the amount of money patients can receive as the result of malpractice.
Thus, it’s no surprise that HealthInsight sometimes sounds more like a cheerleader for the medical industry than a watchdog.
Another quality-control organization, the Joint Commission, is paid by hospitals to provide inspections and accreditation, which creates an incentive for the organization to avoid harsh sanctions, especially considering the accreditation is optional.
Hospital lobbyists and officials tout the commission’s standards to assure patients they’re held to strict quality of care standards. But sometimes the commission’s findings contradict those of other agencies.
For example, Medicare threatened to stop paying UMC for kidney transplants in 2008 because its death rate was about twice what was expected. That same year the Joint Commission gave UMC its Medal of Honor for Organ Transplantation.
Also in 2008, the commission did not publicly report any infection-control problems at MountainView Hospital, awarding it its gold seal of quality. A month later, Medicare threatened to make MountainView ineligible for its payments because of its failure to adhere to infection-control standards.
Sometimes state legislators undermine oversight. It was known that the Nevada State Health Division, which licenses hospitals and investigates complaints made by patients, lacked enough inspectors to do the job effectively. In 2009, legislators addressed the problem by allowing fee increases to fund additional positions. But in October, the Legislative Commission’s Subcommittee to Review Regulations voted to not impose those fee increases, leaving the problem unresolved.
The health division has also been limited in assessing fines by Nevada law.
In California, health care facilities can be fined up to $100,000 if they put a patient in immediate jeopardy.
And then there’s Nevada.
When a woman wearing an oxygen mask was being prepared for surgery at Desert Springs Hospital in March 2009, technicians made two mistakes, according to a state investigation. They cleaned her chest with an alcohol-based solution but draped her before it dried, trapping the combustible vapors. The techs also failed to remove a pad under her body that had absorbed the flammable solution.
When the surgeon sparked the electric knife, the patient erupted in a fireball. She suffered second- and third-degree burns on her neck and chest.
The state fined the hospital the maximum allowed, $800.
Legislators increased fines in July 2009 but they have yet to go into effect. Future fines could be much higher for incidents where patients are harmed, said Richard Whitley, health division administrator.
NOT LEARNING THEIR LESSONS
The state tracks unexpected injuries in hospitals so lessons can be learned and mistakes won’t be repeated. Toward that goal, hospitals are required to conduct a “root cause analysis” to determine factors that led to an injury.
But Las Vegas hospitals have been reluctant to acknowledge shortcomings.
When the Desert Springs patient caught fire, the hospital violated its procedures by failing to call the fire department, a state investigation found. And the health division investigation was launched by the family’s complaint, not the hospital’s disclosure. The hospital has since submitted a plan to address the issues that caused the tragedy.
In 2008, a man received a call from Valley Hospital, saying his mother, who had Alzheimer’s, was ready to be discharged. As he walked through the hospital’s parking lot to pick her up, he saw her standing alone at the sidewalk as if she was going to cross the four-lane city street, a state investigation found.
The man took his mother back to her hospital room and reported her escape.
“Not again,” a nurse said.
The nurse told him that his mother had previously escaped, but he had not been informed, the state’s report said.
Valley Hospital’s records reported a different version of events, the state report said. Medical records said that when the son came to pick her up she was “in her room … reading the newspaper.”
The hospital’s risk management inquiry said the son had found his mother “downstairs” and that she “was OK and waiting for him.”
Summerlin Hospital Medical Center waited more than two years to report the suspension of a surgeon to the Nevada Board of Medical Examiners in 2006. Nevada law requires such actions to be reported within 30 days. The medical board said the hospital’s CEO apparently entered into a “nonreporting agreement” with the surgeon, which the medical board deemed contrary to state law.
And a March 2009 state investigation found that when an 18-year-old woman was oversedated at MountainView Hospital during childbirth, the facility failed, as is required by state law, to analyze or report it to the state as a sentinel event — an unexpected injury or infection that takes place in a hospital. The hospital’s vice president of risk management acknowledged that the facility failed to follow its policies. The hospital was not fined; the woman recovered.
Valleywide, hospitals appear to be underreporting to the state sentinel events, the Sun analysis of hospital records has found.
A state investigation prompted by the Sun’s analysis found patients suffered 342 preventable injuries or infections during the second half of 2009, while facilities reported only 44 sentinel events. Each of the 342 cases seems to fit Nevada’s definition of a sentinel event.
Bill Welch, president and CEO of the Nevada Hospital Association, has said that the fear of malpractice lawsuits leads hospitals to fight public reporting of sentinel events.
The fear of malpractice lawsuits also plays a role in discouraging hospitals from admitting mistakes to patients. Internally, Silver said UMC uses accidents as teaching opportunities. But the hospital does not usually initiate a discussion with patients and family members when something goes wrong, she said, adding that when conversations occur, the process is patient driven.
“There is this fear in the back of everyone’s minds: ‘Is this going to result in a lawsuit if we talk about this?’ ” Silver said.
What’s too often lost in hospitals’ fear of lawsuits and pursuit of profits is their fundamental mission — placing the needs of the patient first.
Toward that end, the Institute for Healthcare Improvement, an independent not-for-profit organization based in Cambridge, Mass., has campaigned for hospitals to more candidly and proactively examine their shortcomings.
When something goes wrong, the hospital should respond immediately, with transparency, an apology and accountability — first to the patient and family and next to the staff, the institute says.
“The risks of not responding to ... adverse events in a timely and effective manner are significant, and include loss of trust, absence of healing, no learning and improvement, the sending of mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media,” the organization says.
Dr. Peter Pronovost, a medical director at Johns Hopkins University and national leader in the health care quality movement, said reform begins when patients become the focal point — the North Star that guides the way health care is delivered.
In Las Vegas, the Sun’s findings suggest that other interests eclipse patient care.
Alex Richards contributed to this story.