Many sides in health care debate

Leila Navidi

Sern Englestead sits in his recliner chair on top of a pillow in his home in Henderson October 12, 2010. Englestead developed a large pressure sore on his buttocks after heart surgery at Sunrise Hospital in January 2009. The wound is still being treated and has not fully healed.

By Sun Staff (contact)

Sunday, Nov. 21, 2010 | 2:01 a.m.

Do No Harm: Part Four

Launch slideshow »

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

See the results

• Explore the data on patient complaints with an interactive graphic.

Related documents

• See the source documents behind the project.

Share your stories

• Have you or someone you know been harmed in a Las Vegas hospital? Make your voice heard.

The Sun’s most recent installment in its series, “Do No Harm: Hospital Care in Las Vegas,” which examined the causes behind mediocre hospital care in Las Vegas, was a recent topic on KNPR’s public affairs program “State of Nevada.”

Joining the conversation with host Dave Becker and Sun health care reporter Marshall Allen were, among others, Larry Matheis, executive director of the Nevada State Medical Association, and Kathy Shafer, an Iowa nurse who was featured in the Sun’s story because of her experience at Sunrise Hospital and Medical Center in March while recovering from a broken hip.

Here are excerpts from the show, edited for clarity.

Shafer: My problem at the hospital started after I was sent upstairs after surgery. It took 12 hours just to get a pillow. They kept telling me, “We don’t have any.”

The second thing I remember is that when I woke up, the drainage bag that my catheter was draining into looked like a beach ball. It hadn’t been emptied in so long it was draining back toward my bladder. Me and my friends who were visiting pushed the call light four times before anyone came, but when they did, they left, saying it was not their job. They did not empty catheters.

Finally, one of my friends threatened to empty it on the floor, so then someone finally emptied it.

Becker: What was the problem with your leg?

Shafer: I tried to tell them my leg was filling up with blood. It kept swelling up and swelling up. And they kept telling me, “You just had hip surgery. It’s normal to be swollen.” It got twice its normal size. And my hemoglobin kept dropping. They didn’t know why and I kept telling them, “It’s the blood accumulating in my leg.” And not a doctor, not a nurse, nobody would ever check into it. I was so white, and my husband thought I was going to die.

Becker: Did you ever talk to a doctor, or to a fellow nurse?

Shafer: Yes. I kept telling every doctor and every nurse that I talked to that there was something wrong with my leg — it’s filling up with blood. We do total hip replacements at our hospital and I’ve seen enough legs after surgery to realize that my leg was not normal.

Becker: When you told your doctor this, how, what was the response?

Shafer: They said, “We’re checking into your hemoglobin. You need blood.” But I never got an answer that, “we’re going to find out where the blood is going.” Where was it going? Nobody bothered to check. Here’s where it was going: The underneath tissue was not properly closed, and it was just leaking.

Becker: Did Sunrise offer to fix your leg?

Shafer: No, because they denied that there was anything wrong with it. I had to check myself out of there against medical advice. They made arrangements for me to be checked into the hospital where I work in Iowa so that our orthopedic doctor could open it back up. He evacuated over a liter of clots that had formed in there from the leak.

Becker: So you had to go to Iowa to get this fixed.

Shafer: Yes, and Sunrise wouldn’t release me. They wouldn’t take out my IV; I took that out myself. They wouldn’t help me get dressed. They wouldn’t give me any papers for discharge. They wouldn’t give me a prescription for pain medication and they wouldn’t give me a card telling the airport that I just had this done in case my new hip beeped in the X-ray.

Becker: You’ve been (a nurse) for 28 years. Was the Sunrise team doing things differently than you would do for a post-surgery patient?

Shafer: Ignoring me and treating me like I was stupid. I wasn’t just somebody who came off the street who knew nothing about this procedure. Like I’ve said, we’ve done it many times before. And I never got smart with them — I just said the blood is accumulating in my leg. Nobody seemed to care.

Becker: Beyond being ignored, what would nurses in Iowa have done differently?

Shafer: We would have reported the different sizes of the leg, how it was changing every day. We would have measured it and then the doctor would have ordered a procedure to see what was going on. And if he thought it was swelling up and it was leaking inside, he would have opened it back up and repaired it.

Becker: Marshall Allen, what is the issue here?

Allen: I can’t say the specific reasons for Shafer’s treatment, but generally speaking Las Vegas is the only city of its size or larger in the nation without an academic medical center. And there’s not an emphasis on academic medicine in Las Vegas. Twelve of the 13 hospitals are privately owned. Nine of the 13 are for profit. And 70 percent of the beds in Las Vegas are owned by for-profit corporations.

For-profit medicine is not necessarily worse than nonprofit medicine, but it does decrease the emphasis on academic medicine, on best practices, on investing, on research and innovations that are going to create the type of patient safety programs where nurses are trained to listen to patients, for instance.

The push for profits also results in staffing problems, and staffing problems are one of the main complaints that I hear from the patients and from nurses. For whatever reason, they often don’t staff enough nurses per shift. Some people say that the hospitals are trying to save money by staffing too few nurses.

Becker: What do nurses in Las Vegas tell you?

Allen: They talk about how they are so stressed because they are so short staffed, that they are responsible for too many patients at a time, so they’re not able to give the patients the attention that they know the patients need. UNLV in 2005 surveyed nurses, and 65 percent of them said they were not able to give the patients the attention that they needed.

Becker: Did they agree that the hospitals had the kinds of problems that Kathy Shafer was just telling us about?

Allen: Yes, absolutely.

Becker: What did they suggest could fix them, or did they?

Allen: Hospital workers need to listen more. There’s a staffing issue, but if a patient is complaining about something directly, that needs to be addressed. At a certain point the nurses are responsible for what takes place, which is the bind the nurses are put in if they’re short staffed. But I have heard stories of incompetence by nurses, too. There are good professionals and bad professionals in any profession you’re in, and it may be Kathy had the unfortunate reality of having nurses who were not as competent.

Becker: Eric joins us on the phone from Las Vegas.

Eric (caller): Nice to hear about this being reported. My wife and I both work in the medical profession here in Las Vegas. She’s a critical-care nurse and I’m a doctor. My comments are really about the reporting from Mr. Allen in the Sun.

You interviewed patients with severe diabetes who were 400 pounds and complaining about wounds that wouldn’t heal. When you become 400 pounds and morbidly obese and are a diabetic, that’s what your life is like. It’s not the hospital’s fault.

Also, so many of these patients do not follow through with any of their outpatient care and the things that they’ve been told by the hospital, so you get frequent-flier people on diabetes who use the hospital as their primary-care physician. When they leave they’re told to go to a specialist, but they don’t go or take their medication. Then they come back three months later near diabetic coma. None of those things are addressed in any of these Sun articles. It’s just been sensationalized.

Allen: The patient was not 400 pounds, so I don’t know what Eric is talking about in that case. I selected cases that are black and white. A bedsore is considered a “never event” because they’re never supposed to happen. Medicare doesn’t reimburse for these things anymore because they are considered preventable. Eric can quibble about the cases, and there are always complications with patients — these are very sick people and I know they’re complicated to take care of — but to suggest that the cases we’re using are not solid is ridiculous. I run them by medical experts before I put them in the paper.

Also, this project is based on analysis of hospital billing records. I wish Eric could tell us what he thinks about 3,689 instances of preventable infections and harm that are identified in those records. These are hospital-acquired infections and injuries and things that are considered preventable that are taking place in the hospital, so it’s not like a few anecdotal patient stories that we’re trying to sensationalize.

Becker: Let’s go to Audrey, on the phone.

Audrey: I have been a nurse for 33 years, in Chicago and for the past eight years in Las Vegas. I am also a professor of nursing. The problem here is that the ethics are terrible. The other issue here is that because of the nursing shortage, they cut the curriculum in nursing schools, so that new nurses get clinical experience in their first year, and they’re only in school for two years now.

Becker: Larry, why are we seeing those kinds of problems?

Matheis: I think it’s a complex set of reasons. In Ms. Shafer’s case, she talked about five different parts of a hospital system and she had specific problems with each. It’s not one thing that can be done to address her experience and to make sure that experience doesn’t happen again. It’s going to require a team in the emergency department; it’s going to require a team in the surgical suite; it’s going to require a team in the rehab unit; a team in the recovery area. All of which look to the specifics of what went wrong in that setting, and then to set into place systems that will work to resolve it. So, in every in every anecdote you may find that there are multiple sources and multiple problems.

Becker: What are we doing with this information?

Matheis: That’s the biggest challenge. In reading the Sun’s series and looking at data and working on responding to where the system failed, where preventable illnesses are caused by the system itself — you lose perspective. Most care is appropriate. Most people get the care they need, leave and they are better off. Most of the care that’s provided is quality.

Southern Nevada is still a young community, and our health care system is still young. It doesn’t have 100 years of history and hasn’t developed a lot of things that communities and states that have much longer tradition have been able to do. We’re trying to backfill, and a lot of the problems come from trying to backfill. A lot of these problems are continuity care. You have understaffing where you have too few doctors, too few nurses. The handoff in monitoring how people are doing is harder and harder, and we all know it.

Becker: What’s being done to raise the bar so these events don’t happen anymore?

Matheis: When you have the information that something is gone wrong, you respond to it. You look and say, “Is that atypical, is that a unique situation in which case you handle the accountability one way?”

After we had the hepatitis C outbreak several years ago, we’ve been part of a national effort to look at injection practices that cause those kinds of outbreaks. There have been over a hundred of them nationwide and the CDC is changing how it teaches those things. They are setting standards.

The complexity of the health care system is such that you just can’t wave a magic wand and the system changes. You have to dig in, find the individual problem and where the system breaks down, and work on that. You raise the bar by committing to working on these problems and committing that over time they’re not going to happen.

Transcribed by Nadine Guy of the Sun.