Curbside Consult with Dr. Jayne 6/24/13

There are some days where I just have to shake my head. Today is one of them. I received some news from one of the hospitals where I moonlight. It was the kind of news that defies all logic, and especially in the era of healthcare cost cutting, makes you wonder what in the world people are thinking. In trying to process through it, I’ve decided that there must be some kind of extraterrestrial accounting system (not to mention logic) that only applies to hospital administration.

It reminded me a little of the starship Bistromath in Life, the Universe, and Everything by Douglas Adams. For those of you who aren’t sci-fi aficionados, the Bistromathic Drive is a propulsion system that “works by exploiting the irrational mathematics that apply to number on a waiter’s bill pad and groups of people in restaurants.” Read the full description — it’s good for a laugh. I always think of it when I’m with a group trying to figure out who owes what part of a check.

I’m not against hospital administrators. This is not an “us vs. them” rant. I understand they have to make the same types of difficult choices that all of us do in trying to deliver high-quality, cost-effective care to the right people at the right time. Some of my best friends are administrators. They seem to be between the proverbial rock and the hard place a good percentage of the time, especially those at non-profit and safety net facilities. How they juggle the competing requests for resources and determine how one priority takes precedence over another is often beyond me.

What did they do this week however that was so logically convoluted I had to take my jaw off the floor? The administration of a semi-urban safety net hospital decided to close the “quick care” part of the emergency department. I’ve written about my work here before, joking that we could provide more cost-effective care by stationing a well-trained Boy Scout with a first aid kit at the front door.

People come to this hospital for everything under the sun. I’ve worked on the express care unit for half a decade because the “real” emergency physicians don’t want to go there. Those of us that are board certified in other specialties enjoy the work because it looks a lot like a primary care practice although without a stable patient population.

Quick care has been doing its part to keep the overall ED wait times low. We handle all patients door-to-door in close to 60 minutes or less, which is amazing when you consider the population, their lack of follow-up, and the volume. The hospital is one of the busiest facilities in the region, which is why I was completely floored when I received notice today that the quick care unit was closing. Since this isn’t my full-time hospital, I had no idea it was coming. Worse yet, neither did the staff with whom I just worked last week.

The hospital has decided to take the unit and roll it into the rest of the ED. As another part of the cost-saving measure, they’ve decided to terminate the services of all the part-time physicians. Quick care patients will be handed by nurse practitioners and physician assistants embedded in the “regular” emergency department.

Why doesn’t this make sense? Several things jump out at me.

The physical quick care unit will be repurposed and the patients will be physically seen in the existing ED. This is a net loss of nine beds. The existing ED physicians will be expected to supervise the midlevel providers in addition to their normal shift duties. Nursing staff ratios will be kept the same and the quick care nurses were laid off as well. I almost cried when I realized that. These men and women are the rock stars of the ED, handling nine patients at a time and keeping the flow moving while doing the same level of documentation as the rest of the ED, often having to clean rooms themselves because of the lack of other support staff and sometimes taking care of really sick overflow patients still at a 9:1 ratio. They are hard workers who know just how to juggle patients to keep the visits under 60 minutes. Most of them have been in quick care for more than a decade.

It was this realization that led me to believe they must be using some kind of Bistromathic accounting. In this healthcare climate, who lays off nurses? Especially nurses who can juggle patients and flip rooms as fast as this crew? Who thinks they can just take an additional 50 to 60 patients per shift and funnel them into the ED workflow without drastically sabotaging the ED wait time statistics? And with nine fewer beds? I also wonder who thought the ED physicians would be game to supervise additional midlevels without compensation, which is part of the package.

I think there may have been a bit of sorcery involved as well because none of the line staff seemed to know this was coming. I’m sure the department chair and the nursing directors were in cahoots with the administrators and accountants, but the rest of the team sure wasn’t. Keeping a secret like that is pretty impressive. They managed to keep it quiet a good long time too, only showing their hand the week before the closing. I guess I won’t be bringing my famous chili dip to the July 4 shift party after all.

For those of us that don’t have regular shifts, it was like a death in the family – realizing that you may never again see people you’ve (literally) shared blood, sweat, and tears with. For the handful of staff that are losing their full-time jobs, it’s stunning. Maybe it will go better than I expect, although I can’t wait to see the next quarter’s numbers for wait time, patient satisfaction, and provider productivity.

I’m mourning for my colleagues and missing them already. I suppose it’s a good thing since I’ll have unexpected free time. But if you happen to need a skilled adrenaline junkie to pick up some shifts, give me a call.

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