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An ER Code Blue

The California Department of Health Services finds 'serious problems' in Dominican's emergency room

By Kelly Luker

IT ISN'T ALL THAT UNUSUAL FOR people to die in an emergency room. But a former head nurse in the ER at Dominican Santa Cruz Hospital says people may have lost their lives unnecessarily there. And a just-released investigation by the California Department of Health Services found that he could be right.

The state recently spent three days investigating alleged problems at Dominican. A 16-page report released last week documents numerous deficiencies.

Some critics say these problems come as the result of personnel cuts at Dominican which parallel trends in the medical industry nationwide. Those cuts, critics say, may have forced an otherwise excellent staff to be stretched too thin and dangerously overworked.

The state's findings followed a 22-page complaint filed by James MacColl, a nurse who worked in the Dominican ER for 10 years--seven of those years as a charge nurse. MacColl had alleged a series of serious errors he says he witnessed in the ER. The state corroborated several:

  • A CT bran scan was left unread for three days. This incident may have resulted in the death of a patient.

  • Volunteers, rather than staffers, were assigned to perform CPR on a 15-year-old drowning victim who later died.

  • A homeless man with a history of serious alcoholism-related health problems was released after 13 hours and not given proper social services referral.

    Albert Quintero, district manager of the Department of Health Services' San Jose office, says that not all of MacColl's original charges were corroborated. But his staff found reason for concern.

    "There are some serious problems here that concern the department," Quintero says. "It's one thing to have a documentation problem. It's another thing when someone fails to read a CT scan."

    Dominican public relations director Penny Jacobi declined to comment on the individual findings by DHS, noting that the hospital will submit a written "plan of correction" to DHS within 10 days.

    Impatient Advocate

    MACCOLL, WHO RESIGNED in February of 1996 and has worked at Sutter Maternity and Surgery Center for the last year, says he blew the whistle only after repeated attempts to notify hospital administration. He says his concerns were either ignored or met with anger by his superiors.

    Meeting after a graveyard shift at Sutter, MacColl talks about the events that led to his resigning from Dominican and eventually notifying the state of his concerns.

    Quiet and low-key, MacColl has been labeled a "disgruntled former employee" by Dominican administrators. But neither his former co-workers nor MacColl's stellar record suggest a typical ax-grinder. He enlisted for four tours of duty as a military medic--his first one in Vietnam when he was 18. He has since volunteered for five humanitarian missions with the International Red Cross to war-torn areas like Kuwait.

    Present and former co-workers describe MacColl as the classic "patient's advocate" and an excellent nurse.

    "It was not hard to buy into the mission values of Dominican," MacColl says of the Catholic nonprofit hospital's philosophy. But he says that as hospitals were swept into the growing competitiveness of the healthcare industry, layoffs increased until the personnel shortage became critical. MacColl's perception is echoed by numerous local critics.

    "What we're seeing as nurses is a rampant rush to cut costs," says Kit Costello, president of the nurses' labor union, the California Nurses Association. "Dominican is no different than other hospitals--we are looking at Draconian staffing cuts."

    Problems from decreased staffing in hospitals were documented last year in a Metro Santa Cruz article that showed clinical staffing rose only 5 percent nationwide between 1981 and 1992, while the average "acuity"--or illness level--rose 21 percent. That situation leaves short-handed nurses trying to juggle an increasingly larger, sicker patient load.

    "If you know what's going on, you know to never, never, never leave someone unattended [by family members or friends] at hospitals now," Costello says. "It's like a Third World country."

    The Business of Health

    ACCORDING TO FORMER Dominican nurse MacColl, problems at the hospital were aggravated by a business management model called CPI--or Continuous Process Improvement. Dominican vice president Roger Hite instituted the CPI model about four years ago. MacColl and several other staffers say they fear that their hospital is valuing "process over patients" under the program.

    "Roger changed the course of the hospital a few years ago when he went to CPI to measure quality," MacColl says. CPI "teams" were developed, and staff was expected to adopt a more business-oriented way of speaking about their industry. "Patients" were now "customers," and nurses, LVNs, doctors and administrators were now "associates."

    MacColl says he voiced concerns about the CPI model in a three-page memo to Starn, stating that "CPI has failed to address diminishing professional RN standards and a crisis of declining departmental morale." He wrote that many of the staff members were either unaware of what CPI meant or else contemptuous of the concept.

    Two weeks later, MacColl received a "standard" evaluation--a finding that his work was of average quality. In every previous evaluation, he had been rated as "outstanding."

    More problems arose, more memos from MacColl were sent to Starn. Finally, MacColl says, he turned in his resignation in disgust.

    In his complaint, on file with DHS, MacColl describes an ER patient with stroke-like symptoms whose CT scan was not read by the radiologist.

    The patient was discharged, then returned two days later with symptoms that had worsened. When the mistake was discovered, another CT scan was ordered that revealed serious problems, but it was too late--the 50-year-old patient died.

    MacColl also describes a stabbing victim who lost 3,000 cc of blood--about three-fifths of the body's total volume--because an inexperienced nurse could not get a piece of equipment to work. That patient also died.

    In another case, MacColl writes of a heroin-overdose victim who was brought to ER, and although a nurse notified a doctor several times, the patient was not seen. An hour later, the patient died.

    One of his most harrowing tales involves a homeless alcoholic who came to Dominican with acute diarrhea and maggot-infested sores. After receiving cursory treatment, he was released to the streets. Curiously, MacColl himself wheeled the man to a bus stop.

    After reviewing the state's findings, MacColl is cautiously optimistic. But he still does not believe the state has gone far enough.

    "The report is limited in several regards," he says. "It is especially timid in probing and vigorously pursuing the facts surrounding several patient deaths."

    Problems and Profits

    FIVE-YEAR RECORDS SHOW that Dominican has had substantially more complaints filed against it than two other comparably sized hospitals--San Jose's O'Connor Hospital and Columbia San Jose Medical Center.

    Even though many of the complaints against Domincan could not be substantiated, according to state records, Dominican still has had more substantiated complaints than the other two hospitals.

    Dominican may have a higher complaint rate, notes Quintero, because it has three facilities--the acute care hospital, the mental health unit and its skilled nursing facility, now located at the former Community Hospital.

    Since 1988, Dominican Hospital has been affiliated with Catholic Healthcare West, one of the health industry's quickly growing mega-corporations. CHW now owns 37 hospitals in California.

    Last year, CHW made $160.5 million in profits on revenues of $2.7 billion--roughly a 6 percent margin. But keeping a healthy profit margin now seems to require trimming fat--and sometimes those cuts draw blood, according to would-be reformers.

    "There are fewer and fewer ERs and the waits are longer than before," says Jamie Court, director for Consumers for Quality Care, a Los Angeles-based watchdog group. "We find more and more people turned away from emergency rooms.

    "That is one of the byproducts of the corporatization of the hospital industry."

    A physician's assistant who worked with MacColl--and who declined to be identified--concurs.

    "Dominican has one of the nicest ERs I've ever been in," he says. "We have excellent physicians and we have good nurses. But it's suppressed by management. You have a 'nonprofit' worrying about the bottom line."

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  • From the May 22-28, 1997 issue of Metro Santa Cruz

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