Working on killing floor--the ER

by Htun Lin

There is a daily calamity across America that does not usually make headlines. Unlike earthquakes and hurricanes, this calamity is purely man-made. It is the death and injury tolls in hospitals, especially emergency rooms, due to systematic neglect and substandard care. There is occasional outrage from grieving family members, and maybe even the once-in-a-blue-moon lawsuit over a wrongful death or injury. But this unnecessary toll is taken as business as usual.

For example, when Esmin Green, a 49-year-old mother of six, fell out of her chair after more than 24 hours in the emergency waiting room of King County Psychiatric hospital in New York City, hospital staff ignored her while she convulsed to death on the waiting room floor. In the end, hospital administration fired or suspended seven employees, including a doctor, two nurses, and two security guards.

This blame game may give some immediate satisfaction, but the problem of patients neglected and harmed by long emergency room waits is a national epidemic. It is a deliberate way to control costs by denying care.

Analysts claim the national epidemic of long ER waits is due to a "real shortage" of admission beds. Those of us who work on the frontlines of healthcare know that it is both real and imagined. Certainly HMO restructuring for the last decade has reduced not only the number of hospital beds but ERs and even hospitals.

As healthcare became a focus of a new round of accumulation for investors, HMOs not only deliberately divested their infrastructure but also deliberately cut back on their workforce by reducing the number of healthcare providers, from doctors and nurses to housekeepers. It's all about maximizing profit by minimizing cost.

As more and more American workers are denied health insurance, and as private clinics increasingly refuse to schedule appointments for patients on Medicaid, increasingly more people are appearing in the ER as healthcare of last resort. In poor communities like Oakland, the waits can be upwards of 24 to 32 hours.

HEALTHCARE DELAYED IS HEALTHCARE DENIED

A major cause of ER crowding is the hospital practice of "boarding" inpatients in the ER. These patients have already been admitted by doctor's orders, but due to deliberately short-staffed medical-surgical wards, they are unable to go to a floor bed. One recent study showed that critically ill patients who board for more than six hours are 4% more likely to die. The nurse-patient ratios in the ER can be as high as eight to one.

In California, Gov. Schwarzenegger failed in his attempt to scuttle the nurse-patient ratios which nurses had pushed through the legislature, but it doesn't matter. Hospitals can violate those ratios by simply bottlenecking the ER by "boarding" inpatients there. The ER is thereby used as a loophole around state law.

So, how does "ER boarding" work? Simply deny a bed for a patient. It's not that we've run out of physical beds, but there are no nurses and aides to go with those beds. Management huddles every morning to find new ways to cut staffing levels down to the bone: not replacing sick calls, canceling upcoming shifts, sending nurses home, or shutting down particular wards by instructing the charge nurse to refuse to take any more admits. It is a daily battle to place patients.

Patients are seen as adversaries both to managers and to some workers. They are reduced to a cost imposed on managers' budgets, or just another burden to my eight-hour shift, as we workers are all harried, overworked, and short-tempered. It's about self-preservation. Managers have to protect their budgets, and RNs become obsessed with their own particular workload. In the process, the patient loses.

LETTING WORKERS TAKE THE BLAME

Why are front-line caregivers giving in to "ER boarding"? A recent study by Doctors Meisel and Pines (see "Waiting Doom, how hospitals are killing E.R. patients," http://www.slate.com/id/2195851/) speculated: "Put yourself in an inpatient nurse's shoes. You are overworked, and your current patients need attention. You get a call from the ER, saying that a patient like Green is ready to come upstairs. The bed is clean and ready. But you have 20 more things to do before your shift ends in two hours. You won't get in trouble for stalling, because no one really measures how long patients stay in the ER. So you tell the ER nurse that the bed isn't ready yet."

This is called "bed hiding," and it is a national epidemic in hospitals across America. We are so inured to substandard care as the norm that we spend time documenting non-care, i.e., why a patient isn't placed within the 24-hour legal deadline, instead of delivering care. It is the system that sets us up for failure. We must refuse to be unwitting accomplices.

We must find a way not to harm the patient in the course of this protracted battle over labor time. Our ultimate goal in healthcare work must be finding a new vision of healthcare labor, which promotes health, not capital's expansion.

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