Is Good Care Unachievable?

Sometimes it takes a real crisis to jumpstart action.

That’s probably what happened recently at one hospital in San Diego. I only know what I know from reading the local newspapers, but here’s the story in a nutshell, according to those accounts:

The hospital—a large, respected teaching institution—is threatened with losing reimbursement from Medicare and Medi-Cal (California’s version of Medicaid) because of serious violations which investigators say caused at least one death. The violations included putting patients “on hold” for 24 hours in the emergency department without physician oversight; delaying filling prescriptions in a timely manner; failing to prioritize the need for stat medications; failing to follow doctors’ orders in a timely manner; violating confidentiality of records; and failing to meet California’s mandated nurse-to-patient ratio.

Phew. Scary.

In one instance, a patient arrived in the ED with a low serum sodium. She signed out AMA, then returned the next day in worse condition. Lab tests showed her sodium levels had dropped even more, but IV saline was not ordered for about four hours and didn’t arrive at her bedside for another chunk of time. More than eight hours after the patient’s lab work was completed, the IV saline finally arrived at her bedside. Then—and this part is a bit horrifying—the nurse who received the IV was told to go on break. She left the saline on the bedside table and while she was gone, the patient coded and died.

When I read this, I had questions.

Why was the nurse told to go on break? Why didn’t she recognize that this was a bad time to take a break? Did anyone on the unit understand how serious the patient’s condition was? Was there miscommunication about the lab values? Why was there so much time in between the blood draws and the execution of orders?

I’m sure investigators had these and a lot more questions. In the end, among other things, the state team judged that all patients in that hospital were in immediate danger because the pharmacy was too slow to fill stat orders.

Then the feds were called in. They also laid a lot of blame on the pharmacy, and added that nurses weren’t prioritizing med orders; all were labeled “stat.”

Looking at the list of above violations, I also wonder how many of the problems might be related to the hospital’s failure to meet the state’s mandated nurse-to-patient ratio. We know bad things happen when there aren’t enough nurses on a unit and I don’t know why this hospital hasn’t been able to comply with California’s mandated ratios. Is it too difficult to get the nurses? Are they skimping on expenses? Is the hospital’s budget adequate for hiring the required number of nurses?

And the final question I have: Is this a story we’re going to hear again and again?

Nursing care in acute-care hospitals has gotten so complicated, multifaceted and paper-laden that I wonder if we’ve finally reached the point where good care is unachievable.

What do you think?