Tuesday, September 16, 2014

One-fourth of bed alarms were broken before UCSD patient wandered away to his death

When Thomas Vera wandered away from UCSD to die in a nearby canyon in May 2013, executives across the University of California Health System were cutting positions of staff members who dealt directly with patients.

But those positions weren't cut because there was no money. The money was being shifted to administrators. It seems that the University of California's priorities have been shifting away from patient care to profit over the past several years.

But the greed of the executives and doctors at UC isn't the only factor at play in tragic patient deaths. I see another problem here, and we're all to blame for it. It's our refusal to talk about what should be done for terminally ill or injured patients. Sometimes hospitals are held hostage by families who demand miracles for their dying relatives. Losing a loved one is difficult, and some people can't accept the inevitable. They demand every test and treatment that might possibly give some short term benefit, and they even threaten to sue when their 95-year-old grandmother dies.

Few people want to talk about how to apportion health care dollars. The major exceptions to this are the vocal advocates of leaving large numbers of Americans without health coverage. In other words, these individuals want to let economics decide who should live and who should die. The advantage of this position is that it insulates its adherents from making specific choices about who should suffer or die. They want to let the market choose. Of course, the market is increasingly controlled by wealthy corporations and individuals who are taking a bigger and bigger share of the economy each year. The wealthy and their advocates apparently believe that fewer and fewer people should have health care.

Currently we spend an inordinate amount of money on the elderly during their last year of life, and, in particular, their last month of life. The truly disturbing aspect of this enormous outlay of healthcare dollars is that those who receive expensive hospital care during their final months have a lower quality of life than those who receive hospice or home care.

In the Archives of Internal Medicine, a study asked if a better quality of death takes place when per capital cost rise. In lay terms...the study found that the less money spent in this time period, the better the death experience is for the patient.

--Why 5% of Patients Create 50% of Health Care Costs?
Michael Bell

Obviously, if UCSD can keep the latest high-priced medical equipment in good repair, then it's perfectly capable of keeping bed alarms working. The California DHHS recently revealed some facts about the case of Thomas Vera, a UCSD patient who wandered into a nearby canyon and was found dead several days later:

State inspectors said the hospital failed to routinely test the buttons and failed to repair them when broken.

Prior to Vera’s disappearance, the most recent test had revealed more than 1 out of every 4 panic buttons at UCSD’s two main hospitals didn’t work.

--Broken Bed Alarm Blamed for Walkaway Patient's Death
By Steven Luke
NBC 7 San Diego
Sep 15, 2014

Is this the best that all these high-priced UC administrators can come up with? A patient dying of hunger, thirst and exposure in a nearby canyon? Obviously, UCSD can do better than this. AFSCME notes: "Care providers are forced to give special treatment to VIPs—so-called because of their wealth or relationship to UC administrators—at the expense of other patients."

It seems quite possible that Thomas Vera might not have recovered from his head injury even if he hadn't wandered away. He had apparently been in the hospital for weeks, too ill for surgery, and suffering from the delusion that he was being held captive in a garage in Texas. Perhaps he would never have become a good candidate for surgery. Would this man have had a better quality of life in his last days if he'd been in hospice care, or at home? It seems clear that he would have.

And would another person have benefited more from being in that hospital bed? It's hard to see how anyone could have benefited less than Thomas Vera did.

Perhaps UCSD administrators engaged in a chain of thought similar to these musings of mine when they created the situation that allowed Thomas Vera to wander off and die of exposure in a canyon. Did UCSD make a conscious decision to maintain expensive medical technology while neglecting low-tech life-saving gadgets for certain rooms?

The University of California has an enormous amount of political clout. Why not use that power for something besides making billions in profits from its health care system? Why not lead the discussion about how much of our health care resources should go to the terminally ill or injured?

A QUESTION OF PRIORITIES: Profits, Short Staffing, and the Shortchanging of Patient Care at UC Medical Centers
This report was written by AFSCME Local 3299 over the course of several months in 2012 and 2013. It is based on interviews with Local 3299 members employed at UC Medical Centers, reports by the California Department of Public Health, inpatient discharge data from the State of California’s Office of Statewide Health Planning and Development, as well as additional sources.

The public sees University of California Medical Centers as premier, world-class facilities. We rely upon them when our loved ones face the most serious illnesses because we expect them to provide the highest level of care. With the UC Medical System earning $6.9 billion in operating revenues and hundreds of millions in profits, it has the resources to do just that.

But recently, patient care advocates have witnessed something else: administrative decisions that prioritize UC’s profit margins over patients’ health. These decisions reflect a shift in values that reached a tipping point with a system-wide policy in 2011 that decentralized UC budget practices, and turned each medical center into an independent profit center.

This culture change is evidenced by a sharp rise in management salaries and compensation, excessive management costs, and unprecedented borrowing to construct new buildings.

Since 2009, management at UC Medical Centers has grown by 38 percent, adding $100 million to the annual payroll cost of management.

Debt service payments have almost quadrupled since 2006.

This diversion of patient care dollars results in management’s need to capture “efficiencies” to bolster profit margins.

While “efficiencies” can be positive, they can also have serious negative consequences. Often taking the form of aggressive cost-cutting measures, some translate into chronic short staffing, over scheduling of operating rooms, prioritizing “VIP” patients over everyone else, shortchanging charity care, and outsourcing essential services.

These degrade the medical centers’ core mission.

Care providers are painfully aware of administrative priorities that too often leave them unable to provide the care that patients deserve. Patient care workers suffer unnecessary stress and fatigue, and at times work without adequate training on the use of hazardous materials used to sterilize patient care areas. Some report being so rushed in their work that dirty patient care areas may not be properly sanitized before new patients arrive.

While workers are already feeling squeezed, the University is threatening to cut staff. At UCSF Medical Center, management recently announced its plan to reduce 300 hospital workers, or 4 percent of its full-time workforce. These reductions are being proposed at a time when the medical center is only just recovering from having to ration respiratory care services in January 2013 because of inadequate staffing levels. To make matters worse, the hospital’s CEO admits that, in his view, these cuts are needed, at least in part, to free up resources for new construction...

Frontline care providers give examples of how UC policies degrade safe staffing and patient care.

Patients often fall trying to go to the bathroom by themselves because short staffing delays staff response times. In one instance, a patient classified with “altered mental status” did not receive one-on-one attention and was found standing on a windowsill.

Chronic short staffing creates excessive workloads and stress. One nurse’s aide reports being afraid to take breaks because it would increase the ratio of patients to CNAs from 10:1 to 20:1.

The UC health system seeks to “re-align” Medicare and Medicaid patients to non-UC hospitals under the assumption that they often do not require the level of care UC provides.

Care providers complain about dirty patient care areas. An operating room assistant sees dried blood and fluids in the crevices of an operating table month after month...

Profitable high-level procedures get overscheduled, causing stress and exhaustion for care providers and delays for patients.

The State of California provides significant funding for the University’s Health System. In the fiscal year 2012-2013, it will provide approximately $300 million in public dollars for health sciences instruction....[Read more here.]

Broken Bed Alarm Blamed for Walkaway Patient's Death
Thomas Vera died after he became disoriented and walked away from his hospital room at UCSD Medical Center in May
By Steven Luke
NBC 7 San Diego
Sep 15, 2014

California Department of Health and Human Services records obtained by NBC 7 shed new light on what went wrong inside UCSD Medical Center when a disoriented patient walked away from his supervised room into a nearby canyon.

The [May 2013] lapse in hospital security led to a tragic search which ended when ...Thomas Vera’s body was found [several] days later less than a mile from the hospital entrance in Palm Canyon.

Family blames the hospital for allowing 58-year-old Thomas Vera, suffering severe head and neck injuries as well as [delusions], to leave the facility...

According to the CHHS investigation, Vera’s bed alarm never sounded. Vera was under video surveillance, and when nurses were notified, the report states they “attempted to contact security by paging security twice with no response and then pushing the panic button twice with no response.”

The panic button was “broken for 8 days,” according to the report.

State inspectors said the hospital failed to routinely test the buttons and failed to repair them when broken.

Prior to Vera’s disappearance, the most recent test had revealed more than 1 out of every 4 panic buttons at UCSD’s two main hospitals didn’t work.

“That’s incomprehensible to me. This is a big time, generally well thought of medical facility, and it’s like clown school” said legal expert Joel Brant, an attorney who specialized in elder care law.

[Maura Larkins comment: I don't believe they're clowns. They're clever, and they're calculating. The buttons were not a priority. UCSD pays huge amounts of money to maintain the equipment it wants to keep maintained. Were the walkaway patients paying full price? Were they a drain on UCSD financially?]

UC San Diego Health Sciences director of communications Jacqueline Carr released this statement in response to the incident:

“UC San Diego Health System underwent extensive internal and external investigations to identify the reasons that led to this tragic event...”

Fifteen months after the incident, CHHS says no fine or penalty has been issued as a result of the mishap...

Read more here.

Missing Hospital Patient's Body Found in Canyon: Officials
By Monica Garske and Dave Summers
Jun 1, 2013

The body of a missing hospital patient was discovered by search and rescue officials in a canyon Friday evening after an extensive search.

Chula Vista resident Thomas Vera, 58, had been missing since Monday. For the last several weeks, he had been a patient at the UCSD Medical Center.

Vera was admitted to the hospital after falling down the stairs at his home. He suffered a concussion and broken collar bone, according to his family, and was awaiting surgery...

Family, Cops Search for Missing Hospital Patient
By Brandi Powell, R. Stickney and Monica Garske
NBC 7 San Diego
May 31, 2013

A Chula Vista man, suffering from a head injury and broken bones, walked away from a San Diego hospital wearing only a hospital gown four days ago.

On Friday, San Diego police officers and family members spent all day searching canyons near Mission Valley for any sign of the man who officials say was likely disoriented and confused...

His daughter Tanya said Thomas last spoke with his wife on Sunday night.

"These are his words - he was being held in a garage in Texas - we're from Texas so he's thinking he's in Texas - that people were holding him against his will and drugging him, and so he was crying and telling my mom he was very scared," she said...

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