Does Size Matter?

“You are asking the wrong person,” said the restaurant owner and hostess. “They almost killed my grandson. He had a facial laceration. The doctor ordered ketamine for sedation. The nurse in the ER injected the entire vial – 100 times what was ordered. My grandson stopped breathing.

“Thank goodness the physician knew what he was doing. He put him on a ventilator right away” she continues. “We later found out the nurse was one of those contract nurses. Nurses I know around here don’t want to work at that hospital.”

Your medical scribe was dining outside Orleans Parish. The small hospital under discussion was heavily dependent on agency nurses, according to the healthcare savvy grandmother. A high percentage of such rent-a-nurses usually signals a weak hospital. Permanently employed nurses are the lifeblood of a hospital. Good nurses attract good physicians and vice versa.

Physicians hear hospital horror stories on a regular basis. Many spill over into non-medical cocktail parties. Whether large or small, hospital size is no immunization against less than optimal care. Just recently I had a patient with a lung resection for cancer by a surgeon tops in his field. The surgery was successful with cancer-free margins and negative lymph nodes. The oncology surgeon was all over her like gravy on grits before surgery. After surgery, he put on a Houdini-like disappearing act.

A first year resident was the only physician who examined her post-operatively. A couple of days post-op, one side of her neck blew up like a balloon. The young resident told her she would be going back for urgent surgery that afternoon to fix a herniated lung.

Fortunately the missing-in-action surgeon did look at her chest X-ray and scratched the return to surgery. The problem was a simple air leak that healed on its own.

Hospital doctors often repeat unnecessary tests because it’s quicker to reorder the test than to call the patient’s primary care physician. A clinic nurse takes a call from a home health agency concerning a leukemia patient with high fever and orders a blood culture instead of the urgently needed hospitalization. An oncologist orders the wrong chemotherapy drug. A newborn baby is dropped in the delivery room, sustaining permanent injuries.

And the war stories get more serious when people die, though I’m the first to acknowledge that physicians as Monday morning quarterbacks often lack full details on what goes sour. For example, did a woman really die of sepsis because the hospital-employed urologist would not come out in the middle of the night to remove an infected kidney stone? Would the elderly man with severe pneumonia still have died after the hospital doctor missed a diagnosis of Legionaire’s disease for weeks until the family requested an infectious disease consultation?

Even physician colleagues are not immune recipients of bad outcomes. A top-notch surgeon with a national reputation does an outpatient procedure on a physician and hands him off to the post-operative care team who may or may not have missed important signs of problems. Regardless, the physician is sent home the same day, hemorrhages and dies.

Each time a patient is “handed off,” the chance for a fumble escalates. Chairman George, a nickname given Dr. George Burch at Tulane Medical School years ago, wrote: “The practice of medicine by teams, an ever-increasing trend, reduces to practice by committee. Personal attention and responsibilities to the patient are lost. The treatment you get depends on the doctor you have. Patients and their families need one doctor, not a committee, not an institution or a building” (The Celestial Society by Vivian Burch Martin).

Being everything to everybody is still a tough task for smaller hospitals. Efficiently staffing an emergency room, operating suites, intensive care units and floors of hospital beds inhabited by patients from cradle to grave is a big order. Our only tertiary metropolitan hospital providing inpatient care on the same physical campus for everything from birthing babies to complex cardiac and neurosurgery procedures to provision of psychiatric services is East Jefferson Medical Center.

Touro Infirmary only has cradle to grave care if there’s no need for psychiatric hospitalization. They closed their once well-respected psychiatric inpatient unit several years ago following a Medicare investigation over an arrangement with a community psychiatrist who’s now in jail. What was once the largest obstetrical operation in the state migrated from Charity Hospital to Touro after Medicaid reimbursements for childbirths made care of the uninsured pregnant women a cash cow.

Babies are no longer delivered at the original Ochsner campus on Jefferson Highway. Ochsner farmed out obstetrics to the hospitals they bought for fire sale prices from Tenant Healthcare after Hurricane Katrina. But don’t feel bad for Tenet; they first made a deal with their insurance carriers to pocket a percent of their hurricane- and flood-related insurance claims if they could take the money and flee the state rather than spend the proceeds to repair and rebuild the lost facilities, a common provision in commercial insurance policies to help prevent warehouse fires.

Like bees, small hospitals across the United States are not faring well. Hospitals are mandated to treat anyone for an emergency. Not many restaurants could stay in business if anyone who says, “I’m hungry,” could legally walk out without paying the check. Most small independent hospitals in Louisiana are in the red
The $18 billion yearly federal infusion to help reimburse hospitals for uninsured care is being diverted to the Patient Protection and Affordable Care Act; a program Louisiana rejected, meaning money left on the table. Other factors for small hospital colony collapse syndrome include competition with nearby larger hospital systems, rising expenses, workforce shortages, weak margins and decreased payments from insurance carriers including Medicare and Medicaid.

Meaningful data comparing hospital size to outcomes and patient satisfaction are hard to interpret. “Measured by occupancy percentage, small and large not-for-profit hospitals appear to achieve higher efficiency levels than government-owned hospitals do, but the larger hospitals of both ownership types report greater efficiency than smaller hospitals,” according to a study of hospitals in Washington State titled “Hospital Cost and Efficiency: Do Hospital Size and Ownership Type Really Matter?”

Some Louisiana “tweener” hospitals with between 25 and 100 beds depend on parish millages to survive. Others are classified as important to a rural area, sometimes rather creatively, and are eligible for Medicare supplements that make their care much more expensive that the giant hospital down the road. That funding may or may not last, and most such operations have problems recruiting quality staff.

Small community hospitals all across the United States are closing or downsizing to outpatient services. An emergency room may remain as more of an urgent care facility, perhaps with an attached unit for one- to two-day observational care. Their prior acute care wards are either mothballed or turned into beds for other purposes, such as nursing homes or drug treatment centers.

Take River Parishes Hospital last year. Ochsner bought the 106-bed hospital with a dwindling census and discontinued inpatient services. The renamed Ochsner Medical Complex – River Parishes still provides emergency care along with some other outpatient services, but its acute bed days are long gone.

Hospital community boards populated by potential donors and civic leaders still abound, but hospital survival, whether large or small, is dependent on strong administrative leadership. And that’s the missing link in all too many small Louisiana hospitals. Good old boys and want-to-be sheriffs are not what we need running hospitals these days.



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