State’s ‘no diversion policy’ is putting strain on Massachusetts hospitals

From the Massachusetts Nurse Newsletter
April 2009 Edition

Nurses in the commonwealth are sounding the alarm about the quality and safety of patient care in the state’s acute care hospitals—a problem that has been exacerbated by the January implementation of a “no ambulance diversion” policy by the Department of Public Health.

In response to the policy, the MNA conducted a media blast calling on members of the nursing community to share their thoughts and experiences on how the new DPH policy is affecting patient care. A significant number of nurses responded and MNA staff members also met with numerous nurses throughout the state—both union and non union—to gather additional input.

The responses show that, while some hospitals are taking appropriate steps to address the policy change, many are not. Some hospitals are taking steps that make the problems related to the new policy even worse. And still other hospitals had already voluntarily avoided diversion for over a year.

What follows are some of the common themes and issues identified by nurses in response to the current situation.

Wait times on the rise
Many nurses across the state reported that their emergency department wait times were increasing, some significantly. According to one respondent from a Partners-owned facility, when she came into work at 11 p.m., “The waiting room was packed. There were 17 patients waiting to be seen and those actually in the department had been waiting an average of four hours to be seen.”

Another nurse from a hospital on the South Shore reported wait times of 10 hours, which decreased to seven hours after the implementation of a new hospital patient-flow project.

Others report that psychiatric patients are waiting even longer for care. “We also see a large number of psychiatric patients and do not have a ‘dedicated area’ for them,” said a nurse from a suburban hospital outside Boston. “While these psychiatric patients wait for bed placement they stay in the ED, taking up beds which could be used for other patients. As there are limited psych beds in the state, we’ve had psych patients in the ED as long as three days—hardly therapeutic.”

Another nurse from a North Shore hospital reported, “Many nurses are exhausted and have been in tears because they are afraid someone will die on their watch. Patients wait with significant pain in the waiting room because there isn’t an open space in the ED. A myocardial infarction went undiagnosed for hours because the ED doctor was called to the intensive care unit twice to intubate another patient.”

Here’s another story from a Boston area nurse: “There were stretchers up against the nurse’s station with patients on them. Our department has only one bathroom. I had to hold a sheet up around a gentleman so he could use a urinal because the bathroom was occupied. One of the patients was hypotensive and being treated right there in the hall because there wasn’t anywhere else for him to go. We had two ICU patients waiting to be transferred out of our hospital because our ICU didn’t have enough staff to accommodate two more patients. These critically ill patients tied up three nurses and two physicians, leaving a nurse and a physician’s assistant to deal with all of the others. We were extremely lucky nobody died.”

Policies push patients out of the ED
In establishing the no diversion policy, the DPH had expressed the hope that hospitals will develop policies and procedures to move patients out of the ED and into other areas of the hospital. Suggestions DPH has given for doing this includes, opening new beds, expediting discharge policies, adopting “balanced admitting policies” (including management of elective surgeries) and adopting other patient flow procedures. Unfortunately, while many hospitals are attempting to implement policies to decompress the ED, few are doing so with a comprehensive, well-thought out strategy. And many are doing so in ways that do not work, or simply shift the problem to other departments.

At some hospitals, patients are moved out of emergency departments with arbitrary time limits. For example, nurses in other units are told that they have thirty minutes to turnaround a room to receive a patient—whether or not they are prepared to do so. The MNA has received other reports of hospitals admitting patients to floors without orders.

According to a nurse, “We are forced to take the patient without medical orders and to call the respective house officer to have orders written within 15 to 30 minutes of patients arriving on the floor. This is an extremely dangerous practice for both the RN and the house officer. One patient was on the floor for five hours before a nurse was able to conduct an assessment.”

Inadequate staffing to deal with policy
The MNA received no reports of efforts to increase staffing to compensate for the new policy. In fact, the MNA recently conducted a separate survey of Massachusetts hospitals and found that more than 20 have cut staffing, implemented hiring freezes or have chosen to leave positions unfilled. This is on top of drastic cuts in ancillary staff, including transporters secretaries, technicians and aides.

One nurse from a South Shore hospital reported that “The hospital has not increased ED nurse staffing . . . there isn’t a holding area . . . and there isn’t any staff to care for patients waiting to go to a room; they remain the responsibility of the ED nurses.”

According to a nurse from a community hospital in Western Mass., “The staffing levels have not improved in the least . . . actually, we may have less staff on the evening shift as there are very frequent time holes to fill.”

Excessive floating to cover EDs
Across the state, we are hearing from nurses who report that floating nurses to the ED is the primary means of covering for excessive patient volume in hospitals. In addition, the MNA, through its contract negotiations across the state, has seen nearly every hospital seek to negotiate the right to dramatically increase the floating of nurses as an alternative to providing appropriate staffing.

Here is a comment from a nurse at Boston’s Faulkner Hospital about the practice. “We frequently are floated to the ED and the ICU, and we are expected to take on full assignments. We have never been oriented to the ED, and do not have access to the computerized documentation system (we’re told to write it down and the charge nurse will enter it). I have to add that none of us have been trained in critical care, and we are certainly not what a prudent nurse would consider experienced critical care nurses.”

Patients held in recovery
To get patients out of the emergency department they are being moved to other units until an appropriate bed opens up, but this is being done to the detriment of the unit to which they are being moved.

“I work as a hospital RN in a busy Level I PACU. Since this new law has passed, I have seen an increase in patients ‘boarding’ in the recovery area,” said one local nurse. “Just last night, our ER was in ‘red’ status which means beds that were originally for post-surgical patients were taken away and given to ED patients who were awaiting admission. I understand that the ED gets overcrowded, but I feel that it is unsafe for patients to hold in recovery while other patients are coming out of the operating room and they are recovering from anesthesia. When I am responsible for a patient who just had major surgery, it is a policy of one nurse to one patient. It can be very unsafe to care for a post-operative patient and to have boarders that need your attention as well.”

Patients in hallways of inpatient units
The MNA has received reports of non-union hospitals that are admitting patients to hallways of inpatient units and, most recently, two  hospitals represented by the MNA have implemented this dangerous policy. This occurred after one of the hospitals cut its nursing staff and increased its patient assignments for nurses by 25 percent.

According to one nurse, “There are screens around the patient’s bed but this affords no privacy really … it’s like using the bed pan in the middle of Grand Central Station with cleaning carts, food carts, and people going by your bed … you are either on display for the world to see or stuck behind curtains that are around your bed. There is no suction or oxygen, so portables must be used and they are noisy … there are no call bells so the patient has to ring a little hand bell and hope someone hears them. They said the patients in the halls would be ‘less acute,’ but this isn’t the case. We had a patient experience grand mal seizures in the corridors along with elderly patients who are disoriented and patients with internal bleeding. Patients who are waiting in the halls have experienced complications and have fallen. It is a horror show.”

Luckily the nurses at the hospital have a union and have been advocating against the policy, and the practice has ended and changes have been made.

The story at St. Vincent Hospital
Months ago, the nurses at St. Vincent Hospital in Worcester fought the good fight against hospital management’s attempts to implement a hallway admission program . . . and they won, or so they thought. After running a successful campaign dubbed “Hall No, We Won’t Go” hospital management stepped back from its proposal—for a short time that is. Last month, and to the outrage of its nurses, hospital management at St. Vincent chose to board a patient in the hallway of an in-patient floor.

Since that time the hospital RNs have been alerting the public to their strong opposition to hospital management allowing patients to be cared for and boarded in hallways and corridors on inpatient units as a way of dealing with the problem of emergency department overcrowding. Their activities have included public leafleting outside the facility; the placement of ads detailing the RNs opposition to the policy and its risks to patients; and community outreach to senior centers and other groups who have an interest in the quality and safety of patient care at the hospital. Hundreds of nurses have signed petitions opposing the practice, and many are wearing buttons that say, “Hall No, We Won’t Go.” The leaflet and ads advise patients to refuse placement in a hallway and to call their physician and insurer to demand care in a patient room.

“The nurses of St. Vincent Hospital are outraged by this decision and are committed to informing the public and all responsible officials of the dangers posed by this practice,” said Marie Ritacco, RN, a recovery room nurse and member of the MNA local bargaining unit at St. Vincent. “As professionals, we are personally accountable for the safety of our patients, and we are obligated under our license to advocate for our patients. We will not allow the safety of our patients to be needlessly jeopardized by shortsighted practices.

Increase in workplace violence
At a time when the system is forcing more people into emergency departments, when they are waiting longer for care, or being cared for in inappropriate locations such as hallways, the industry has exacerbated the problem by making dramatic cuts in their security departments—making EDs a breeding ground for frustration and assaults against nursing staff.

According to Evelyn Bain, who leads the MNA’s occupational health and safety program, “As reports of violent events in emergency departments escalate, a recurrent theme is emerging across the state. The theme is that security personnel are not available to assist in the ‘show of force’ that is required to quell an incident or subdue a perpetrator. In some hospitals the security force have been reduced in numbers due to lay-offs, at a time when violence is on the rise or they have been assigned desk duties that require them to stay in specific locations. One hospital in Western Massachusetts utilizes maintenance staff to assume the security role for which they have not been trained. Often, those who are available have not been trained in the specific skills that are required to respond appropriately to these events.”

Hospitals must be held accountable
In surveying the hospital landscape, the MNA is concerned that this major change in policy has occurred without holding hospitals accountable for making the changes that are necessary to make the policy a safe and effective means of delivering care.

“Forcing hospitals to accept all patients without expecting them to do those things that can make it work is not a solution, it is window dressing,” said Beth Piknick, MNA president. “If the hospitals had appropriate staffing, if they implemented balanced admitting policies that acknowledge the workload of nurses and the resources available to take care of fluctuations in ED volume, if they had the courage to manage their physicians instead of abusing their nurses, then we wouldn’t need to worry about ‘no diversion’ policies. Until they do, this policy is doomed to fail, and as a result, patients and nurses will continue to be placed in jeopardy.

As one nurse from a Western Mass hospital put it, “I personally feel the ‘no diversion’ policy is dangerous to patients and unsafe, for both patients and nurses. We need to have that buffer when things get out of control to bring things back into a safe range. I guess it is going to take a very public death to occur before anyone will open their eyes to how very bad this policy is for everyone involved.”

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