Records reveal that many Jackson Memorial doctors say there are huge problems in the ER that are slowing patient care
Doctors in Jackson Memorial's emergency room say their work is hindered by a hugely dysfunctional system that has trouble processing blood samples, getting basic diagnostic imaging and finding hospital beds for patients.
Public documents requested by The Miami Herald revealed that the doctors had plenty of complaints when a manager asked them what they would like to see changed in the ER.
The issue is crucial because Jackson Health System executives now are studying bids from nine outside companies about taking over doctors' services in the emergency rooms -- a step that has already brought vehement objections from a half-dozen county commissioners and protests from leaders of women's groups who fear the move will hurt the rape treatment center at the hospital.
At a county commission hearing last month, Jackson Chief Executive Carlos Migoya complained that a Jackson ER doctor takes care of only one patient an hour. That compares to a national average of two to 2.5 patients an hour, Migoya said. "We are very slow."
The average patient now spends six hours in the ER if they're sent home, according to Jackson's statistics. Those being admitted to the hospital average 13.7 hours in the ER. Jackson officials say they're working to improve those figures, but that they're far better than the 26 hours the average admitted patient spent in the ER in December 2010. The national average for all ER patients is four hours, four minutes, according to the American College of Emergency Physicians.
The documents obtained by The Herald were emails from ER doctors replying to ER Medical Director Lilly C. Lee's request for "top 10 items that you want to change."
Julie Kanter, a veteran ER doctor, wrote that "many hours of patient delays" were caused by not having a hospital cell phone to communicate with other doctors about a patient's problem. "In every other [ER] I have worked in, we carried a hospital cell phone." What's more, "I'm running upwards of four hours ... just to get the X-ray taken."
Another doctor, Vanessa Price Davis, wrote: "ER physicians waste too much time looking for [intensive care] beds," often making many calls trying to deal with the Jackson bureaucracy to get a patient admitted.
What's more, "it is not uncommon for patients to wait for hours after being admitted to have orders written by the hospitalist," Price Davis wrote, meaning the ER physician has to continue taking care of the patient.
Several doctors complained there are often lengthy delays in getting blood samples analyzed because the sample goes bad -- a process called hemolyzed -- and the test needs to be redone, sometimes two or three times. Veteran ER doctor Art Diskin said he has never seen a hemolyze problem other than at Jackson.
Alex Contreras-Soto, chief administrative officer of Jackson Memorial, said he's well aware of the doctors' complaints, and his managers are working hard to correct many of them, such as finding a way to provide doctors with cell phones so they're not perpetually playing phone tag with consulting doctors, and adding 40 more beds to the hospital floors so that ER patients can be more quickly admitted to the hospital.
In some cases, Jackson says the complaints were not justified. Jackson spokesman Edwin O'Dell said studies show that the time recently needed to get a diagnostic image is about the same or just slightly above industry standards.
Still, Contreras-Soto said there are "so many other issues" in the emergency room, "I'm nowhere near to start demanding that my doctors see more patients."
He said Jackson was still considering outsourcing as just one exploratory component of finding better efficiency in the ER, and many systemic problems need to be fixed whether the doctors are in-house or from an outside company.
Martha Baker, president of SEIU Local 1991, which includes Jackson's doctors, says that much of the dysfunction in the Jackson Memorial ER has been known for years -- and often ignored. The most recent outside analysis was done in July by Fitch Healthcare, a Chicago consulting firm hired by SEIU, that reported that improved efficiencies in the system could help ER doctors increase productivity to 1.4 patients an hour, saving the system millions.
Fitch's study of Jackson's ER doctors found that they spend large amounts of time having nothing to do with medical care: such as battling to get patients admitted to the hospital -- a process that now averages two to four hours, when it should take no more than 20 minutes.
Much more time is wasted trying to get a consultation from a specialist about what's wrong with a patient -- something that should be done within 90 minutes, Fitch stated, instead of the five hours it takes at Jackson. Most of the consultant specialists are University of Miami faculty.
What's more, because of long wait times for patients to get into a primary care clinic, Jackson ER doctors often do tests and procedures in the ER because they know there won't be a quick follow-up trip to a clinic, the Fitch report said.
O'Dell said Jackson is working to expand its clinics and speed up wait times to take pressure off the ER.
Last month, Jackson's board approved a proposal by Chairman Marcos Lapciuc to delay an ER outsourcing decision until January and to give management time to talk to the ER staff about how to improve performance. Union leader Baker said that resolution has led to improved communication about exploring ways to fix the system.
Baker questions whether outsourcing would save Jackson money, because Jackson doctors, as government employees, have sovereign immunity, which protects them from large malpractice judgments. Outside companies would not have that protection, meaning they would have to factor into their bids significant sums for liability coverage.
The exception is the University of Miami, one of the nine bidders on Jackson's ER contract. Last year, the Legislature passed a bill giving UM doctors sovereign immunity when they practice at Jackson. A UM spokeswoman said Thursday the school had no comment.
Contreras-Soto, the Jackson executive, noted that records show a wide variety of performance of Jackson's ER doctors. One averaged 1.6 patients per hour for the past year, while three averaged 0.5 patients. At some point, he said, those performances need to be addressed.