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Nov 21

Progress and Unintended Consequences

The November Seattle Health Innovation meetup featured “Code Black”, a full length documentary on a busy emergency department at Los Angeles General Hospital, followed by a discussion. It wasIMG_6017  attended by about 55 people from around the Seattle and Eastside areas. It was sponsored by WebMD. Dave Chase, former CEO of Avado and now a Senior VP at WebMD welcomed the audience.

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The documentary, as well as some of the discussion touched on something that we do not talk about very often- the unexpected and sometimes negative consequences of changes intended to be positive.

Spoiler alert, I’m going to talk about some elements of the story line of the movie. I doubt if that will matter if you do get a chance to see it because the documentary’s intensity stems not from the story line but from the subject matter itself.

The film begins in 2008 in the old hospital, built in the 1920’s as a modernistic cathedral of medicine and the only safety-net hospital in the region, and was completed in the new hospital in 2012. “C-Block” was the old emergency department where the intense life-saving activities were all done in a relatively open area, separated only by small curtains, with minimal privacy for patients. “Code Black” is a condition in the ED when the facility is desperately overwhelmed by patient volume, a situation that occurs too often. The sparkling new facility was updated to provide more room and more privacy for patients, as well as eliminate the need for waivers from some regulations.

In the documentary we follow a cohort of Emergency Medicine residents from their first year in the old hospital to their 4th year in the new facility. Accompanying their move to the new facility was the loss of various waivers from HIPAA and other regulations, so that in the new facility the staff had to contend with what they experienced as burdensome, “soul-crushing” paperwork. The film highlighted the sense of loss from the old system to the new, more private yet more isolated and bureaucratic. We learn some of the personal stories of these residents and come to admire their strong qualities and we empathize with their frustration. The story line evolves around their growing resolve to recreate the best features of C-Block within the new facility. The residents want to bring the most serious cases from the waiting room into the treatment area. The resistance comes from the nursing supervisor, concerned that this would dilute the ratio of nurses to patients,thus increasing liability to nurses from potential errors made under impossible conditions. Undeterred, our heroes (the resident physicians) are able to achieve this reorganization of the beds and waiting area and feel that they once again are able to monitor what’s happening visually.

The film exposes the brutal realities of the injuries and illnesses afflicting the poor and uninsured in a metropolitan area. It highlights unintended consequences of progress- such as the design of the new facility that disconnects the medical team from the patients. It also hits the cumbersome regulatory compliance and defensive clinical documentation workloads of clinicians. The modest victory achieved by these residents in making ED patient flow changes stood in stark contrast to the empty, but desperately needed, wing of the ED closed to maintain the statutory patient-nursing ratio.

After the film Nathan White, MD, of the Department of Emergency Medicine at the UW School of Medicine, and Linda Riggione,RN provided commentary and responded to audience questions. Dr White said that the film accurately captured many of the issues facing emergency medicine. Ms Riggione represented a nursing perspective and noted that the film could have shown more of the roles of nursing and the allied health professions. One question from the audience was about the impact of the Affordable Care Act on Emergency Departments. Dr. White said that while some had predicted that ED utilization would decrease as a result of greater access to primary care, that this has not occurred. He said that ED utilization has in fact increased because people now have health insurance. He pointed out that ED’s are open 24×7, you don’t have to have an appointment, and are often more convenient for some populations than going to the doctor’s office. ED utilization is going up.

In response to a question abut where the opportunities for innovation are in emergency medicine, Dr. White mentioned a UW startup company making a microfluidic device that will detect blood clots. Dave Chase also responded with the observation that many of the innovations needed are upstream from the ED, and pointed to Iora Health as a company that is innovating with a new patient-centered model that through preventive health can avoid some patients from having to go to Emergency Departments.

In the networking portion of the meetup I had a chance to speak with two nurses from a major ED in the Puget Sound area and asked for their response to the documentary. One of them responded with a very nuanced answer. She chose her words carefully. She said that for those things that it covered it was true. I sensed that there was a deeper answer and asked where the holes were in the documentary’s coverage. “There is a lot more that goes on in an ED than what the residents do”, she said. When I asked about the portrayal of the nursing staff as barriers they both weighed in. I sensed that there was a bit of sadness in their measured remarks about the missing other unsung heroic roles in the ED.

This was the 8th Seattle Health Innovators meetup. We’ve been holding community-building events since June 2013. To join the distribution list for the next Seattle Health Innovation Forum sign up here.

 

 

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