Delays Put Lives at Risk at County-USC

It was a lethal problem with a simple solution: Los Angeles County-USC Medical Center often couldn’t provide dialysis to critically ill patients because specially trained nurses didn’t work nights or Sundays.

But the problem wasn’t fixed until three patients in the last 10 months died after prolonged waits, according to doctors and medical records. Numerous others were endangered, saved only by stabilizing medications or transfer to smaller hospitals with round-the-clock treatment.

Doctors had complained, verbally and in writing, for more than two years before a new medical director in January simply arranged for the hospital’s dialysis nurses to respond to emergencies around the clock.

The litany of officials who were warned includes county Health Director Mark Finucane, hospital Chief Executive Roberto Rodriguez, two previous hospital medical directors, a county hospital inspector and the dean of USC’s medical school.

“They have to wait for three people to die?” said Dr. Edward Newton, vice chairman of County-USC’s emergency medicine department, who added that he had complained to no avail. “To me, that’s inexcusable--immoral.”

The dialysis problem is just one dramatic example of how poor management and a lack of accountability aggravate delays in care for patients who desperately need it at the largest public hospital in the West.

County-USC, like most big-city public hospitals, is overwhelmed with impoverished patients and starved for funds. But the hospital has made bad situations worse by failing to take action where it could. The dangerous delays go beyond dialysis:

* In April, one patient bled to death in the ER when specialists in stopping internal bleeding did not arrive in time to save him.

After three hours of back-and-forth among doctors, including debates about whether the right paperwork had been filed, emergency room doctor William Mallon was told it would be 45 minutes more. “You don’t need to bother,” Mallon recalled saying. “He’s dying right now as I watch.”

* Patients sometimes wait days in the crowded emergency room for hospital beds where they can receive more medical attention. The record is a man who languished for 84 hours--half a week.

The waits haunt Dr. Gail Anderson Sr., who founded and still chairs the hospital’s emergency medicine department. “I feel like crying,” he said. “But crying won’t fix it.”

* Key diagnostic tests and surgeries also are delayed. In January, it took 16 hours for the hospital to perform a standard brain scan on a man with a head injury, the minutes of a faculty meeting indicate. And heart surgeries regularly are postponed because of lack of available operating rooms or staff, doctors said.

Doctors and patients said first-rate medical care is generally available at County-USC’s General Hospital. The Beaux Arts-style building, which crowns a hill just east of downtown Los Angeles, is viewed by many as a symbol of the county’s commitment to health care for all.

Asked about the dialysis delays, the hospital’s chief nursing officer, Katherine Eaves, said fixing it “has always been a priority.” But she said there had never been enough dialysis nurses for 24-hour staffing.

No other top hospital official would discuss dialysis delays in detail, other than to say that they were more complicated than they appear and to caution that prompt dialysis might not have saved the seriously ill patients who died. For the most part, they insisted they couldn’t discuss individual cases because of rules governing patient confidentiality.

County health Director Finucane, whose department runs the hospital, acknowledged that County-USC has chronic problems. But he blamed national trends in health care. Public hospitals, which mostly serve the poor, are struggling everywhere, he said--largely because they don’t have the dollars they need to accommodate the influx of uninsured patients.

“You’re talking about a chronic underfunding of the health care system dedicated to serving the poor people of Los Angeles--and Detroit, and New York, and Florida,” said Finucane, who resigned from his post in March and will depart next week.

“If you think it’s bad now, wait to see what happens in the next five or six years.”

The financial woes are real. But a review of the way dialysis delays continued over the years shows County-USC troubles do not all stem from a lack of money.

Woman’s Kidneys Were Failing

The first dialysis patient to die was Christine Powers, 46.

Powers came to the hospital late on Aug. 2, complaining that her back and joints hurt and she had been throwing up for four days.

Powers, who had sickle cell anemia, was rail thin, with 113 pounds on her 5-foot-7-inch frame. She had turned to heroin and cocaine more than a decade before, claiming to friends that she needed them to blunt pain from sickle cell. The illegal drugs, she said, were cheaper than legal medicines.

Before she turned to drugs, Powers worked as a bookkeeper, said longtime friend Mona Reed. After she lost that job, the college-educated woman turned to street prostitution to finance her habit.

Whenever Powers needed care, Reed said, she headed for County-USC. “She loved that hospital.”

In the emergency room last August, doctors ordered lab tests, which showed that Powers’ kidneys were failing, coroner’s records show. Emergency room doctor Stuart Swadron said in an interview that he and a kidney specialist discussed whether she immediately needed dialysis, a treatment that removes potentially lethal bodily wastes that are normally disposed of by functioning kidneys.

Swadron said doctors decided that Powers did not immediately need dialysis, and at midday Powers went to an intensive care unit.

Around 6 p.m., however, Powers’ condition worsened. A kidney doctor ordered emergency dialysis, records show.

As a trauma center, County-USC was contractually obliged to provide emergency dialysis around the clock. The hospital had a staff of specially trained dialysis nurses working during business hours. But after hours, County-USC relied for years on outside companies--often called registries--to send nurses. Hospital administrators acknowledge that the nurses from these companies did not always show up.

That is what happened in Powers’ case. No nurse could be found, and Powers died--without receiving dialysis--a little more than four hours after the kidney specialist deemed her case an emergency.

Top hospital officials, including chief executive officer Rodriguez--who steps down this week after resigning in March--and chief of quality assurance, Dr. Stephanie Qualls, refused to discuss Powers’ case or that of any other dialysis patient.

Doctors’ Remedy Was Rejected

Several years before Powers died, doctors were repeatedly complaining about delays in dialysis.

Dr. Ronald Kaufman, then the hospital’s medical director, said that kidney specialists and dialysis nurses proposed around 1998 that nurses be on call for emergencies--a similar solution to the one proposed this year.

Nursing chief Eaves rejected the idea as hopelessly flawed. It relied on non-staff nurses who worked with County-USC doctors at a private clinic. Each nurse effectively wanted an individual contract with the county, a demand that proved impossible to implement, she said. “I had to say no to something I desperately needed,” Eaves said.

Doctors continued to raise warnings.

In November 1998, emergency room doctor Kathryn Challoner told a meeting of senior county physicians that she knew of an ER patient who needed emergency dialysis but had to be transferred by ambulance to another hospital to get it.

Challoner said that over the next two years she made similar complaints to a hospital quality assurance committee. Such committees are internal review boards where medical professionals try to address concerns about patient care.

On June 19, 2000--six weeks before Powers died--a kidney specialist wrote a memo to then-acting Medical Director Dr. Edward Wong, saying a patient’s life was endangered because it took 17 hours to get him emergency dialysis.

“This has been a recurring theme for the [kidney] service for many years, since there is no hemodialysis nurse on call at this level 1 hospital,” wrote the physician, who did not sign his name.

Wong recalled receiving the memo and giving it to the hospital’s quality assurance committee.

For Challoner, quality assurance was not working.

Last October, she broadened her avenues of appeal to include the hierarchy of USC’s Keck School of Medicine. The county owns and operates County-USC; the university provides physicians under contract with the county.

Challoner first went to the USC medical school’s faculty assembly. A former president of the group, she persuaded them to express concern about delays in emergency care--including excessive waits for dialysis--in a letter to the dean of USC’s School of Medicine, Dr. Stephen Ryan. Because Challoner did not yet know that anyone had died , the letter said diplomatically that “access to emergency dialysis . . . at times is difficult.”

The letter created no sense of urgency. It was two months before a dean’s representative asked the hospital’s medical staff president about it. The president, Dr. David Goldstein, said he responded that the matter was being handled by quality assurance.

The next month, the coroner’s office got involved. After an autopsy on Powers, a coroner’s official was disturbed enough about the delay that, in a Nov. 14 letter, he notified the district attorney’s office and county health Director Finucane that County-USC had a “quality of care issue” worth investigating. The district attorney’s office also wrote Finucane on Nov. 27, asking him to report back on what he found.

In an interview, Finucane said he regarded the correspondence as needing prompt attention and handed it off it to the county’s overall quality assurance unit, which then alerted the hospital. Finucane, who is not a doctor, took no other action to correct the life-threatening problem, saying he wanted to leave it to doctors.

ER Doctor Writes of Second Death

As winter hit, emergency room doctors began hearing reports from colleagues that there had been other dialysis-related deaths.

On Jan. 4, Challoner wrote an e-mail disclosing that she had heard of a second death from one of the kidney specialists.

“I am told by a member of the renal faculty that there has been another patient death,” an aggrieved Challoner wrote in an e-mail to the medical staff president, Goldstein. “This has been an ongoing problem for the last several years and I have filed numerous statements of concern.”

Goldstein said in an interview that he broached the matter with hospital director Rodriguez.

Details of this second death, including the name of the patient and the date, could not be determined, although the death was alluded to in internal correspondence.

Three days after Challoner’s e-mail, another ER physician, Mallon, almost lost a patient. Mallon said he spent six hours on a Sunday waiting for dialysis nurses to treat a 73-year-old county jail inmate who was dying of kidney failure. Finally, he transferred the patient to nearby White Memorial Hospital, where he was told the patient would be dialyzed in 30 minutes.

“Rather than have him die here, I jammed him down White’s throat,” Mallon said. “Why is it that a little hospital can get dialysis done in 30 minutes and the biggest hospital in the county can’t?”

Challoner appealed again to the medical school’s faculty assembly, telling the group that emergency care conditions had continued to deteriorate and that dialysis delays persisted.

The president of the faculty assembly, physiologist Harvey Kaslow, met with the dean and his cabinet.

Around the same time, rumors began to circulate that prosecutors were interested in mounting a criminal case over Powers’ death. (In fact, prosecutors considered the problem a matter for health officials to correct.)

Newton, the vice chairman of emergency medicine, wrote a memo to his staff on Jan. 18 urging them to protect themselves from the threat of criminal prosecution by meticulously documenting their efforts to get needed treatments.

“Because of the inordinate delays in obtaining an appropriate level of care, [including emergency] dialysis . . . patients left in the Department of Emergency Medicine for prolonged periods are at risk for adverse outcomes,” Newton said.

The next night, Theodore Searcy had a seizure in his South Los Angeles home, and paramedics brought him to the emergency room.

Patient in Crisis; Needed Dialysis

The 73-year-old retired garment cutter was having difficulty breathing and was placed on a ventilator. His kidneys were failing.

Searcy’s potassium levels were so high they threatened to stop his heart, according to Dr. Richard Lafayette, a Stanford University kidney specialist who reviewed portions of Searcy’s medical records at the request of The Times.

Doctors decided he needed emergency dialysis, and administrators began calling registries for nurses.

Challoner was the physician in charge of the emergency room that night. “I could not get emergency dialysis,” she later wrote in a shift report.

She wanted to transfer Searcy to White Memorial, but was blocked.

“When I tried to get a patient transferred out that night,” Challoner said, “the senior administrative nurse that night told me the policy was that she had to call all nine [nursing] registries and all nine registries had to call back and say they could not supply anyone before authorization to transfer patients would be issued.”

Challoner then called the hospital’s designated administrative officer of the day who, she said, confirmed the rule. “This was the first time I had been told of this policy,” Challoner said.

She said she told the administrative officer, “This patient may die.” Over the next two hours, Challoner said, she called the nursing office twice and was told “they were still working on [it].” She admitted the patient to intensive care.

Eaves, the nursing chief, disputed that account. She said it took only 30 minutes to call all the registries and get calls back. She said she did not know why Searcy was not transferred, but that it is generally easy for doctors to get a transfer authorized.

In the intensive care unit, a doctor noted in Searcy’s chart that a decision had been made to wait until morning when the regularly scheduled dialysis nurses came in.

Before that could happen, at 7 a.m., Searcy’s heart stopped.

Medical records show doctors managed to resuscitate him. Then nurses gave him dialysis.

Searcy never recovered. He remained on a ventilator until he died three weeks later.

Searcy’s sister said the hospital never told her there was any delay obtaining dialysis.

Because Searcy had been under a physician’s care for more than 24 hours when he died, the hospital was not required by law to refer his death to the coroner for an autopsy. His death certificate made no mention of his kidneys, saying he died of a stroke and cardiac arrest.

Challoner agreed that the man was “desperately, critically ill” and that he might have died anyway. But, she said, “emergency dialysis was recommended and I believed it would help.”

Doctors Complain to USC, Regulator

Although the dialysis-related deaths were not openly discussed in the hospital, word seeped out in faculty meetings and from supposedly secret quality assurance discussions. Three emergency room doctors--Mallon, Newton and Michael Orlinsky--said in separate interviews that by late January, they had learned that three patients had died.

Mallon, the emergency medicine residency director, stepped up his complaints--and his rhetoric.

“The renal service continues to kill people,” he wrote the USC medical school’s senior associate dean for faculty affairs, Dr. Leslie Bernstein, on Jan. 25.

Mallon wrote to an outside regulator, Dr. Mindel Spiegel, on the same day, complaining about three dialysis-related deaths.

“The most alarming feature of these cases to me is this: The hospital administrator and the nursing administration have known about these problems for over one year and not corrected them.”

Spiegel, who inspects private hospitals for the county, was not the right regulator. She did not alert state regulators with authority to investigate the dialysis problems.

She said in an interview that she vaguely remembers calling Mallon to direct him to the right person. Mallon said Spiegel never contacted him.

State authorities say they should already have known about the patient deaths. State law requires hospital administrators to report their own facilities to California licensing authorities whenever “unusual occurrences” take place.

But County-USC officials never reported the dialysis problems, regulators say. In interviews, hospital officials refused to discuss the matter. Moreover, they would not say how many patients died after dialysis delays.

New Medical Director Changes Procedures

By late January, the hospital was finally coming to grips with its dialysis problem.

Earlier that month, a new, temporary medical director who happened to be a kidney specialist, was appointed. On his first day on the job, Dr. Lawrence Opas held a meeting of senior doctors who told him about the dialysis delays.

Opas said he decided to limit the hospital’s reliance on outside dialysis contractors, and to require the hospital’s own dialysis nurses to be on call for emergencies after hours.

The policy was formalized in a Jan. 26 memo, one day after Mallon had sent his last, blistering letter.

Nursing chief Eaves, in an interview, ascribed the dialysis problem to a nationwide nursing shortage. For much of last year, she said, the hospital had only seven dialysis nurses, not enough for round-the-clock staffing.

She said the dialysis nursing staff was expanded to 11 in January and had begun working certain nights even before Opas made his changes.

Recruiting nurses had long been difficult at County-USC. The scarcity of nurses, in fact, caused backups throughout the hospital. At least part of this problem was of the hospital’s own making: Hiring was mired in delays.

Eaves confirmed that the hospital’s complex hiring process took six weeks--if everything went perfectly. That changed abruptly when, in response to complaints, Los Angeles County Supervisor Gloria Molina paid a surprise visit in February to the recruitment office. The hiring time was cut to a few days, administrators say.

Besides recruiting more nurses, the hospital had other options to solve its dialysis problem. For example, Women’s and Children’s Hospital, within the same medical center, cross-trains a range of staff nurses to handle dialysis emergencies.

Other hospitals contract exclusively with a major company that specializes in emergency dialysis. A budget aide to Molina said this would not have cost substantially more than the hospital was already paying.

Instead, the hospital took its chances, calling a potpourri of these smaller companies in emergencies. And some county contractors said that, with limited resources, they gave County-USC’s requests lower priority than those of other hospitals that gave them more business.

“They wait until they need someone on the spot and then they call,” said Joseph Baiden, the administrator of Nurse Connection Inc. “Dialysis nurses don’t just sit and wait” for last-minute calls.

Since the hospital stopped relying on these companies, doctors, nurses and administrators say there have been no other inordinate delays in emergency dialysis.

But county-USC continues to face other hurdles in delivering emergency care.

Some of these--most important, a lack of funding--are outside the hospital’s control. With more uninsured residents than any other county in the nation, Los Angeles’ health department, which funds the hospital, faces a projected deficit of $884 million in five years. Health officials are currently planning cuts.

County-USC, which has 45,000 admissions annually, has been steadily shrinking. Licensed for 1,500 beds, it is budgeted for about half that, and county supervisors are planning to rebuild the quake-damaged hospital in seven years with only 600 beds and an 80-bed annex.

But critics on the hospital staff say that, by tolerating a wide range of inefficiencies, it is not doing all it could with the money it has.

For example, unnecessary delays in getting surgeries and routine tests leave patients stuck in precious hospital beds while other patients in need of beds pile up in the emergency room.

In his Jan. 18 memo that urged emergency room physicians to document delays in critical care, department Vice Chairman Newton rattled off a list of “inordinate delays” in getting 12 types of tests and specialized care. These ranged from brain scans to cardiac catheterizations.

Dr. Susan Stone, associate director of the doctor training program for emergency medicine at the hospital, said she faced one such delay in the case of Jose Garibay.

‘Don’t Worry, They’ll Take Care of You’

On the night of April 13, Garibay, a self-employed, uninsured auto mechanic, was coughing up so much blood it was streaking the walls of his mother’s Echo Park apartment. His brother, Jorge, called an ambulance. When the paramedics asked where the family wanted him to go, their answer was County-USC.

Jose Garibay had been there before, most recently a week earlier to treat liver damage from his chronic alcoholism. At 47, he was still reeling from the damage done by his last binge during a visit to his adult daughter in Fresno.

Jorge, who followed his brother’s ambulance to the hospital that night, said he clasped Jose’s hand as nurses wheeled him back into the ER soon after midnight. Doctors fed a tube down Jose Garibay’s throat to ensure he could breath, and he struggled to talk to his brother. “Don’t worry,’ Jorge recalled saying, “they’ll take care of you here.”

Stone was the physician in charge of the emergency room that night. She saw to it that digestive specialists were called to try to stop Jose’s bleeding. When they failed, she tried surgeons.

All agreed that interventional radiologists were Garibay’s best bet. His blood had backed up because it was unable to pass through his scarred liver. A vessel had burst in his esophagus. These high-tech specialists might be able to insert a small metal tube in his liver to reroute the blood flow.

Stone and other doctors on the case rated Garibay’s chances of survival as 50-50.

The first call for the specialists went out just before 6 a.m. and a resident called back and said they would come, Stone said.

Ordinarily, that would mean a team could have been ready to go to work on Garibay by 7 a.m., said Dr. Michael Katz, the head of the interventional radiologists.

But he and the emergency room doctors disagree on why that did not happen. Katz said the delay was largely because ER doctors failed to communicate the gravity of Garibay’s condition and did not file the correct paperwork. The emergency room physicians say they followed correct procedures and made the urgency clear.

Katz, who would have performed the procedure, said he was not even called by his subordinates until just before 8 a.m. He said he told them then to forget about the paperwork and arrange to treat Garibay as soon as possible.

It was too late. Garibay began to have trouble breathing. And a key member of the radiology team who had been called to help Garibay was redirected to help a heart attack victim. Katz estimated that a replacement was 45 minutes away.

Garibay stopped breathing while Katz was explaining this to Mallon on the phone.

Katz’s group has an excellent reputation at County-USC for showing up promptly for emergencies, according to senior staff.

But to Mallon, Garibay’s death was another example of how patients who come to County-USC at inconvenient times do not always get the help they need.

“I think,” he said, “if he’d have had the good sense to bleed during the daytime hours, we’d have had the resources to save him.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Pleas for Help

Doctors tried for years to get reliable, round-the-clock emergency dialysis service at County-USC.

Nov. 19, 1998

Minutes of a meeting of senior county doctors showed Dr. Kathryn Challoner warning about the dialysis problem:

“A patient who was severely fluid-overloaded and hyperkalenic had to be transported by ambulance to another facility for treatment because of a lack of acute hemodialysis services at the medical center.”

June 15, 2000

Six weeks before Christine Powers died, a kidney specialist wrote the medical director about another critically ill patient who waited 17 hours to get the procedure:

“Registry nurse was called. However, within an hour, we were told that no registry nurses were available. This has been a recurring theme for the nephrology service for many years since there is no hemodialysis nurse on call at this level 1 hospital. . . .

We need hemodialysis nurses to be available 24 hours every day, and someone in charge who will not withhold treatment, especially in emergent situations.”

Nov. 14, 2000

After Powers died, the coroner’s office wrote County Health Director Mark Finucane to warn him about the problem.

“I would like to report this case to your office, as there is a quality of care issue involving a county health care facility. The decedent was admitted to [County-USC] Medical Center on Aug. 2, 2000, for sickle cell crisis and acute renal failure. On Aug. 3 at 6:10 p.m., the nephrology fellow requested a hemodialysis nurse for emergency dialysis. However, despite several attempts to obtain a nurse, there was no dialysis nurse, registry nurse or ICU nurse available. The patient died at 10:15 p.m. that same day.”

Jan. 4, 2001

Dr. Challoner wrote a hospital official about a second fatality.

“We again could not access emergency dialysis and I am told by a member of the renal faculty that there has been another patient death. This has been an ongoing problem for the last several years and I have filed numerous statements of concern.”

Jan. 25, 2001

Another frustrated doctor, William Mallon, wrote a USC associate dean:

“The renal service continues to kill people. There have been three deaths in the last nine months.”