Hospital of Ebola patient posts poor ER benchmarks

DALLAS -- Diplomas from outstanding medical schools. Records free of discipline. A team trusted by a president.

For all the strengths of Texas Health Presbyterian Hospital Dallas, the first U.S.-diagnosed Ebola patient walked through its seemingly weakest link: the emergency room.

Presbyterian met or exceeded 75 percent of 138 specific measures of care, according to its most recent data. But its emergency department failed to meet all five national patient safety and quality benchmarks the hospital reported. Those measure how long it takes for patients to be seen, admitted, or otherwise cared for in the ER.

"When wait times get longer, it creates an environment where people are more likely to make mistakes," said Dr. Ashish Jha, a Harvard University professor and director of the Harvard Global Health Institute. "It's a recipe for things not going well."

The hospital itself says emergency wait times may indicate understaffing or crowding that "can result in treatment delays and more stress for patients."

Thomas Eric Duncan first entered Presbyterian's ER on Sept. 25, complaining of abdominal pain, severe headache, dizziness and nausea. He was discharged after a few hours, but returned two days later and eventually died of Ebola. Two of his nurses became infected.

For the year ending March 31, patients in Presbyterian's emergency department waited 44 minutes on average before their first contact with a health care professional, 50 percent longer than state and national waits. They spent more than five hours in the emergency department, on average, before being admitted, more than an hour longer than state and national averages. Presbyterian reported meeting one of six emergency department benchmarks in 2012-2013.

Hospital spokesman Wendell Watson said, "Wait time is only one component of patient care and patient experience." Others insist longer wait times can reflect a workflow problem, with lags for X-rays, tests or admissions.

"To miss your benchmarks in emergency room waiting times is probably the greatest indication that your ER is not up to snuff," said Jamie Court, president of the not-for-profit Consumer Watchdog.

In other areas where Presbyterian reported data and for which federal benchmarks exist, the hospital largely met or exceeded national averages.

Presbyterian -- where former president George W. Bush underwent a heart procedure last year -- exceeded seven national benchmarks for strokes, earned perfect scores on a number of surgical measures and met six of 10 criteria on heart attacks, according to its data. It had nearly no infections from IV insertions, about 75 percent fewer than national benchmarks.

Those infections had been a problem for Presbyterian in 2011, when increasing cases prompted a hospital task force. This summer, a Presbyterian infection prevention specialist published a study describing how the hospital dramatically decreased infections by strictly enforcing rules about how long to scrub the hubs of catheters before inserting them.

Health safety consultant Michael Millenson, a visiting scholar at Northwestern University, says it's laudable Presbyterian addressed the problem, but added federal standards are weak and it took years to do what should have taken weeks.

Texas Health Resources began posting detailed data online from heart attack mortality rates to post-surgical infections for each of its 17 hospitals this summer. U.S. hospitals are required to send such indicators to the U.S. Centers for Medicare & Medicaid Services, but do not generally post them on their websites.

"We've committed to show it all, both the good and the bad," said now-retired Texas Health CEO Douglas Hawthorne.

When Duncan first appeared in Presbyterian's ER, several potential warning signs apparently went unnoticed.

"He had symptoms that could be Ebola but could be any number of things when he showed up at his first visit," said Dr. Greg Moran, an emergency and infectious disease specialist at UCLA who reviewed Duncan's medical records. "The miss was basically a simple question that the physician didn't ask: Had he traveled? I don't see documentation that the physician asked that question."