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News: ED Closing Puts Native Americans at Risk

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000499521.51004.15
News
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“They made us many promises, more than I can remember. But they kept but one. They promised to take our land ... and they took it.”

— Red Cloud, a Sioux leader (Native American Tribes: The History and Culture of the Sioux; CreateSpace, 2013.)

In a series of treaties between the U.S. government and the Sioux tribes of the Great Plains in the late 1800s, the federal government promised a variety of services to the Native Americans who gave up their land and agreed to live on reservations. Promises of food, education, housing, and health care received short shrift in the ensuing years, problems that persist to this day. The situation at the Indian Health Service Rosebud Hospital in an isolated area of South Dakota is an example.

For at least seven months, a steady stream of ambulances plied the roads between Rosebud, SD, where the ED closed Dec. 5, 2015, and the three closest hospitals: Cherry County Hospital in Valentine, NE (44 miles away); Bennett County Hospital and Nursing Home in Martin, SD (53 miles away); and Winner Regional Hospital in Winner, SD (55 miles away). During that time, they ferried often critically ill patients from the closed emergency department at Rosebud to the closest facilities where they could receive care. (The Rosebud surgery and obstetrical services closed in June because of personnel shortages. The emergency department reopened July 15, just as this article was going to press.)

The Centers for Medicare and Medicaid Services had been threatening to cut off payments for treating the elderly and indigent at Rosebud because of serious health care problems uncovered in a survey in November, but the decision by the Indian Health Service to halt emergency care at the hospital came as a shock.

“One point I would make is that it's the Indian Health Services' sole decision for all of this,” said Evelyn Espinoza, RN, BSN, the health administrator for the Rosebud Sioux Tribe. “CMS did not say you are providing unsafe care. They said, ‘Go back and fix your process.’”

While the 35-bed hospital struggled to meet the deficiencies found in the CMS report, the Indian Health Service elected to shut down the often-understaffed ED even though a statement it issued during the seven-month hiatus said it had “renovated the emergency department, inventoried equipment, repaired or replaced equipment due for an upgrade, revised processes to improve patient assessments, and upgraded technology systems.”

The Indian Health Service web page describing the hospital lists the Rosebud staff as 11 physicians, nurse/midwives, and physician assistants, but Ms. Espinoza said the hospital had one to three permanent midlevel providers at all times, one permanent obstetrician/gynecologist, and one permanent internal medicine physician. The Public Health Service provides some medical personnel, and the rest are contracted through private agencies.

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Deficiencies in Care

The CMS review, which its staff declined to discuss, found significant deficiencies in care, including an EMTALA violation. A Nov. 11, 2015, CMS survey at the hospital revealed that a 2-year-old had been brought to the emergency department with “fever, hand cramping, difficulty breathing, wheezing, ill x 6 days, +RSV, and difficulty breathing/fever/dehydrated.” A health care provider there noted no shortness of breath or dehydration symptoms, however, and discharged the child within 30 minutes. When the child was taken to the outpatient clinic the next day, the physician noted that the child was not eating or drinking fluids and might be dehydrated.

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The mother told the physician, “The [doctor in the ED] looked at [the patient's] eyes, and said he was OK and that he has growing pains and a cold and he would get better.... [S]tates he did not examine anything else.” Other deficiencies noted included no indication that the outpatient records were consulted, that a pediatrician was consulted, or that the patient was assessed for dehydration or vomiting in the emergency department.

When an adult patient showed up with chest pain, the nurse put him on a monitor and consulted the physician, the CMS report said. The monitor showed atrial fibrillation with rapid ventricular response, elevated blood pressure and pulse, and chest pain through to the back. The medical provider did not see the patient for an hour after ED admission, and noted that the patient denied chest pain. CMS noted that the hospital failed to provide a comprehensive medical screening exam.

In another case, an elderly patient was found outside, cold to the touch, agitated, and nonverbal, with evidence of alcohol consumption, decreased breath sounds, and cyanosis in the extremities. CMS found that his status was ESI level 1 while the emergency department classified him as ESI 2. The physician who saw the patient did not note the cyanosis or decreased breath sounds.

The recertification survey also found that the hospital was out of compliance with seven conditions of participation in the government plans, including that the hospital did not prevent unauthorized release of patient medical records, that its quality assurance and performance improvement programs in almost all areas of the hospital were ineffective, that the hospital failed to ensure that physicians were accountable for the quality of care provided to patients, and that it did not ensure that the facility, supplies, and equipment were maintained at safe and quality levels.

The report also faulted the emergency services provided by the hospital as unacceptable, noting its failure to provide a dedicated ED that provided care in a timely manner or as ordered by a physician or designated person. Among the problems identified were patients whose care for heart problems, preterm labor, or trauma after a vehicle crash were deficient. More than 80 grievances filed by patients were not addressed promptly, CMS found.

The call buttons in bathrooms and patient rooms did not work and had not for a week, forcing patients to use their room phones to call nurses. There was no work order to fix the buttons, according to the CMS report. The hospital also provided the police department with information that a patient had alcohol in his blood after a vehicle crash, resulting in the patient's incarceration. No signed consent was obtained, and the patient was released to corrections, even though the record contained no notation that he was on hold by the police. In another case, a patient with untreated tuberculosis was not noted on the ED log or sent for testing and treatment.

Yet another patient with contractions came in at 34 weeks of pregnancy, and was permitted to go to the bathroom without a nurse attendant. She gave birth in the bathroom, the baby blue and on the floor when the nurse entered. She rushed him into the OB room and resuscitated him.

The problems read like a hospital's worst nightmare:

  • The autoclave for two operating rooms was not working and had not been for 10 months at the time of the survey.
  • The blanket warmer for the two ORs was not working.
  • The main washer/disinfector in central supply did not work for six months. Staff in the interim washed surgical instruments by hand.
  • One of the endoscopy processors was not working for 10 months, and the system for monitoring proper sterilization technique in the endo room had not worked since Nov. 13, 2014. A note on the form for this said, “I'm working on it.”

But if all this sounds horrible, consider this: After the ED closed, at least six patients died in ambulances on their way to distant hospitals, said Ms. Espinoza. “Two ladies have had babies on the floor of the restroom. Our ambulances are running constantly. The time to transport has tripled. It's very stressful for all the health providers involved.”

Patients who have insurance or other methods of payment go elsewhere for care. Those who are left include “the most vulnerable,” she said.

Former Sen. Byron Dorgan (D-North Dakota), the former chairman of the Senate Committee on Indian Affairs and currently the founder and chairman of the Center for Native American Youth, said the decision to close the Rosebud Hospital emergency department was emblematic of providing services to Native Americans overall. “Obviously, the issue of health delivery was promised to Native Americans long, long ago,” he said. “We have to do it. Our country should do it well, and it does it poorly. It is underfunded, a chronic problem. That, however, does not excuse sloppy care. We have to fight for more funding. When I was there, Congress never seemed willing to meet its obligations. The scandal is full-scale health care rationing on the reservations.”

Sen. Dorgan and his committee outlined the problems in providing health care to Native Americans in a 2010 report, and many of them were repeated in the CMS survey of Rosebud Hospital. (“In Critical Condition: The Urgent Need to Reform Indian Health Service's Aberdeen Area,” Sept. 28, 2010; http://bit.ly/29Tjhkk.) Those problems stem not only from underfunding, but also from poor administration at regional and national levels, he said. During one tour in what was formerly called the Aberdeen area of the Indian Health Service, a public health service doctor proudly showed Sen. Dorgan where a new x-ray machine would be going. “When do you get it?” Sen. Dorgan asked. “‘I found it had been sitting on a desk in Aberdeen, SD, for one-and-a-half years,’ he said. You hear that kind of thing all the time. It was desperately needed. What is missing is accountability for outcomes. It is frustrating.”

The Indian Health Service announced May 17 that it had awarded the Arizona-based AB Staffing Solutions a $60 million, five-year contract to temporarily staff and operate three hospital emergency departments — Rosebud Hospital and Pine Ridge Hospital in South Dakota and Omaha Winnebago Hospital in Nebraska. The move was part of a systems improvement agreement with the CMS, but a spokesman for the Indian Health Service said at the time that the Rosebud emergency department remained “on diversion status” until the IHS could complete actions needed to safely reopen it in compliance with CMS standards.

Frustration has spread to the federal courts, where attorney Timothy Purdon has filed a suit pro bono on behalf of the Rosebud Sioux tribe against the Department of Health and Human Services, its secretary, and the Indian Health Service directors. “Our lawsuit asks not just for the emergency room to be opened, it asks the federal government to live up to its fiduciary responsibility to give these people access to high-quality medical care,” Mr. Purdon said.

“That means not just an open emergency room. It means an emergency department that has an autoclave, an emergency room that is staffed so babies aren't born on the bathroom floor,” he said. “We filed this suit because the executive branch — the Health and Human Services Department and the Indian Health Service — has been unable to solve this problem. When that happens, you go to the judicial branch. The tribe does not have faith in the executive branch.”

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IHS Response

In a response to Emergency Medicine News nearly a month after it was made to IHS Acting Director Mary L. Smith, who identifies herself as a member of the Cherokee Nation on the IHS website, a spokesman for IHS said it and CMS have recently agreed on a systems improvement agreement for Rosebud Hospital as a way to improve safety and quality standards. (http://bit.ly/29TfFPD.) They are seeking telehealth services for all seven Indian Health Service Hospitals in the Great Plains area, including Rosebud, he said.

Lack of funding is part of the reason, he noted. The fiscal year 2017 budget requests $6.6 billion for the entire Indian Health Service, an increase of $402 million over FY 2016, he said. (IHS News Release; http://bit.ly/29XAq8Y.) The budget for 2017 proposes a 6.5 percent increase over FY 2016, he said, but it falls short of what is needed. The Indian Health Service expenditures per capita are less than what is spent on health care for federal prisoners, the spokesman said. Per capita spending in the IHS in 2014 (the most current year available) totaled just $3,107 per capita, compared with $8,097 per person nationally. Health spending on former U.S. military is $7,035 per veteran. Separating out the medical costs only, the National Congress of American Indians estimated that the total is only $1,940.

Closing the Rosebud emergency department was a Hobson's choice, Sen. Dorgan said. Is a bad emergency department better than none at all? “The hospital has chronic, persistent, and very serious problems. We have tried in many ways to put pressure on them to alter behavior,” he said. “We found serious things going on [in the Aberdeen region] in almost every area — cronyism, shoddy management, and drug abuse. Bad employees doing bad things are just transferred to another region.

“Much of the delivery of health care to Native Americans is outside the public view,” Sen. Dorgan said. “The scandal is full-scale health care rationing on reservations and an incompetent agency that cannot resolve its problems.”

The problems are often life-and-death, and some people have died waiting, said the former senator. “Somehow, we have to wake people up. People of the first Americas are living in Third World conditions.”

A July 2 opinion piece in TheWall Street Journal written by U.S. Sen. John Barrasso (R-WY) and U.S. Sen. John Thune (R-SD) said the Indian Health Service is failing in its responsibility to provide health care for more than two million Native Americans who need care. “During the committee's investigation, which began last summer, we have heard accounts of nurses unable to administer basic drugs, broken emergency-resuscitation equipment, unsanitary medical facilities, and seriously ill children being misdiagnosed,” they wrote. (Wall Street Journal, July 1, 2016; http://on.wsj.com/297bKt3.)

They place much of the blame at the door of the Indian Health Service. “Because the IHS can no longer be a place where inept, entrenched employees come first and patients come last, we have introduced the IHS Accountability Act of 2016,” which they said they hope will make it easier to hire permanent employees. (Congress.gov; http://bit.ly/2a9GpKr.) The bill also charges the Department of Health and Human Services with oversight of the Indian Health Service. While the senators, both on the committee overseeing the Indian Health Service, noted that funding for the agency has grown by 43 percent since 2008, they do not note the disparity in funding between patients of the service and those in the general community.

Ms. Espinoza said she was happy that the senators — present and former — are concerned about the conditions at her hospital, but said she is tired of the political games. “This country has a legal, moral, and ethical obligation to the people of this tribe. And that obligation is not being met today. Pointing fingers is not solving anything. While they are playing these games, our people are dying. It is cruel and unusual. It is literally genocide that I'm witnessing today.”

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