Take me to Grady

This is part two of a three part series on the past, present, and future of Grady Memorial Hospital.

In 2011, more than 600,000 patients visited the Grady Health System. Across the Atlanta superstructure’s 16 floors and the institution’s six neighborhood health centers, 5,300 doctors, nurses, and staff members do everything from refill prescriptions to resuscitate lives. With more than 950 beds, Grady is the state’s largest hospital. For Fulton and DeKalb counties’ uninsured residents, the safety-net facility isn’t simply a mammoth infirmary — it’s a lifeline.

Six years ago, Grady nearly closed its doors. Although the 121-year-old hospital has experienced a recent turnaround, it’s not out of the woods yet. For this three-part series, CL spoke with more than 50 doctors, patients, administrators, politicians, advocates, and others to learn about the fall, rise, and uncertain future of one of Atlanta’s most important institutions.

On a Tuesday evening in February, Dr. Leon Haley Jr. leads about a half-dozen doctors and medical residents through the organized chaos of <a href=”http://www.gradyhealth.org/clinic/69/” target=”_blank” http://www.gradyhealth.org/clinic/69/">Grady Memorial Hospital’s emergency room. Three hundred and seventy patients flood the facility over the course of the brisk winter night, including 66 distressed men and women anxiously awaiting medical treatment in the waiting room.

During the 12-hour shift, Haley’s team zips through austere halls past nurses’ stations as orderlies shuttle patients from room to room. Patients toss and turn in their stretchers as they wait for care in the bustling corridors. Ambient beeps resonate from an assortment of machines, occasionally interrupted by a radio dispatch from Emergency Medical Services.

The group discusses the patients, whose ailments range from hypertension to heart failure. One septuagenarian with chest pain remains stable despite the seriousness of the condition. Another nauseated sixtysomething has been vomiting profusely since arriving hours earlier.

In one room, an overweight woman hyperventilates from an asthma attack, gasping for air as a nurse tries to calm her down. The entire scene is a jarring sight to an outsider, but everyone making the rounds carries on with routine precision.

During Haley’s 16 years at Grady, he’s worked as its chief of emergency medicine, a senior administrator, an Emory University medical professor, and a researcher. Few people know the ins and outs of the 1.87 million-square-foot facility better than he does.

“You have to remember, everything comes through the emergency room department,” he says, scanning the room for incoming patients.

As the region’s premier level-one trauma center, Grady has earned much of its high standing because of the emergency care it provides. Over the years, though, the hospital has also gained a reputation for shabby accommodations and poor financial management, a fact supported in no small part by the $60 million debt it had accumulated by 2007. But Grady’s 2008 privatization and subsequent financial turnaround created the resources needed to improve many departments and boost staff morale.

The public hospital received critical equipment upgrades including new beds, imaging equipment, and trauma bed bays. Doctors that once “MacGyver”-ed their way through procedures saw their departments revamped. Grady’s leadership also invested in specialty clinics such as the burn unit and stroke center, which have helped the hospital become a destination institution, rather than only a hospital of last resort.

But the most critical overhaul didn’t include cutting-edge technology — it involved recordkeeping. In 2011, Grady installed a new $40 million electronic records system that shaves minutes off a patient’s trip to the ER and helps reduce treatment errors. While the change may seem mundane compared to angiogram suites and CT scanners, increased efficiencies can be the difference between life and death. “We measure the minutes because they’re so vital,” says Dr. Michael Frankel, Grady’s chief neurologist. “They make all the difference in the world.”

The advances arrived around the same time that the Affordable Care Act threw a wrench into Grady’s already precarious financial situation. As part of President Barack Obama’s controversial effort to provide Americans with greater access to health insurance, the federal government has linked some hospital funding to patient satisfaction. To earn that cash, Grady’s staff must make patients happy — something the hospital’s trying to accomplish not only through better care, but also by adding amenities such as gourmet wild salmon to the menu and premium cable in patient rooms.

Grady CEO John Haupert says specialty clinical services and upscale comforts are important, but he stresses that the institution won’t stray from its founding mission of treating the poor.

“At a hospital like Grady, one of the ways you do that is to create growth opportunities that help dilute the payer mix,” he says. “Not at the sake of the mission, but to sustain and grow the mission.”

Today, most conversations about the hospital revolve around financial woes and political turmoil. On the rare occasion that people hear about patient care, it’s usually a terrifying tale about a victim passing through the trauma center, or a friend of a friend’s horror story from the emergency room. To understand Grady today, CL went inside the 950-bed facility to follow firsthand the varying experiences of doctors, nurses, current and former patients, families, and administrators.

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Yvonne is a “Grady baby.” She was born just more than a decade before the hospital was desegregated in 1965. The 59-year-old African-American woman from Decatur has returned to the hospital over the years for medical treatment. Doctors replaced her knee in January, but she needed to be readmitted after complications arose. When we talked in her sixth-floor room, she felt hopeful about returning home that evening.

Grady’s going to take care of you. I was born here. Grady’s what I prefer. In my 59 years, Grady’s changed a lot. It’s come from being a hospital where poor people came and had to wait, to being a caring hospital.

I had an aneurysm in 2011, so my memory isn’t quite clear from that visit. This time I came for a knee replacement. I caught an infection in the knee replacement and had to come back. I’ve been here for eight days. The sixth floor has been great for me. They are caring. The nurses do their job physically and mentally. When you feel down and out, they lift you up.

Grady saved Kate Spahr-Walchle’s life. In 2007, the 36-year-old Decatur resident spent five weeks hospitalized in Grady’s burn unit — one of only two in Georgia — after Emory University Hospital doctors diagnosed her with Stevens-Johnson syndrome, a rare and potentially deadly skin disease typically caused by an adverse drug reaction.

The malady causes blisters that must be removed, leaving the body highly prone to infection. She says the meticulous skin-cleaning process can be excruciating — like a Brillo pad scraped against raw flesh. Imagine the sharp discomfort of gently touching a dime-sized blister on your foot. She felt that pain exponentially across four-fifths of her body.

Spahr-Walchle experiences some long-term SJS impacts. She’s constantly fatigued and literally unable to cry. But she is alive because of the medical care she received at Grady. Now a mother, Spahr-Walchle lives approximately two miles from the hospital. She can’t drive on the Downtown Connector’s Grady curve without feeling reverence for the infirmary.

Grady saved my life. I love Grady. I considered naming my son Grady. It is a really important place to me. I’ve gone back to visit, in particular, a few of the physical therapists and Dr. Walter Ingram, who is the head of the burn unit. He is a saint. ...

... SJS occurs when the body doesn’t know how to effectively eliminate the medicine, so the only way it can come out is through your skin ... You’re set on fire and stay on fire for weeks. All they can do is keep you from dying from infection. When your skin comes off that much, you basically have zero immune system. I would have pain beyond the maximum amount of painkiller they can give. They had to work fast before I went into shock and possibly died. They put me into a medically induced coma for around three weeks.

Once I had begun my recovery, there was a week where my skin would keep trying to grow back and then would burn back off. We guessed that it was because the medication I was on had a very long half-life. During that week I had about a 30 percent chance of survival, so I walked that edge. If I had gotten an infection, I wouldn’t have made it.

Last year, the Wall Street Journal reported that 85 percent of Grady’s admissions in 2011 came through the emergency room and averaged 7.2 hours per stay, exceeding the national average. Long waits rarely make for happy patients.

They also fail to inspire glowing survey responses, which now help dictate how much federal money Grady receives. At hospitals nationwide, patients receive a 27-question Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey about the quality of the staff, treatment, and facility maintenance. As a result, Grady officials estimate that an additional $4 million will be spent on efforts to raise survey scores so that the hospital can receive more federal funding. Chief Nursing Officer Rhonda Scott says the money will help improve overall patient experience, even if it is used to purchase everyday comforts.

We serve the famous, not-so-famous, the rich, the poor, insured, uninsured. We get everyone here. We’re challenged to meet everyone’s needs. ... When you have 350 people coming to your ER every day, there are only so many beds in the emergency department. It’s very difficult when you get 460 people at your door.

I need to make sure that the room is cleaned, it’s quiet at night, your pain is being managed, that you like the food and that it is served at the appropriate temperature. Food quality was a big issue for us. Based upon the patients’ feedback ... we’re having taste tests ... different pastas, meatloaf, salmon. It actually is good; I tasted it myself.

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Did we have cable service and good TV reception before? Yes. But now I’m saying, “Hmm, let’s talk to our patients. What else can we do?” They were getting limited channels so we enhanced their experience by adding ESPN, ESPN 2, CNN — things that consumers want to see.

We still have to make sure, based on patient needs, that we have enough staff. We’re not compromising. [http://philanthropy.com/blogs/philanthropytoday/woodruff-foundation-awards-200-million-to-atlanta-hospital/14787|Because of the new nonprofit corporation and an infusion of cash] ... whatever the nurses need, I’m able to purchase that. ... We actually lowered the cost of the services we were providing and have provided more services to the patient, so it’s not one or the other.

Quality and patient care have to trump everything. It will always be my priority, so I have to be sure that we’re giving the right care to the right patient at the right time. You could be with us for 24 hours or six weeks.

One part of Grady where patients could stay for weeks, or months, is in the sixth floor’s intensive care unit. Dr. Omar Danner is an assistant professor at the Morehouse School of Medicine and has been an attending trauma surgeon at Grady for four years. Morehouse takes trauma calls and tends to the ICU patients on a regular basis.

As Danner’s team makes its rounds through the ICU, it reviews a teenage male that was shot at least 10 times. He entered Grady in hemorrhagic shock and experienced numerous setbacks along the way to healing.

The trauma service is a 24/7 service, 365 days a year. Each day, a different attending surgeon with a staff and team of residents will be responsible for patients in the trauma bay. It’s one total system between Emory, Grady, and Morehouse. Everybody does his or her part to make the whole system work.

The patients here either came to the operating room or the intensive care unit for injuries that needed a higher level of monitoring, intervention, and care. ... We try to get patients to a point where they are safe to be transitioned to another level of care at a different facility without causing additional harm.

The gunshot victim had multiple injuries and complications related to the bleeding, the fractures, and the blood-thinning medication. He’s been adequately resuscitated and will now head to orthopedic surgery once he’s stable. ... He’ll be set to resume a normal life, and that’s the most important thing. ... Including ancillary staff, maybe 40 or 50 people are working in concert. It all goes to care for that one patient. When you’re talking about a level-one trauma center, this is the level required to get people through the system safely.

Several floors above the ER, specialized centers have been added not only to provide care for the poor, but also to attract patients with private insurance. Frankel says the Marcus Stroke and Neuroscience Center, filled with 18 ICU rooms and state-of-the-art technology, has become a regional leader since opening in 2010.

We created the Stroke Center at a time when we saw an aging population and a huge demand in an evolving field. It’s a field that will evolve the same way that interventional cardiology evolved 20 or 30 years ago. ...

The angiogram suite differentiates Grady from other hospitals. ... It allows you to look at things in three dimensions and allows the endovascular surgeon to approach the brain from inside the artery and fix aneurysms or blocked arteries that cause a stroke. Those arteries can be opened up just like you open up a coronary artery to keep the heart from dying. Here, you open up a brain artery to minimize the injury and hopefully eliminate paralysis or difficulty with speaking. It all happens very fast. We’re talking about minutes.

I think the emotional baggage that comes with neurological disease is very heavy, and it cuts across socioeconomics. If that’s a poor person with no resources, they cause tremendous problems. ... For those who are insured or employed, when they are disabled from neurological disease, it’s devastating.

We can have the richest person in Atlanta in one bed and the next room can have the poorest person. We’ll take care of them the same way. We’re including everyone and elevating the care at the same time.

The Stroke Center stands among the niche clinics that make Grady a destination hospital. While some administrators think such resources could be the key to Grady’s survival, others aren’t as convinced. When chief hospital psychologist Dr. Nadine Kaslow came on board in 1990, she wanted to work in a health care system invested in caring for people with chronic mental illnesses. She remains committed to Grady, but has concerns about its direction amid recent cuts.

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There’s more talk about service excellence. I actually think that there’s been so much increased attention to numbers and to following the rules that sometimes just really putting the patients first has gotten lost in the shuffle. For example, our patients don’t really have money to pay these prescription co-pays. Patients used to get their prescriptions here for free. I have a lot of patients now that simply don’t take their medicine because they can’t figure out how to pay for it.

We are spending a lot of time doing other things and not as much time as we need to with our patients. Grady just closed its Child Mental Health Services in 2012. ... I don’t personally believe that we have adequate mental-health services, outpatient mental-health services, for children in our community, so I think it’s a serious loss.

Mike Lunney worked as a Grady paramedic from 2007 to 2012. While he provided care to the very sick and severely wounded, he also tended to uninsured patients who have no choice but to visit the ER for low-acuity ailments such as fevers, colds, and minor headaches. Grady provides for everyone, and that has its drawbacks. Caring for such a diverse swath of the population puts a huge burden on an already overloaded ER. At times, EMS even becomes a free transportation service for those who can’t afford the bus or MARTA, occupying paramedics who could otherwise be focused on saving lives.

We would go into the housing projects, to $20 million houses in Buckhead, and everything in between. Grady’s patient base is a really interesting cross-section of American life.

A good call for me is a bad day for someone else. We yearn for the opportunity to use the skills that have the potential to make all the difference, but you also have lots of low-acuity patients and 911 calls that didn’t require lights and sirens. Taking people to the ER to get a medication ... that comes out of Grady’s pocket. Although the chance to save someone’s life is a large reason why EMTs do their job, more often than not, they are operating as a non-emergency transportation service to the disadvantaged and underserved.

Someone could say, “My back hurts.” They just had gotten into a fender-bender on the Interstate. I’m not going to be able to tell you a whole lot. I can take you to the hospital. I can’t tell you this isn’t going to cost you money and I can’t tell you it’s going to be worth your time. I can give you all that information and let you make a decision on your own.

We can’t deny them service. So even if it’s a splinter in their finger or a baby that won’t stop crying, it’s like, “Get in the ambulance and let’s go to the hospital.”

Last December, George Chidi’s mother, Jeanne, felt a sharp pain in her lower abdomen, along with some pelvic discomfort. George, a former Atlanta Journal-Constitution health care reporter, took her to Grady’s walk-in clinic because she was uninsured after recently being laid off. They spent five hours in the facility that usually refills prescriptions and treats minor ailments before doctors sent Jeanne to the emergency room. George started live-blogging in the understaffed and overcrowded emergency room, which treated 438 people that night. The Chidis spent a total of 28 hours at Grady.

I began to hear other people talking about how long they had been waiting: eight hours, 10 hours. That can’t be right. ... I knew what the averages were because of my prior reporting experience. We were starting to see the dysfunction pile up. They were running out of chairs.

It was scary and it felt dangerous. It felt like we were in a homeless shelter, not a hospital. I felt like I was at a bus station. People would pee on the floor, it really wouldn’t get cleaned up and they’d throw like an oversize maxi pad on it. There had been a triage process, but people were just sitting there in pain and misery.

We thought Jeanne’s condition might have been an ovarian cyst or cancer — something deadly. A serious diagnosis would have meant death because of her financial condition. My mother turned to me at 2:30 in the morning and said, “I’m not ready to die yet.” Those were the circumstances in that room, where she felt that she needed to utter a statement like that.

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There are bigger issues here than whether or not my mother got care. It wasn’t perfect. The care was acceptable, if not good. A diabetes diagnosis — you could probably be a little hands-off.

I really was steamed. I try to understand it in hindsight. I don’t know how extraordinary that experience was. I don’t know ... whether or not I should be outraged.

In the early morning hours of their ordeal, George met a dapper senior administrator, who “looked like he was wearing a thousand-dollar suit.” That man was Haley, who regularly talks to distressed men and women awaiting care.

Patients don’t choose the time of their heart attacks or their strokes. So we have to be prepared at 2 p.m. as much as we are at 2 a.m. I understand what patients go through. I understand that as an administrator, I know what it’s like to care of patients.

I purposefully work evenings, nights, and days depending on the nature of the shift. It gives me a sense of what patients have to manage on a regular basis. Hopefully, as we make decisions as a health system, we have a better sense of what the patient has to go through so you can be more patient-centered in your decision-making.

Five years ago, I honestly think the reputation of this place was pretty poor from the community perspective. People just had sort of a negative vibe about it, but that’s been a huge change.

The Grady experience surprised Sheila Sandas, an uninsured homeless woman who spent 11 hours in the ER in February after experiencing a headache and briefly losing consciousness. The middle-aged North Carolina native has a history of aneurysms.

My preconceived thoughts about Grady: city hospital, long waits, and a whole bunch of people. Honestly, I would’ve gone to another hospital before I came here, but I’m living at a women’s shelter with no insurance.

I was actually very shocked. They were prompt, right on top of getting things done, explaining everything to me. Communication was there, and I liked that.

Haupert is striving for experiences like Sandas’ to be the rule, not the exception. The safety-net hospital struggles in its effort to be all things to all people, but Grady’s CEO says he’s confident that the hospital will continue to improve patient service. Only time will tell.

Years ago, the model in public health care was, those who had money and were insured went to private health care. Those who didn’t have money went to public health care and what you paid with was your time.

Maybe it’s a bit naïve, but there’s a lot we can do from a service experience — a whole lot we can do from a service experience to improve those scores. We’re starting to see that happen. We’re not quite there. Most of public health care isn’t there. There’s no reason why we can’t have better patient care.

In part three of this series, CL looks at how Grady’s future hangs in the balance of crucial policy decisions at the federal, state, and county levels.

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