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It was no routine inspection. The investigator who showed up at the Santa Rosa, Calif., hospital that June morning three years ago wasn't interested in checking for germs on table counters. Anonymous reports had come to her agency, the state's department of health services, claiming the hospital was endangering the lives of surgical patients."We all had to go meet with the official, one at a time, in private," says a nurse who is on the hospital staff. "It created quite a stir. But a lot of people were relieved because they knew what was happening was wrong."
The official quickly uncovered the truth: An unlicensed assistant was performing surgical procedures, including suturing deep-tissue wounds and placing pins in bones. "Patients had no idea that the person doing these things could be an assistant without even a college education," the staff nurse says. Although the hospital denies that patient care was ever compromised, a quick end was put to the assistant's illegal operating career. Too bad it didn't put an end to the story. A survey the following year by the California Healthcare Association revealed that unlicensed staff was assisting in surgery in at least 20 California hospitals.
If you think this sounds a little scary, you're in for an even bigger fright. For what unfolded in California is only a symptom of something far more serious. In a six-month investigation, Reader's Digest has uncovered evidence that your health -- even your life -- is being put at risk in the last place you'd expect. In hospitals, doctors' offices and outpatient clinics, the person you have the most contact with may not be a physician or a nurse. He or she could easily be someone whose medical education consists of a few days or weeks of training, much of it provided on the job. It could be someone who doesn't even have a high school degree and who, not long before, was cleaning tables in the hospital cafeteria.
The full price we are paying for this amateur care is tough to know because so many incidents are shrouded in secrecy. Lawsuits stemming from medical-staff errors are usually settled out of court, and then hushed up by gag orders.
Most of the nurses and aides contacted by Reader's Digest were willing to speak only if their names were not used. Several acknowledged that they'd been in situations where unqualified nursing care endangered a patient's health, yet they wouldn't discuss details for fear their employers would punish them.
Among those interviewed was a former aide in a Pennsylvania hospital, who spoke bluntly about her trials as an unlicensed assistant: "I often felt like I had a patient's life in my hands, and I was wondering, 'What do I do here?' I would be scrambling to take vital signs and respond to patients' calls. Then I'd try to evaluate what were the urgent things I should get a nurse for and what I could take on myself. It was wrong because I'm an aide, not a nurse."
It used to be that the duties of unlicensed aides were limited to tasks that required little training, such as taking patients' temperatures, bathing them or helping them move from bed to chair. But during the past decade, pressures to slash costs have changed the aide's job, sometimes radically.
Nowhere was the money squeeze tighter than in hospitals, where Medicare payments were falling even as competition heated up for managed-care contracts. To boost their bottom line, hospitals hustled in management consultants who told them, among other things, to cut labor costs.
You didn't have to be a brain surgeon to figure out the next step: Unlicensed aides typically make $10 an hour, compared with $21 for registered nurses. So hospitals and clinics began hiring more "unlicensed assistive personnel," as they were called, who took on new duties previously carried out by registered nurses or licensed practical nurses (trained to a lesser degree than RNs). Inevitably, too many aides wound up in situations where they were dangerously over their heads.
Early one January morning in 1996, a woman in Hayward, Calif., called her doctor's clinic complaining of symptoms that were classic for an abdominal aortic aneurysm -- an extremely dangerous swelling of the artery that carries blood from the heart. Unknown to her, the medical-advice phone line was manned by unlicensed assistants.
She called four more times during the day, yet the aides decided she didn't need immediate attention. Not until late in the afternoon was the woman allowed to see a doctor, and by then it was too late. The aneurysm ruptured while she was being prepared for emergency surgery, causing her to suffer an excruciating death.
Horror stories like this shouldn't surprise anyone, given the wrenching changes in nursing staffs. According to Peter Buerhaus, senior associate dean for research at Vanderbilt University School of Nursing, some 100,000 unlicensed aides were hired by hospitals from 1995 to 1996, half of whom were let go the following year. Their numbers then remained relatively stable through 1999 -- the last year for which Buerhaus has solid calculations. To come up with his figures, he had to use U.S. Census surveys, since no one tracks the nationwide employment of aides in hospitals anymore.
"The American Hospital Association stopped collecting data on unlicensed aides in 1994, and a lot of nurses think they did it on purpose because they didn't want the public to know what was happening," says Christine Kovner, a nursing professor at New York University.
This suspicion is unfounded, says AHA Senior Vice President Rick Wade. He maintains that survey questions about the number of aides and other support staff hired by hospitals were eliminated for a practical reason. Confusing and inconsistent job titles, he says, made the task of identifying aides too cumbersome.
As for RNs, tens of thousands were cut by hospitals in the mid-1990s and then added back, according to Buerhaus. Lost in the shuffle were untold numbers of experienced nurses who, not coincidentally, made the most money.
Amid this staff turmoil, RNs have had to face additional burdens. Many find themselves hostage to huge piles of paperwork that can keep them from checking on their patients. "We're required to do much more documentation than ever before, both for managed care and for legal reasons," says Sandy Eaton, an RN at Quincy Medical Center in Quincy, Mass. "On one floor there is a ten-page paper that must be filled out each time a patient is admitted. And since only RNs are allowed to complete all those forms, they spend less and less time with patients."
Then there's the matter of the patients themselves. In trying to cut costs, hospitals have been quickly releasing all but the sickest patients, and RNs say they're bearing the brunt of it. Already stretched thin, they're now caring for people who have been shuffled out of the intensive care units (ICUs) onto other floors of the hospital.
As an RN with 30 years' experience describes the situation at her California hospital: "Patients who are still on ventilators or cardiac monitors are being moved out of ICUs to floors where there's one nurse for every five or six patients, rather than one nurse for every two patients as they would have in ICU -- the only place where I'd feel comfortable leaving a family member alone these days."
Even her daughter's presence at the bedside couldn't help 61-year-old Shirley Keck, who was hospitalized with a diagnosis of pneumonia in February 1998 at Wesley Medical Center in Wichita, Kan. Keck's condition steadily worsened, according to the later testimony of her daughter, Becky Hartman. Eventually, her mother "was ripping at IVs, drenched in sweat, literally gasping for breath," says Hartman.
Keck's daughter testified that for 3 1/2 hours she begged for more help, but it appeared to her that her mother's nurse was always in a hurry. Hartman recalled hearing the nurse "bark out that they were understaffed, had been working six days a week, twelve-hour days, and that she could only get to one person at a time." According to Hartman, the severity of Keck's condition was missed by this nurse and others on the hospital staff who entered the room. Hartman also stated that at one point someone who appeared to be a nurse came into the room to check Keck's vital signs. When Hartman began asking questions, she testified, the woman told her that "she was sorry, but she was from pediatrics and they were short-handed. She would let the nurse know I was concerned."
Finally, Hartman put in a frantic call to her father, who was home ill himself. Returning to the hospital room, she was met by a nurse who said a chaplain was waiting for her. Her mother had gone into near respiratory arrest, but Hartman was told that "they had worked hard and saved her." "Saved her?" Hartman replied. "You did this to her!"
By then Keck's oxygen-starved brain was permanently damaged, according to a suit brought against Wesley by the Keck family. Keck's attorney asserted that under the hospital's own guidelines, at least five RNs, two licensed practical nurses and four aides should have been on duty. In fact, he contended, there were only four RNs, no LPNs and three aides to care for Keck and 41 other seriously ill patients.
The hospital has denied all liability, maintaining that the staffing of nurses and other professionals met appropriate standards, and that the staff was not negligent in monitoring and treating Keck. The hospital further claimed that the fault lay with doctors who misdiagnosed Keck and did not order proper treatment -- a charge the doctors denied. Last year, Wesley settled for $2.7 million.
Whether the issue is distracting paperwork or chronic understaffing, one result is clear: When you ring that call button, the odds have jumped that an unlicensed aide will come through the door.
Some health care experts think that the problems posed by these unlicensed aides are greatly exaggerated. "We've tried to reduce costs without affecting quality," says Michael Waters, a former chairman of the board of governors at the American College of Healthcare Executives. "Hospital errors do take place, but they are rare. I believe hospitals are very safe places to be. I don't want to see unlicensed aides doing things they're not qualified to do -- but you don't need an RN to change sheets or empty bedpans."
Hugh Greeley, a consultant to hospitals on medical-staffing issues, suggests reasons why nurses are raising concerns about these aides. "The nursing profession believes this is a serious issue," he says. "But it also believes that hospitals should be staffed with a greater ratio of nurses per patient, and that these nurses should be paid more."
In any case, Greeley says, there's no cause for worry in nationally accredited hospitals, because they don't allow aides to perform tasks that could endanger a patient's life.
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