State investigates complaints at South Shore ER

WEYMOUTH -- It was built to be a true 21st-century emergency department, the biggest in the state, with 82 beds and a staff of 350. South Shore Hospital's two-year-old emergency room was so vast that when 17 ambulances once pulled up in a single hour, doctors didn't turn away a patient.

But the most important ER in Southeastern Massachusetts now faces serious questions about one of the most basic jobs in medicine: making sure the sickest patients get prompt care. Seven patients have complained to the state in the last two weeks that they waited hours with urgent conditions from acute appendicitis to a stroke, and an eighth wrote to the hospital last December about a nine-hour wait for treatment of chest pain.

"My experience in the ER was not only deplorable but also put me at great risk given my diagnosis," Stephen Swenson, a 58-year-old healthcare industry executive, wrote to South Shore administrators. He said medical staff left him waiting despite symptoms that could have been a heart attack, before they finally learned that the pain was caused by blood clots -- also potentially lethal if left untreated.

The complaints are under investigation by the Department of Public Health, which has sent investigators to the hospital to determine why some delays occurred. The controversy has also intensified an internal review of ER procedures at South Shore, which treats 75,000 emergency patients a year. Hospital officials say they have been making improvements for months, hiring a new emergency department director four months ago and, in June, launching a new system for determining how long patients can safely wait for care. Margaret Holda, the hospital's vice president for communications, declined to say whether the changes came in response to patient complaints, saying only, "Enhancing our emergency service is an ongoing priority."

Just two days before the new triage system began, the medical staff ran into problems providing care to seriously ill patients. On the night of June 1, despite arriving by ambulance with a diagnosis of appendicitis, Norma Jean Chiulli had to wait six hours. Her appendix burst while she sat in the waiting room.

"I don't understand how they build these big extensions to the hospital and they always say they don't have enough beds," said Chiulli, 42, who is recuperating at home in Rockland.

Dr. John Benanti, South Shore's emergency director, admitted in an interview that the hospital made a mistake in not treating Chiulli faster, saying that she and Virginia Chiulli, her mother, "expected their experience to be better and, I acknowledge, so did we."

Another hospital official apologized to Swenson earlier.

Some analysts say the complaints at South Shore illustrate a crisis that has hit many emergency departments. Massachusetts has lost more than a third of its acute-care hospitals since 1981, leaving just 67 to care for 2.7 million emergency room patients annually. Partly as a result, hospitals set a record for diverting ambulances to other facilities last December when a flu outbreak caused backups at many ERs.

"Every hospital is running at capacity," said Dr. Alan Woodward, director of emergency medicine at Emerson Hospital in Concord. "Any time there's a surge of any sort, we're treating patients in the hallway. That's not the way we want to work."

Unfortunately, emergency departments alone cannot solve the problem, according to Eugene Litvak, a professor at Boston University's Health Policy Institute who has studied the issue extensively. About one of eight ER patients needs to be admitted to the hospital for care, and Litvak has found that many of the delays and ambulance diversions could be avoided if hospitals did a better job of making sure beds in the main hospital were available.

"Everything boils down to the competition for rooms" at other hospitals he has studied, Litvak said. Boston Medical Center, for example, trimmed average ER waiting time from 60 to 40 minutes this year in part by rescheduling elective surgery to make more room for ER patients.

But South Shore Hospital, which just underwent a $65 million expansion, doesn't easily fit the model of the overburdened ER unable to find a place for patients. The expansion nearly doubled the number of beds in the emergency department from 48 to 82, while adding 14 operating rooms. The hospital went "on divert" -- sending ambulances to other hospitals for emergency cases -- for just 49 hours from January through May, a tiny amount for an ER its size.

As a result, much of the state investigation is likely to focus on how nurses and doctors at South Shore decide who gets care first. The trick is in making the right decisions based on limited information. "There are a number of places where errors can be made and the system can break down," said Paul Dreyer, state director of health care quality.

Problems could lie anywhere from the nurse who initially questions patients to the number of other patients who need treatment at the same time, he said.

Several patients who have complained about their treatment at South Shore say they sensed indifference to their suffering and a failure to recognize potentially life-threatening situations. For example, Maryann O'Neill said hospital personnel made her wait more than two hours when she arrived just before 10 p.m. on Aug. 20, 2003. She was sweating profusely, disoriented, and complaining of a headache so severe she could neither walk nor stop crying. "It felt like, if somebody threw an octopus on my brain and all the tentacles were squeezing as tight as possible," said O'Neill, who now lives in South Carolina.

When she finally saw a doctor, he raised the possibility that she could have suffered a stroke, a life-threatening condition that often requires clot-busting drugs to prevent brain damage. But she said he concluded the headache probably was the result of high blood pressure and prescribed an antidizziness medication before sending her home.

A few days later, still suffering, O'Neill returned to South Shore, where doctors quickly diagnosed a massive stroke and transferred her to Massachusetts General Hospital for treatment. There, doctors told her husband, Denis, that she had suffered a stroke on Aug. 20 as well. "We as a family feel that, if [Maryann O'Neill] was given the proper treatment on August 20, 2003, [the stroke] may have been prevented," the O'Neills wrote in their complaint to the Department of Public Health this week.

Citing confidentiality, South Shore officials declined to comment on O'Neill's complaint.

Swenson, who is an executive at a company that makes blood-transfusion equipment, said the ER staff was curt and insensitive when he arrived with excruciating back and right chest pain as well as shortness of breath Nov. 6. For five hours, he waited without getting an EKG that could have determined if he was having heart problems.

When Swenson wrote to South Shore CEO Richard H. Aubut detailing his treatment, he said he got an apologetic phone call from South Shore vice president Bonnie Matthews. "They looked into it and concurred that they dropped the ball," said Swenson, who said he was reassured that ER policies would change so that staff would be more prompt and attentive. Six months later, said Swenson, "it does not appear that anything has changed."

However, Benanti said ER changes are well underway. Early this month, the hospital implemented a five-level priority system for deciding how long patients can wait for care. Benanti said he has also emphasized improving communication so that patients know what to expect, and so medical staffers can keep track of patients as well as the more than 25 ER doctors and 150 nurses and nurse-practitioners. He was pleased with how smoothly the ER handled the sudden rush of 17 ambulances in one hour earlier this month.

"We were able to do it by communicating," he said.

But the hospital has a tall order to win back the trust of people like Christine Howard, who went to South Shore's ER for an asthma attack, but got so anxious waiting that she called an ambulance to take her to a second hospital.

"They didn't take into consideration the seriousness of my asthma," said Howard. "I'm not going [to South Shore] again."

Scott Allen can be reached by e-mail at allen@globe.com.