This might explain a lot: the Dallas Ebola hospital E.R. is run by an outside contractor.

[pnwmom]

Not by the hospital itself. No wonder their actions were so poorly coordinated. (And oriented to the bottom line.)

A recipe for disaster.

http://www.dallasnews.com/business/health-care/20141018-ebola-crisis-is-testing-presbyterian-hospital-dallas.ece

Presbyterian’s website says emergency department doctors are independent physicians — common language in hospitals, where the separate but interlocked interests of single doctors, physicians’ groups and the institution itself can be bewildering.

At Presbyterian’s ER, the rest of the story is even less known. The signs all say Presbyterian, but Presbyterian doesn’t run it. The entire department is outsourced to an independent contractor.

SNIP
In such arrangements, common nationwide, companies typically assume many duties for the hospital, including recruiting, scheduling, supervising and disciplining doctors and nurses. They also maintain electronic medical records, coding — the process of identifying the services rendered for billing purposes — and bill insurers and patients.

The arrangement means it is possible that the night the ER sent Duncan home with antibiotics and a wrong diagnosis of sinusitis, no Presbyterian employee was involved.

Emergency Medicine Consultants’ help-wanted ads indicate its doctors are independent contractors to the company, not the hospitals, and are then assigned by the company to ER shifts.

SNIP

[Aerows]

1. Waste disposal

is going to be a particular hazard.

[pnwmom]

2. Yes, it's been a huge problem already. n/t

[JDPriestly]

6. Yes. Years ago, someone who was in a position to know a great deal about that issue

told me that waste disposal in the US can be a very corrupt business. That's second-hand information, but that is what I have been told. The destruction of the waste and the cleaning of the hospital have to be overseen by some third party, ideally the government. Is that too much to ask in Texas -- even when Texans' lives are at stake?

[pnwmom]

9. Isn't it well known that organized crime is involved in waste disposal?

Probably involved in hazardous waste as well.

That's a scary thought.

[JDPriestly]

13. That is what I have heard. Of course, they might not be involved in the disposal of ebola

waste. But it is Texas, so anything awful is possible. Sorry if that offends Texan Democrats. Obviously I'm not saying that about you. It's the Texas Republicans and right-wing independents who are the problem.

[underpants]

32. Waste Management ( the corporation) was able to

Break into that market in the Northeast. Yes it was heavily controlled by organized crime - great way to clean money.

[Aerows]

10. WELL-KNOWN

Among business owners. Various trades know this well.

[ReRe]

16. Ahem...

... if that hospital (or any hospital for that matter) does not have at least one autoclave in house, it should be shut down immediately.

[magical thyme]

23. Emory doesn't have an autoclave in house

Waste from Brantly and Writebol was a problem for them. They had to go to the neighboring CDC facility to borrow their autoclave so they could get rid of their waste.

Most hospitals don't have on-site autoclaves any more. Everything is disposable.

[ReRe]

25. Disposable doesn't matter.

All specimens/contaminated articles, such as needles, etc., that go into those orange Hazmat bags, are supposed to be autoclaved before they are otherwise disposed of. I used to work in a medical laboratory and one of my duties was to keep the autoclave going. It was a stinky job, but somebody had to do it.

[magical thyme]

29. corrected: most hospitals no longer have the huge autoclaves needed for Ebola wastes.

(Reuters) - U.S. hospitals may be unprepared to safely dispose of the infectious waste generated by any Ebola virus disease patient to arrive unannounced in the country, potentially putting the wider community at risk, biosafety experts said.

Part of Emory's solution was to bring in one of the university's large-capacity sterilizers called an autoclave, which uses pressurized steam to neutralize infectious agents, before handing the waste off to its disposal contractor for incineration.

Few hospitals have the ability to autoclave medical waste from Ebola patients on site.

Dr. Gavin Macgregor-Skinner, an expert on public health preparedness at Pennsylvania State University, said there's "no way in the world" that U.S. hospitals are ready to treat patients with highly infectious diseases like Ebola.

"Where they come undone every time is the management of their liquid and solid waste," said Macgregor-Skinner, who recently trained healthcare workers in Nigeria on behalf of the Elizabeth R. Griffin Research Foundation.

http://www.reuters.com/article/2014/09/24/health-ebola-usa-hospitals-idUSL2N0RP00E20140924

[exboyfil]

27. Rodney Dangerfield - Back to School

Thornton Melon: First of all you're going to have to grease the local politicians for the sudden zoning problems that always come up. Then there's the kickbacks to the carpenters, and if you plan on using any cement in this building I'm sure the teamsters would like to have a little chat with ya, and that'll cost ya. Oh and don't forget a little something for the building inspectors. Then there's long term costs such as waste disposal. I don't know if you're familiar with who runs that business but I assure you it's not the boy scouts.

[underpants]

33. Worldwide - see Somalia

A lot of medical waste from Asia was dumped off the Somalia coast after it's government collapsed.

[TexasTowelie]

8. Not if they burn down the hospital to collect the insurance.

Okay, that is a speculative conspiracy theory. However, if something of that nature occurs I wouldn't want to be an employee of the state fire marshall's office sifting through the evidence.

[Aerows]

11. This isn't whack-a-doodle-do 101

It's pretty well known among business owners that waste disposal is a corrupt industry. They will charge you for an industrial container that gets defaced by no fault of your own, not pickup the trash on the scheduled day, and attempt to double bill you.

Not all are like that, but MANY are, and while the plural of anecdote does not equal data, it's obvious enough that it has been noted by MANY in their communities.

[xocet]

14. Here is some information on the disposal of Ebola-generated medical waste....

Oct. 17, 2014 2:44 PM ET
Koster aims to ban Ebola waste at St. Louis center

JEFFERSON CITY, Mo. (AP) — Missouri Attorney General Chris Koster is seeking to block a sterilization company from handling any medical waste contaminated with Ebola at its St. Louis facility.

Koster said Friday he has asked a St. Louis Circuit judge to grant a temporary restraining order against Stericycle Inc. He says treating waste potentially infected with Ebola poses a threat to workers.

Calls from The Associated Press to Stericycle were not immediately returned Friday.

Stericycle received a federal permit earlier this month to remove waste from the Texas hospital and home where a man with Ebola virus stayed before dying.

...

http://hosted2.ap.org/MOSED/94cae84c359d4d878363bb29ca5cdc01/Article_2014-10-17-MO--Missouri-Ebola%20Disposal/id-0bef69af571148889c603d534e5bb351

Oct. 17, 2014 6:30 PM ET
St. Louis site won't handle Ebola-infected waste

JEFFERSON CITY, Mo. (AP) — A sterilization company on Friday agreed not to treat any waste potentially infected with Ebola at a St. Louis facility after the state attorney general sought a temporary restraining order, alleging that the company had previously violated waste-management laws.

A St. Louis Circuit Court approved the deal between Stericycle Inc. and Attorney General Chris Koster's office. Earlier Friday, Gov. Jay Nixon announced that the state now can test for suspected cases of the virus in a Jefferson City lab.

Illinois-based Stericycle received a federal permit earlier this month to remove waste from the Texas hospital and home where a man with Ebola stayed before he died.

In his filing seeking the temporary restraining order, Koster said that treating potentially infected waste would pose a threat to workers. The company previously violated waste-management laws by failing to properly test and operate its equipment or track infectious materials, the filing said.

...

http://hosted2.ap.org/MOSED/94cae84c359d4d878363bb29ca5cdc01/Article_2014-10-17-MO--Nixon-Ebola/id-821712d1c7d44f54bff587680a3af122

[ColesCountyDem]

20. Why can't the waste be incinerated?

I'm genuinely confused why this isn't done.

[Avalux]

34. Autoclave.

There are only four facilities in this country that are fully equipped to handle patients with an RG4 infectious disease....they autoclave EVERYTHING that comes in contact with the patient.

Ebola such a messy disease, and clean up amasses a lot of waste material. All of it goes in the autoclave, and is then disposed of as normal biohazard waste. This takes a tremendous amount of resources and manpower and as a result, these facilities can only handle a patient or two at a time. Combined, there are only 8 beds TOTAL in the entire country. Emory has a 2 bed capacity, I believe.

[ColesCountyDem]

39. Let me ask the question a different way:

Since an incinerator burns at a higher temperature than an autoclave sterilizes the used sheets, bandages, 'sharps', etc., is it not in fact safer to incinerate the medical waste locally, than truck it somewhere distant to be autoclaved and then placed in a landfill?

I do know that Mr. Nelson was cremated, upon recommendation of the CDC, citing safety concerns about any other method of disposing of his remains. Logically, shouldn't the same be true for medical waste?

[Avalux]

44. Those 4 hospitals have autoclaves that can handle a large volume of waste.

So there's no transporting infectious materials anywhere. Incineration works, but most hospitals don't have the means to incinerate, so they have to transport the waste to do it. Transporting is dangerous for obvious reasons.

That's why there are only 4 hospitals in the country who can handle the disposal of Ebola contaminated waste on site. These chose autoclaving because:

1. not toxic (incineration releases dioxins and furans into the atmosphere)
2. easier to operate
3. less cost to operate (no fuel needed)

[ColesCountyDem]

45. Wait a minute. I was referring to Dallas Presbyterian, not the 4 Level 4 hospitals.

That's the hospital referenced in the OP.

[Avalux]

46. Specific to Dallas Presbyterian?

The waste from that facility is transported and incinerated.

[ColesCountyDem]

47. Yes, that was what I was asking.

I knew disposal of their waste was an issue, which is why I asked if it wasn't safer to simply incinerate it. Some how, our messages got off track. I think we're back on the same page now.

[Avalux]

48. Hmmm....let me ask you a question....

"safer to simply incinerate it" - as compared to what? That's what I thought you were asking; if incineration was safer than autoclave. No it's not, they both use high heat; autoclave is wet.

Incineration certainly isn't simpler, especially when the waste has to be driven somewhere to do it.

[ColesCountyDem]

50. I'm well aware of what an autoclave is, for pity's sake!

It's safer to incinerate the medical waste nearby, or (likely) in the hospital itself, than to transport it far away to be autoclaved. Furthermore, the heat generated by an autoclave is far less than that generated by an incinerator, and an incinerator reduces the medical waste to ash, blobs of sterile glass and sterile metal.

I don't understand why you're so rah-rah about autoclaving the medical waste, rather than incinerating it.

[Avalux]

52. Because I know what I'm talking about. n/t

[ColesCountyDem]

53. Of course you do.

The rest of us are just blithering idiots with no understanding of heat, pathogens, the danger of transporting hazardous material long distances, etc. .

[JDPriestly]

3. Yet another round-about organizational form that permits owners to avoid responsibility

to employees and the public. Ugghh. We need to prohibit these practices. Lines of ownership and responsibility should be clear -- to the owners -- to the employees -- to the public -- and to the government.

[xocet]

15. How true! n/t

[Liberal In Texas]

36. This won't stop Presby from being named in the upcoming lawsuits. n/t

[JDPriestly]

40. Ever heard of bankruptcy court? That's where these fly-by-night

very small private contractors go when they die. It's called no liability heaven. The whole point in forming these small companies and farming out the hazardous work to them . . . . .

[Fumesucker]

4. Good find

And yes, I think it does explain a lot.

Very unlikely to hear anything about this on cable news.

Systems optimized for efficiency of one sort lose robustness in other measures. Dallas Presbyterian's ER is optimized to most efficiently extract money from the patients which means that all other considerations take a back seat to that.

[pnwmom]

7. +1. n/t

[redruddyred]

21. this is the problem with healthcare run as a business.

...namely, that it's run as a business.

I don't get cable tv, but if they're pushing the panicmongering as hard as I hear they are, let's hope something good comes out of it.

eg more and better health care reform.

[Live and Learn]

5. So often, problems are caused by contracted private companies

and yet rarely are they held accountable.

[world wide wally]

12. The 9 most frightening words in the English language are...

I'm from a corporation, and I'm here to help.

[ReRe]

17. You need to copyright that adage...

... unless you seen it somewhere else. And unlike Ronnie's statement, it is a fact. The
Corporation is what can't be trusted in this world. Self regulation? What a fucking joke.

[freshwest]

30. There it is! The sacred profit motive makes anything possible!

[Freddie]

31. ...line my pockets with taxpayer $$

[ReRe]

18. The ER Doctors...

... are private contractors? Wonder how much of the rest of the hospital services were contracted out? "Presbyterian Privatized Hospital" might be the proper sign for the top of the building, in flashing neon.

[DAMANgoldberg]

59. The "green" team here

Carolinas Medical Center & Carolinas Mercy Hospital have privatized ER services. I have not been to the "purple" team (Novant Presbyterian) so I can't speak to them.

[mnhtnbb]

19. Looking at their website--Emergency Medicine Consultants--

it indicates they provide ER docs, Physician Assistants, and Nurse Practitioners. That wouldn't include
any other nursing staff--which would be provided by the hospital--and from experience I can tell
you the Nursing Administration would fight hard--VERY hard--to control the nurse staffing of any
and all departments--including ER--in the hospital. Just because the website says they recruit
Nurse Practitioners, doesn't mean the Nursing Administration at Texas Presbyterian agreed to that.
There could also be a war going on between PA's--provided by Emergency Medicine Consultants--
and Nurse Practitioners if they are both providing services in that ER.

This might explain the early brouhaha about the communication between the ER doc and RN who
saw Mr. Duncan the first time. It's very possible there is a turf war going on in that ER.

The arrangement itself--of contracting ER doc services--is not that unusual for a community hospital.
For a hospital the size of Texas Presbyterian, it is kind of surprising. On the other hand, it's Texas
and I'll wager that a lot of the docs there are still fiercely independent (Republican, too) and not
going to commit to a relationship where they become employees.

http://emdocs.com/our_company


I would also suggest you edit your OP to indicate that the Emergency Department at Texas Presbyterian
is staffed by docs managed through an outside contractor. There is no indication--anywhere--in the article
you cited that the entire hospital is managed by an outside contractor. There really is no answer, either,
to the question of whether any nurse practitioners hired by the outside contractor are assigned to that ER.
One place to look for that answer would be to see if Texas Presbyterian has any open RN or LVN or aide
positions for the ER.


On edit: I just went on the Texas Presbyterian Hospital website--careers--entered RN all department
any category (FT, PT, etc) any shift and it did come up with a listing for an RN FT days for
the Emergency Department. When I clicked it, it indicated it was no longer active. If they had an opening,
with the decline in volume from the Ebola story, they've probably pulled the position. But it does
give credence to the possibility that only the ER docs are provided by an outside contractor, and that, in itself,
is really not all that unusual. But the onus, then, is on the contractor for that doc that night discharging
Mr. Duncan home with an Rx for antibiotics. The hospital can't contract away its ultimate responsibility,
but it does reinforce the need for better management and oversight of the ER docs.

[Fumesucker]

22. A big portion of the purpose of a corporation in the first place is avoiding responsibility

And avoiding responsibility has a lot to do with subcontracting services too.

This will be tied up in the courts for a long time just trying to determine who is responsible for what. The lawyers will be ecstatic even if no one else is happy.

[pnwmom]

28. Thanks for all the info. And yes, I made the change to the subject line that you suggested.

It also made me think about some sub-standard care I received in an urgent care center that is supposedly connected to the larger hospital where I go. I went for treatment for a UTI, and the doc told me he was going to order a urine culture and then failed to do it. When I called up for the non-existent results, the nurse indicated he wasn't a regular employee. Now the screw-up makes more sense.

But he did write that prescription for antibiotics, so I had it to take anyway.

[eShirl]

24. SN:FUBB

situation normal: fucked-up beyond belief

[Sunlei]

26. second class healthcare system for profit. Lets see Mr. Duncans bill.

[hatrack]

35. Kind of like FedEx insisting that its drivers aren't employees

http://www.businessweek.com/articles/2014-10-16/fedex-ground-says-its-drivers-arent-employees-dot-the-courts-will-decide

This should surprise absolutely no one. Public health? Training? Fuck that - if it doesn't help our bottom line, we don't do it.

[pnwmom]

38. I shouldn't have been surprised but I was. Now I understand why so many people

find out their insurance doesn't work in the E.R.

[mnhtnbb]

42. FedEx does that to avoid withholding for social security, taxes, etc.

That's not the rationale in the hospital setting with docs, and the hospital still has an obligation
to provide documentation of appropriate certification, training, continuing education, etc. of the docs
staffing the ER in order to meet accreditation standards--which have to be met for reimbursement. It's not an end run
for any of that.

[AwakeAtLast]

37. Well isn't that just a perfect storm of clusterfuck!

You can quote me on that, BTW.

Basically, it's the fast-food equivalent to health care. Ugh.

[Electric Monk]

41. k&r for visibility. nt

[Tweedy]

43. The comments on your link are a real hoot

Apparently, a lot of state's rights people have no clue what state's rights mean. Many seem to think the federal government controls state hospitals. Remember a short time back when so many were screaming keep the Feds out of health care? How quickly they forget.

Yet, my heart goes out to the beautiful city of Dallas and all of those who have been so tragically hurt by the mistakes made at that hospital.

[butterfly77]

49. Kick...

[The Velveteen Ocelot]

51. And the hospital itself can escape liability (maybe) for what the ER people did.

[Fumesucker]

54. Amber Vinson just hired hotshot lawyer Billy Martin

The lengthy legal joust begins.

[The Velveteen Ocelot]

56. That could get complicated, legally.

If she gets workers' compensation she can't sue her employer (whether that's the hospital or whatever contractor she works for). But there are other people or entities who might be at fault - maybe even the CDC, but there are issues of sovereign immunity and all the hoops you have to jump through to satisfy the Federal Tort Claims Act. No wonder she hired some big-shot lawyer; she'll need one.

[Fumesucker]

57. The only way the truth of what was going on in Dallas is going to come out is through the courts

[The Velveteen Ocelot]

58. Probably true - except that the corporate entities

probably will have a significant motivation to settle - with a confidential settlement agreement, of course.

[KingCharlemagne]

55. Capitalism, baby, got to love it! BTW, where are all the Libertarians now that

Ebola has appeared inside the U.S.? I haven't heard one peep out of any of those retards lately on Facebook or here.