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Inside Stroger Hospital

Cook County Hospital was notorious for its agonizingly long waits in the emergency room. It was well known that a wait in the ER could last well over 12 or even 14 hours.


There's no doubt about it. From the outside, John H. Stroger Hospital looks much more appealing than its decrepit predecessor, Cook County Hospital, which wearily stands across the street. Stroger's shiny glass doors, fresh brick and limestone glisten in the sun, acting as an oasis to the Chicago area's uninsured and underinsured. But is Stroger Hospital more efficient and technologically advanced than Cook County Hospital? Or is the pretty facade a mere mirage?

When it comes to efficiency, it depends on your expectations. Cook County Hospital was notorious for its agonizingly long waits in the emergency room. It was well known that a wait in the ER could last well over 12 or even 14 hours. That problem has not been alleviated with Stroger.

"Once you're admitted, the wait depends on the day," says Dr. David Levine, director of adult emergency medicine at Stroger Hospital. "There are definitely days where people wait more than 24 hours for a bed. There are also days where people are in a bed less than two hours after the doctor decides to admit them. Our busiest days are Tuesday, Wednesday and Thursday, so it's actually easier to get a bed on the weekends."

Many of the 130,000 adults who seek medical attention at Stroger Hospital's emergency room each year come to the facility because they don't have a doctor. So if they have minor ailments like strep throat or the flu, they head to Stroger's ER. These people make up 30 percent of the patients in the ER. During the week, these patients are eventually referred to one of Cook County's off-site Urgent Care Centers, but they still have to go through the ER in order to be referred to the clinics. This contributes to the long waits.

"We're the busiest ER in the Midwest and one of the top 5 busiest in the United States," says Dr. Levine. "Just in the adult emergency department alone, we're seeing about 350 to 450 patients a day. If you look at our admit times, our most severe patients come right back followed by the second most severe. Most of the long waits are by people who don't have access to proper care. These are people who could go to a clinic and would not necessarily be in the emergency department if they had a primary care provider."

Some people blame the wait on Stroger Hospital's smaller number of beds. The new hospital has 464 beds in comparison to the 500 to 600 beds Cook County had upon its closing.

"It's a smaller hospital by far," says Dr. Quentin Young, chair of the Health and Medicine Policy Research Group and past chairman of the Department of Internal Medicine at Cook Country Hospital. "In this new era, I'm very worried that this much smaller hospital will be unable to meet the growing demand for services because of the huge fraction of the population without insurance--a cohort that is growing rapidly because of the chaotic state of the country's health insurance system. It's a good hospital, but if you overwhelm it, it won't be much better than the old hospital."

Hospital officials say the national health care system's transition towards outpatient care, coined 'drive-thru health care' by some, was the primary reason behind the decision to reduce the bed count.

"When I came to County 25 years ago, it was licensed for 1,800 beds," explains Dan Martin, chief of staff for the Cook County Bureau of Health Services. "It started gradually going down as health care started changing. Not everybody was being treated on the in-patient side; the shift was to outpatient care. Right now I think we're experiencing the long waits because of the economic conditions that exist--people losing health care, people losing their jobs including more of the working poor. At any given day, we may have 20 or 30 or 40 patients who may be waiting for an in-patient bed."

Hospital officials have tried to make accommodations a bit more appealing to those who have to wait. The new hospital's emergency room is an expanded version of Cook County's and includes 75 adult treatment spaces and 21 pediatric treatment areas. But even with those adjustments, there are still people lying on gurneys awaiting treatment in the hallways of Stroger's ER.

The new facility cost $623 million dollars to build, but funding is still a problem for the strained hospital. The county's 2005 budget allocated $896.24 million to the Cook County Bureau of Health--$20 million dollars less than what was requested. Even more daunting for those seeking services at Stroger are the impending cuts in staff. In order to save money in the overall Cook County budget, 559 jobs will be cut within the Bureau of Health's system. Two hundred and ninety-five Stroger staffers are getting the axe. This move may end up costing more in the long run considering that some Cook County health care workers are currently earning overtime pay of $50,000--and in some cases $100,000--according to a recent investigation by the Chicago Tribune.

But that's not even the worst of it. Federal funding is also at risk.

"There are two sources that give 90 percent of the funding for the Cook County Bureau of Health," explains Dr. Young. "They are Cook County, using property taxes as a major part of its portion, and the federal government. The state of Illinois is a 50/50 match, which means that if we spend $100 million on funding Medicaid in the state, the feds will give us $100 million. But the Bush administration does not want to fund anything but straight state dollars, not county dollars, which could have a huge impact on the amount of funding the state receives for public health care. It was well known and permissible in other administrations, and even this administration before now, that county Medicaid dollars were included in the state's reported Medicaid funding, which was then matched by the federal government. If Bush has his way, this will no longer be the case."

Martin says other hospitals' economic hardships are also having an adverse effect on Stroger and other county facilities.

"Private hospitals have the ability to say, 'We're not going to care for patients who belong to this certain health plan because we don't make enough money,'" he explains. "By law, everybody has to provide emergency services up to a certain point. But then they can discharge those patients, who will then have to come to the public health care system if they don't have enough insurance. That happens all the time. Smaller community hospitals are operating on the margin. As those facilities close, their patients end up coming to a public health facility, either Stroger, Providence or Oak Forest Hospital."

Despite its smaller patient capacity, the Illinois Campaign for Better Health has not received any complaints about the effectiveness of Stroger, but there are worries about the future.

"We run a helpline and get hundreds of stories about bad health care experiences," says Jim Duffet, executive director of the Illinois Campaign for Better Healthcare. "But for some reason we aren't getting these stories about Stroger; although I'm not sure how they will be able to continue if the meltdown of the insurance system continues. Last year, another 200,000 people in the state of Illinois became uninsured. Those individuals, plus those who are underinsured, may have primary care but no major medical insurance, or vice versa, so they'll be relying on the public sector for health care."

Though demand is growing, Stroger's technological advantages over the old hospital seem to be helping the staff take some of the edge off wait times.

"I think for the most part, the doctors' ability to provide care and the timeliness of when a patient is brought in for treatment and when the doctors do diagnostic testing has certainly improved," says Martin. "In the past, if you were a patient in the emergency room and needed X-rays, you'd have to go across the hospital to radiology. Now the radiology equipment is located by the emergency room. In the past, you'd have to wait for the film to become available and read by the radiologist. Now our X-rays are online in our information system. So a doctor is able to pull up a study as soon as it is performed."

Not only can a doctor evaluate X-rays from anywhere in the hospital, but multiple doctors can examine the image at the same time from just about anywhere.

"The beauty of this is that I can be looking at an X-ray here and the patient's doctor can be in a clinic somewhere in the building and be looking at the same thing at the same time," says Dr. Patrick Dunne, acting chair of the radiology department. "Our goal when we came here was equal access to information for everybody. In the old hospital, whoever had the piece of film in their hand had the information. Additionally, these digital images are accessible from home. So if it's the middle of the night and I get a call to look at an X-ray because of whatever specialty I have, I can get up, go to my home computer and see the X-ray. We've improved patient care by light-years just because of the ease of transfer of information."

In addition, the new digital system can save patients money. In the past, if a patient needed a copy of their X-rays for a second opinion or insurance purposes, they had to pay $5.50 for each sheet of film. For low-to-no income patients, that fee could easily become expensive, depending on the number of X-ray copies needed. Patients now pay a flat fee of $5.50 for a CD with digital images of their X-rays. This means that a patient can get 10 X-rays for $5.50 as opposed to $55.

The system also allows doctors to create voice-recorded reports, which cuts down the time they would usually spend typing up reports. This means preliminary diagnoses get to ER and trauma doctors faster. In addition, Stroger has more angiogram suites, CT-scanners and MRIs than the old hospital. The new equipment also features 3D imaging of X-rays and color X-rays, which show blood flow. These amenities mean more comfort for and accuracy in diagnosing patients.

"At the old hospital, we had state of the art equipment in 1955 when we first opened the radiology department," says Dr. Dunne. "That same equipment was still there in 2002 when we moved. As a result, we had to send our patients to various facilities around the city to get care. Our patients have enough hardships on them. Transportation should not be one of them. Nowadays, Stroger does everything here at this facility, including radiation therapy. So it's much more convenient for the patients."

Patients are not the only ones benefiting from Stroger's costly, but efficient technology--residents are said to be prospering from it as well.

"The fact that we easily can pull up the X-rays and show the residents a classic X-ray that illustrates a certain disease process is a great addition to our teaching tools," says Dr. Kim Nagy, associate chair of the trauma department. "Another advantage is our access to the Internet. If the residents are on duty during the middle of the night with the attending, and we're not sure about an unusual disease, we can get online instead of going to the library, which would be closed anyway because it's 2:00 in the morning."

Hospital officials say they are hoping to streamline another area of the hospital that has not fared as well in the transition. Cook County's long pharmacy lines have moved across the street to Stroger Hospital. Patients, including the elderly, have been known to wait in lines for upwards of 6 hours to pick up medication. Some have even been turned away from the pharmacy and told to come back the next day, even though their doctors specifically ordered the medicine to be taken immediately. The line for the pharmacy commonly snakes through the large room and spills out into the hallway, leaving many patients and their family members frustrated.

"It's terrible," laments Dr. Young. "The problem with the pharmacy is reflective of the larger financing failure of our national health care system. It would be very prudent, fiscally and time-wise, to give patients who are on chronic meds two or three months' worth at a time. But the policy decision to enhance reimbursement makes it so that the pharmacy can only give a month's supply at a time. So people end up waiting hours, sometimes days, for their medicine."

Stroger Hospital is hoping to stop the madness. They launched a mail-order program in March.

"I don't think we're where we want to be when it comes to the pharmacy," says Martin. "But I think we've made tremendous inroads in the last 3 to 4 years to try to address this problem. We fill 6,000 to 7,000 prescriptions a day. The average Osco or Walgreens does 250 prescriptions a day, you can see it's a large volume. Our average patient is on 3 to 5 prescriptions per day, so the demand is very high. We recognize that's a problem so we've tried to develop a plan that would take advantage of automation. We have robots that act as automatic dispensing machines to fill certain medications. The mail-order pharmacy services are available for patients needing refills that are on chronic medication. We're already filling 700 mail order prescriptions per day."

Stroger's trauma department is more streamlined, as well. There are 38 treatment stations in the trauma unit, including 9 observation units in which patients can stay for up to 23 hours for close monitoring. Because they deal with patients that are usually dangling between life and death, a more efficient system has literally helped them save lives.

"A perfect example is this: I was on call last night, and a patient came in who had a big gunshot wound to his chest," recalls Dr. Faren Bokhari, an attending physician at Stroger. "There was not a lot of commotion like there used to be because now you get a call from the ambulatory person, and you know they're coming. We don't have to rush around looking for things and trying to prepare because all of the supplies are in nearby cupboards. Before, we had to run all over the place looking for supplies because the old building plan didn't allow for us to store things. When a patient did arrive and they needed to be put down, it used to be that the nurses would run all over the place looking for medications. Now we have an electronic pharmacy that is located right behind our wall. So we punch in the patient's name and a compartment pops open and gives you the medication. We needed to give this gunshot patient blood, so we called the blood bank, and it came up in 2 seconds from the pneumatic tubes. It used to be that the blood bank people had to come running up here with the blood in a cooler, and if we had already gone to the operating room, they would be running all over the place looking for us. Now they can just call up and see if we've left. If we have, they can re-direct the tube to the operating room."

The old building's inefficiency, lack of comfortable conditions and the growing expense of maintaining the eroding structure, led politicians and hospital officials to decide it was time to build a new facility. The old hospital had an antiquated nurse assistance call system, no private bathrooms, no television, no air-conditioning and only one payphone for use by long-term care patients. Up to 29 patients shared the same bathroom in open wards at Cook County Hospital.

In the new hospital, each patient either has his or her own bathroom or shares it with one other person, has his or her own television, storage spaced and telephone. They have access to a top-notch calling system that continues to ring at the nurses' station until a button is pushed by the nurse attending the patient in need. To monitor nurse efficiency, the system times how long it takes for a patient to get a response. There is also air-conditioning. Regular patients of Cook County, who now visit Stroger, have noticed the difference.

"Now the patients don't want to go home," says Shirley Scarlett, RN, a nurse coordinator at Stroger. "You have a lot of patients who have been coming here for years, and they know how it was back in the old hospital. Now when they come, they are so amazed that they have their own bathroom and TV. Its high-tech, and they love it. They know their family can come here and visit them in a clean environment. The old hospital was beautiful, but it looked like it was from the Stone Age."

Though Stroger Hospital still has major hurdles to surpass when it comes to the excruciatingly long waits for both the emergency room and pharmacy service, the new hospital does excel when it comes to being technologically advanced. For now, patients can expect medical care that's comparable to most of Chicago's private hospitals--if they're willing to wait for it. But if cuts in funding and staff continue, the hospital may be in jeopardy of becoming a modernized version of its inefficient predecessor.

Published: June 01, 2005
Issue: Summer 2005


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