Originally published Wednesday, October 22, 2014 at 6:49 PM
DALLAS -
Even before the crisis, flaking paint, leaking pipes and other problems had begun to show at Texas Health Presbyterian Hospital Dallas.
In recent years, the 48-year-old hospital has been knocked for its emergency care and seen an overhaul in upper management.
Ebola appeared out of nowhere. A delayed diagnosis, a patient's death and two infected nurses reflected a cascade of mishaps while 'Presby,' as the locals call it, became linked to a fearsome disease and global exposure of the worst kind.
This has been a hospital under siege. Ever since a man from Liberia entered the emergency department - one that, as few know, is run by an outside contractor, not the hospital - a new reality has altered Presbyterian's course.
TV crews circle and parking attendants monitor underused garages, while inside, employees struggle to reconcile emotions.
It's 'difficult to be proud to work here right now,' said one physician, who like some other workers agreed to speak only if not identified. 'Suffice it to say, morale is low.'
Workers are 'doing the best we can in an unprecedented and difficult situation,' he said. 'I'm optimistic we will overcome this difficulty.'
With Presbyterian's two Ebola-infected nurses sent elsewhere, the 24/7 tension of caring for them had abated. But scrutiny remains intense over how the hospital treated Thomas Eric Duncan, who died there, and whether mistakes potentially exposed dozens more to the disease.
Presbyterian's employees have tried to maintain a show of calm and integrity in the face of withering scrutiny. Meantime, a hospital generating $600 million in annual revenue faces a deep loss of public trust and, for now, some loss of patients.
Many experts say it's probable other U.S. hospitals might have had the same experience if Duncan had shown up with a Liberian background, fever, bad stomach pains and a piercing headache.
But Presbyterian is where it happened. Initial confidence by executives has given way to open confession of error and apologies, but also increasingly assertive defenses and employee pep rallies, shifts that coincided with the hiring of public-relations giant Burson-Marsteller.
'Thrown under the bus'
The threat of Ebola has dominated conversation in and beyond the hospital. At one of a series of staff forums called by hospital management, nurses spoke favorably of the hospital while castigating the federal Centers for Disease Control and Prevention (CDC), a Presbyterian cardiologist said.
Many ICU nurses 'were angry and concerned,' the cardiologist said. 'They were asking for more specific training. People were frustrated by the way Presby had been represented by the media and the CDC. They felt they had been thrown under the bus.'
The CDC didn't do enough to help the hospital adequately prepare for an Ebola outbreak, they said, and the agency's protocols weren't sufficiently stringent.
Hospital leadership responded, the cardiologist said, by saying it would require employees treating Ebola patients to wear full hazmat suits, more than what the CDC called for at the time.
Presbyterian has long been known as one of the region's more prestigious hospitals. Some of Dallas' most notable physicians practice there, and in 2013 the hospital treated former President George W. Bush for an artery blockage.
The medical complex includes the Margot Perot Center for Women and Infants, named for the wife of billionaire H. Ross Perot.
The hospital first opened in 1966, eight miles north of downtown Dallas, a 300-bed facility near a couple of farms at the city's edge.
Today it's surrounded by some of the densest residential and commercial development in North Texas. Presbyterian is the Dallas flagship of Texas Health Resources (THR), one of the largest not-for-profit health-care providers in the state.
Last year, Arlington, Texas-based THR generated $3.8 billion in total operating revenue and had $6.1 billion in assets. The system has 17 acute-care and six short-stay hospitals, more than 22,000 employees, 3,800 licensed hospital beds and more than 5,500 physicians with active staff privileges.
With nearly 900 beds, Presbyterian accounted for about $600 million in revenue and reported net income of $40 million, according to the American Hospital Directory.
Like many such operations, the emergency department is larger than the label 'emergency room' would suggest. As at most hospitals, its entrance is the only part of the campus where lights blaze into the night.
Each year about 75,000 people arrive there, either unannounced, as Duncan did Sept. 25, or by ambulance, as he did three days later.
By Oct. 8, he was dead, and in the coming weeks, two nurses who had treated him - Nina Pham and Amber Vinson - were diagnosed with the Ebola virus.
Outsourced
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.
The contractor, a Fort Worth-based company, Emergency Medicine Consultants, serves hospitals under the name of its medical practice, Texas Medicine Resources, and uses the website name emdocs.com. The company referred questions to Texas Health.
Texas Health did not respond to a request for details about how the contract divides duties between the hospital and the company, or whether the Duncan case had resulted in any changes in the relationship.
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 then 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.
Emergency Medicine Consultants runs emergency departments for 13 hospitals in the Texas Health system.
A comparison of clients finds that two failed to beat state or federal averages in any category of emergency-care quality.
Two more - Texas Health Presbyterian and Methodist Charlton in southwestern Dallas - bettered those figures in just one category. In five others, they were worse, based on the latest report, from October 2012 to September 2013, by the U.S. Centers for Medicare & Medicaid Services.
Presbyterian ranked 78th for safety among Texas' busiest 100 hospitals in a recent Dallas Morning News analysis of hospital-complication data for 2012. Of 26 North Texas hospitals in the study, it was 17th.
Texas Health Resources and the hospital have lost top leadership recently. Early this year, THR Chief Executive Doug Hawthorne stepped down, replaced by Barclay Berdan. Presbyterian President Britt Berrett said in May he was resigning to take a position at the University of Texas, Dallas. Jim Berg became interim president and chief operating officer.
As criticism has crescendoed, Presbyterian employees' concerns have increased.
In the hospital clinic where one cardiologist works, patient volume is down 60 to 70 percent since Pham was diagnosed a week ago. Patients are canceling or postponing appointments.
That has forced its leaders to make unusual public appeals. Presbyterian 'is a safe place for employees and patients,' Berdan said in a full-page ad Sunday in The Dallas Morning News.
Pitched as a 'letter to our community,' Berdan again apologized for mistakes the hospital made in Duncan's treatment and in failing to have deployed fully its training and education programs before the virus struck. He said the hospital hasn't determined how the nurses became infected.
