Dr. James Stoll got a call early one Saturday morning in September. One of his patients, who had recently returned home from a laminectomy – a procedure that involves removing bone spurs to alleviate pressure in the spine – was feeling disoriented and struggled to speak. Stoll, an orthopedic spinal surgeon, feared the man might be having a stroke and told him to go immediately to an emergency room in Kenosha, where the man lived. Once the patient was stabilized, two days later, he was transferred to Ascension Columbia St. Mary’s hospital in Milwaukee, where Stoll determined the patient needed to have the incision site cleaned as the surgeon believed it was infected.
Stoll, who has a private practice but began doing his surgeries at Columbia St. Mary’s in 2020, scheduled his patient for emergency surgery early that afternoon. But by mid-morning, the surgeon was told he would have to wait. Then he was told to wait again.
To keep himself calm, Stoll began to wander the operating room floor. As he walked the halls, he noticed that the department’s front desk was empty. The phone continued to ring; no one was there to answer it. He overheard a huddle of people bemoaning the fact that there wasn’t enough staff to see a patient who had a craniotomy the previous night and returned to the hospital because he was bleeding. One nurse complained that she’d already been awake for 36 hours straight.
Stoll continued to inquire about his patient and he was repeatedly told to wait. Getting anxious, Stoll began to meditate. By the time the operating room was ready, Stoll and his patient had waited six hours.
Inside the operating room, the problems continued. There, he found an equally exasperated anesthesiologist who was trying to manage an overwhelming number of delayed cases. The anesthesiologist fielded more than 20 calls while standing at the head of the operating table during the two-hour surgery.
In the weeks prior, Stoll had already raised concerns about staffing at Columbia St. Mary’s. Previously, he’d been assigned operating rooms that lacked much of the necessary equipment. He’d also been asked to perform surgeries with limited staff.
But waiting for hours only to find a distracted, exhausted staff was the last straw for Stoll. The following morning, he canceled his remaining surgeries at Columbia St. Mary’s. Delaying his patients’ surgeries, Stoll felt, was safer than operating at the hospital.
Standing on Lake Drive on a small hill that overlooks Lake Michigan, Ascension Columbia St. Mary’s main hospital building has one of the best views in the city. Filled with natural light, the 670,000-square-foot building boasts nine floors including patient rooms, an airy grand atrium facing the water and two-story family lounges. The design, unveiled in 2010, includes two rooftop gardens which were created to help ease patient stress. In total, the hospital and its two parking facilities cost more than $400 million.
The hospital was formed of two historic predecessors, St. Mary’s and Columbia, that merged in 1995 and joined the Catholic nonprofit Ascension health care network four years later. St. Mary’s, Milwaukee’s oldest hospital, was established by a group of Catholic nuns who sought to help the city’s growing number of sick and poor in the mid-19th century. Over the next 100 years, the hospital became an essential arm of the city’s healthcare system. Columbia, founded in 1909, focused on research and postgraduate training. Together, the two hospitals were long considered among the city’s most important, premier health institutions. They served both Milwaukee’s wealthiest residents and much of the city’s low-income community.
But that reputation, according to one Ascension Columbia St. Mary’s doctor, is quickly eroding. Now, they say, “Ascension Columbia St. Mary’s is a first class structure on the outside, but third world inside.”
‘The worst I’ve ever seen’
ACROSS THE COUNTRY, health care is in crisis. Staffing shortages that began in the first months of the COVID-19 pandemic have continued to hamstring hospitals. While many of the 1.5 million health care jobs that were lost in the first few months have returned, staffing shortages remain, and they have crept to the top of patient safety concerns, according to ECRI, a nonprofit patient safety organization.
Ascension, which operates 139 hospitals across 17 states, including five in Milwaukee County, has been no exception. However, according to a December New York Times report, problems at Ascension started even before 2020. Hoping to bolster profits, Ascension began cutting staff in the years leading up to the pandemic, leaving it ill-prepared for the coronavirus crisis. To document how these decisions impacted patients, the Times focused on two hospitals in Illinois and Michigan, where nurses and hospital employees reported chaotic environments in which staff shortages put patients in danger.
Locally, Wisconsin Hospital Association records show that the vacancy rates for certified nursing assistants, licensed practical nurses, surgical techs, registered nurses, and radiology technicians all rose significantly at Ascension Wisconsin between 2017 and 2021. Several positions – certified nurse assistants; licensed practical nurses; surgical techs – outpaced vacancies across southeastern Wisconsin.
According to one Ascension obstetrician, severe staff shortages impact all five local Ascension hospitals. At the labor and delivery wing at St. Francis Hospital, for example, “there are some days and nights where there’s just no staff and they just turn off the lights. They literally shut down the unit,” the doctor says. “I had a patient show up with preeclampsia symptoms and there was nobody there. And that wasn’t the first time it happened.” Ascension closed that unit entirely in late December.
Over the past four months, Milwaukee Magazine has interviewed nearly a dozen current and former surgeons, nurses and other hospital employees to understand the impact such shortages had on one Ascension hospital: Columbia St. Mary’s. They spoke on the condition of anonymity as some remain employed by Ascension Wisconsin while others fear reprisal. MilMag also reviewed state records, emails and complaints filed to administrators and found that many employees believe that the hospital has reached a precarious tipping point.
Ascension Wisconsin responded to the magazine’s questions with written responses in mid-December from a spokesperson who asked that their name not be published. “Hospitals across the U.S. are dealing with historic staffing challenges due to ongoing workforce shortages,” the spokesperson says of the impact of staff shortages on Columbia St. Mary’s. “It is not hyperbole to say that the entire U.S. health care system is in crisis.”
One troubling indicator of that crisis at Columbia St. Mary’s: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a nonprofit that evaluates whether a hospital complies with the national standards of safety and quality care, on Aug. 1 issued a preliminary denial of accreditation for the facility. If a hospital loses its Joint Commission accreditation, which happens very rarely each year, it could lose the ability to treat commercially insured patients. Three weeks later, the Joint Commission approved Columbia St. Mary’s accreditation.
The Ascension spokesperson declined to identify the problems highlighted during the accreditation review. “Ascension Wisconsin, like many health systems, works cooperatively with [JCAHO] to advance quality and safety in patient care,” they say. “An opportunity for process improvement was identified. … This prompted immediate collaborative action planning and the implementation of training on enhanced processes. The action plan was submitted to, reviewed and accepted by The Joint Commission.”
In October, the Wisconsin Department of Health and Human Services conducted an unannounced survey in response to patient safety complaints. The report summary showed that inspectors found Ascension Columbia St. Mary’s was “out of compliance” in its practices of patient safety in two out of four reviewed complaints.
One complaint described a patient who, after experiencing chest pain and shallow breathing, could not reach a nurse for nearly 10 minutes after pressing the call light, yelling for help and pulling the emergency cord in the hospital bathroom. Another complaint outlined how a patient was left on a dirty bedpan for 45 minutes despite calling for help to remove it. In both cases, the state found that the hospital neither properly documented the incidents nor introduced changes to prevent them from happening again.
The Ascension Wisconsin spokesperson shared that in response to the state review, “education was disseminated to hospital leadership … to reinforce the importance of ensuring that patient safety events and complaints are thoroughly investigated per hospital policy and that action plans are developed and implemented to mitigate risk.”
But education may not be enough. Over the last year, upwards of two dozen doctors have left their posts at Columbia St. Mary’s for other institutions across the state and country. Several who shared their experiences cited conditions so bad that they feared for the safety and care of their patients.
“I’ve been a surgeon for more than 40 years,” says Stoll. “I’ve worked out of ORs in Germany, Canada, Japan, Nicaragua and across the United States. I’ve seen a lot of operating rooms, and Columbia St. Mary’s is the worst I’ve seen.”
‘Fumes and luck’
ONE PLACE THESE staff shortages have been felt particularly acutely is Columbia St. Mary’s women’s hospital.
The latest wave of problems in that unit began when Ascension announced in July 2021 that it required all hospital employees to vaccinate against COVID-19 by the following November. According to one employee, nearly half the nursing staff resigned in response to the mandate. After that, a second wave of nurses left when they did not receive raises or bonuses after working through the pandemic.
At full capacity, up to 12 nurses clocked in each shift – one for each of the 12 labor and delivery beds, which is the standard nurse-to-patient ratio in such a department. Those numbers were frequently diminished by as much as two-thirds in spring 2022. As a result, nurses started taking two or three patients each. “We were getting our asses kicked,” says one former women’s hospital nurse.
Ascension administrators hired short-term “travel” nurses to address staffing shortages, but new full-time hires, claims the same nurse, were only trained for 10 to 12 weeks rather than the traditional 16. And even then, labor and delivery staff were still left shorthanded. “It was like putting a Band-Aid over the Titanic when it hit the iceberg,” the nurse says.
“There were times when patients did not have a nurse to take care of them,” says the nurse. “We would pause inductions to try and help free up nurses and prevent more people from going into labor.” Pausing induced labor, says the nurse, carries risks including “an increased chance of infection, especially if the woman’s amniotic sac has already broken.”
WHILE STAFF OF Ascension Columbia St. Mary’s continued to exit the building last spring, two unexpected visitors found their way into the women’s hospital. Last April, two videos of a pair of racoons scurrying through the hallways and climbing the walls of the women’s hospital circulated among staff. In one, an employee can be heard saying: “The doors need to be closed so they can’t get out; this is the women’s hospital.”
On one such night, a woman started delivering her baby without any nurses in the room. In another, after calling out for help for 30 minutes and complaining of severe pain and lightheadedness, a patient passed out and needed to be stabilized in the operating room. At that time, elsewhere on the floor, the skeletal nursing team was also trying to help a newborn who was having trouble breathing, a woman with dangerously high blood pressure, and a patient who was waiting for hours for a blood transfusion, among others. “We were running on fumes and lots of luck,” says the nurse.
Last summer, on days when fewer than four nurses clocked in, labor and delivery staff were told to implement what was called a “diversion and redirection” plan. This protocol required both doctors and nurses to encourage women scheduled for inductions to remain at home and direct those who were already in labor to another Ascension campus. The closest Ascension hospital, St. Joseph, is 6 miles from Columbia St. Mary’s. “The plan never worked,” says a former nurse. “Every hospital has a staffing shortage, and they would tell us they were at capacity, too.”
This left some women in a precarious limbo. And, according to one obstetrician, delaying labor and medical care can come with serious complications for both mothers and their babies. In the case of high-risk patients with conditions such as preeclampsia, those risks can be nothing short of seizure or stroke.
Asked to address the staffing problems in labor and delivery, the Ascension Wisconsin spokesperson said: “Workforce shortages and burnout are real challenges in health care. We are actively working to strengthen our workforce – including putting in place innovative initiatives to grow the nursing pipeline.”
Nurses were not the only staff leaving. This past summer, several obstetricians left, too. Three decamped for Ascension’s Ozaukee campus to mitigate the fallout after six Ozaukee OB-GYNs left for Froedtert Hospital in June. Others left for new jobs in Wisconsin and some moved out of state. The group, which counted 11 doctors at the start of 2022, shrunk to five. By fall, that number dropped to four, two of whom are part-time.
In October, labor and delivery was hit with another blow when the Medical College of Wisconsin removed its medical residents from Columbia St. Mary’s, citing lack of oversight and unsafe working conditions in a letter sent to Ascension leadership. In doing so, they put the longstanding residency program on hold for six weeks. The residents returned on a trial basis in early November. The Medical College of Wisconsin declined to comment.
‘At some point, things are going to get missed’
IN DOCUMENTS REVIEWED by Milwaukee Magazine, several surgeons reported repeated concerns around patient safety to Ascension administration.
In one such incident, a surgeon describes a high-risk patient with a complex case who remained under anesthesia for an additional 90 minutes while they waited for the necessary support staff to arrive.
Surgeons also reported that these problems affected patients in post-operative care, where nurses failed to notice dangerous developments in patients such as significant bleeding that could lead to long term damage or even death.
On Jan. 9, Ascension executives asked doctors at Columbia St. Mary’s to reschedule all non-urgent elective surgeries for the following 30 days. Talking points included in the announcement directed staff to keep discussions around the rescheduling positive and to avoid discussing the reasons for the change.
Problems in Columbia St. Mary’s operating rooms go back years. In a fall 2020 email from the chief of surgery at Columbia St. Mary’s, Dr. Alysandra Lal, to hospital surgeons, she says she’s heard serious concerns from several surgeons about their ability to perform safe surgery at Ascension Columbia St. Mary’s. She asks each surgeon to send a list of concerns, which she says she will then share with hospital administration. In the email, shared with Milwaukee Magazine by one of the surgeons who received it, Lal describes a sample list of concerns, which include lack of pre-surgery screenings; delays in cases due to lack of staff; concerns about the training of nurses; and problems with lost or damaged equipment in the sterilization processing department. Lal signs the note, “Thank you for your time helping make things better for our patients.”
Almost two years later, James Stoll says he experienced similar frustrations when he arrived at Ascension Columbia St. Mary’s to perform a thoracic spinal surgery in spring 2021.
When Stoll walked into his assigned operating room, he expected to find a C-arm, a mobile X-ray machine required for a thoracic surgery. Instead, he found the wrong equipment, the wrong operating table, and no C-arm. The surgery itself wasn’t much better. “You determine your speed based on the team you have,” says Stoll. “And efficiency was pretty low.”
One reason for that, says an operating room employee, is increasingly long hours. “More and more, we’re working for 20-plus hours at the hospital,” explains the employee. “You’re sleep-deprived and delirious on top of being really stressed. At some point, things are going to get missed.”
In Stoll’s case, nothing did, but that surgery took double the usual time, putting the patient under anesthesia for nearly 2½ hours when it normally takes closer to one. Leaving a patient on the operating table for an extended period, explains Stoll, can have serious consequences including elevated blood loss and risk of infection. “The time under anesthesia is the No. 1 variable related to [surgical] complications,” he says.
Some patients, even those in need of emergency surgery, must wait hours before they even get into Columbia St. Mary’s operating room. Every day, hospital administration sends an email to staff sharing the capacity level at the facility. Week after week, the email announces that the hospital continues to operate at the level 4 status indicating that there are no available beds for emergency patients.
“Fortunately, as an integrated system of care,” says the Ascension spokesperson, “we have the ability to flex our staff to take care of patients, provide intrafacility transfers and have a national network of resources available, if needed. We are also actively recruiting clinical staff to fill available positions.”
In their daily emails, Ascension Columbia St. Mary’s administrators encourage staff to prioritize discharging patients in order to make room for new ones. Some days, says one hospital employee, upwards of 130 patients must wait to receive care.
“If a patient comes into the emergency room at 8 in the morning, they will have to wait the entire day to have an emergency surgery,” says one operating room employee. “You can almost guarantee it.”
‘This never happens’
ON THE FOURTH FLOOR of the Columbia St. Mary’s main hospital are four machines that are critical for safe surgeries. They’re autoclaves, which use high-pressure steam to sterilize medical equipment. Three of the four vending machine-sized boxes have yellow, laminated papers taped to the front facade. Two signs read “Immediate Use Steam Sterilization (IUSS); Do Not Use; To be decommissioned.” Another reads “Not permitted for use.”
These machines, used to quickly resterilize equipment that has been contaminated during surgery, were first shut down last summer when, as one surgical tech shares, investigators from JCAHO found that the machines were not operating properly and staff were using the machines to not only “flash”-sterilize surgical equipment, but also surgical implants such as screws, rods or metal plates. That, the surgical tech says, “is a huge no-no.”
According to hospital staff and surgeons, the autoclaves were just the latest in a series of problems with the sterilization process at Columbia St. Mary’s. Hospital employees had long raised concerns about delayed or canceled surgeries due to lack of sterile surgical trays.
In May 2021, the Wisconsin Department of Health Services issued an inspection report for Columbia St. Mary’s that cited a violation in the professional training of staff in the central sterile processing department. As a result, Ascension has “optimized a clear process of oversight for training and maintaining competency for our associates,” the hospital spokesperson says.
But, says one operation room employee, “it’s newbies teaching newbies teaching newbies, and nobody has a leader to tell them what to do or what not to do.”
Staff shortages, says the same employee, have an impact, too. “They’re so understaffed that instrument pans will sit in the sterilization department for two to five days before they get cleaned.”
Asked to address the sterilization concerns, the Ascension spokesperson says: “As part of our commitment to continuous process improvement, we continue to focus on a strong culture of quality and safety. … When improvement opportunities are identified, action plans immediately are developed to enhance processes and provide additional training.”
Sterilization protocols require at least three individuals to confirm that a pan of instruments has been properly sterilized. There are also multiple indicators that surgical techs are meant to check before handing instruments to surgeons.
Such precautions did not prevent the unthinkable in February when one surgeon, while finishing a surgical procedure in Columbia St. Mary’s main operating room, discovered that most of the equipment they’d used had not been properly sterilized beforehand. A prepackaged, single-use cutting instrument was sterile, but all other instruments used in the procedure, including retractors and a camera, were not.
“I was shellshocked,” recalls the surgeon. “Part of our training is preparing for every situation, but I was totally blindsided. This never happens, not in developed-world hospitals. I had this feeling of total violation. Like I had violated my patient and like I had been duped and tricked, too.”
The patient did not develop an infection, and the patient will continue being tested for a year after the procedure. Still, according to the surgeon, multiple members of the administrative team – including Columbia St. Mary’s operating room manager, a member of the hospital’s risk assessment staff, the chief medical officer, and a member of Ascension’s national infection prevention team – were notified. A meeting was held with the patient in April, and, after a several-month investigation, Columbia St. Mary’s administrators assured the surgeon that the sterilization process had been revised and they were working to resolve the problems. “The sterilization process did not occur, and action plans were developed and implemented to prevent future recurrence,” the hospital spokesperson says.
But a conversation at a November operating room staff meeting suggests otherwise. Nearly half of the roughly hourlong meeting was spent discussing problems within Columbia St. Mary’s sterilization process. During the meeting, the hospital’s infection prevention specialist told a room full of staff that the hospital was working to resolve the sterilization problems cited by The Joint Commission, including spraying and pre-cleaning the instruments and inspecting them thoroughly. He also discussed instrument shortages, some of which were due to a large number of rusted and corroded devices.
When an attendee asked whether the hospital is investing in educating members of the sterilization department – “that’s been the problem for 10 years,” she said – the infection preventionist assured her the hospital is working to get the department back on track. “At the end of the day, patient safety is on all of us,” the infection specialist told the group. “We support a culture of safety very strongly.”
Given all of this, Milwaukee Magazine asked Ascension whether Columbia St. Mary’s remains a safe hospital for patients and staff. “We maintain a safe environment in which patient care and safety are the highest priorities. Staffing is a continual, ongoing and active process,” the Ascension spokesperson says. “We continually review staffing and care models, while providing compassionate, personalized care.”
‘It’s my job to worry’
AFTER JAMES STOLL finished the spinal surgery in September, he filed a complaint with JCAHO, alerting the nonprofit to the unsafe working conditions at the hospital. He received a response explaining that his complaints helped inform an on-site review and that Ascension Columbia St. Mary’s had been reaccredited. Stoll, for his part, was not convinced anything had changed. He applied for privileges elsewhere and received them in November. He has no plans to return to Columbia St. Mary’s.
“When people come into a hospital, they are scared and they want to know that the hospital is doing everything in its power to make these scary experiences go OK,” says Stoll. “And it’s not. They are putting people at enormous risk.”
Sounding the alarm, says Stoll, is only half the battle. “It’s my job to worry,” he says, “but no one at Ascension is listening.”
Milwaukee-based freelancer Elly Fishman wrote “State of Abortion” in the November issue.