Gambling with Children 

Kaiser says its new hospital in Oakland offers first-rate services, but critics say the healthcare giant's decision to close pediatric care facilities in the East Bay has had grave consequences.

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The consolidation of hospital services is an industry-wide trend that has been gaining momentum in the last three decades, according to a 2013 study published by the American Medical Association. In the United States, most hospital consolidation occurs when larger health systems acquire smaller hospitals and integrate them into a "hub and spoke" health system, in which one central hospital serves as the hub for specialized services, offering resources to surrounding, less comprehensive hospitals. Sixty percent of US hospitals are now part of consolidated health systems, according to the study.

Many healthcare providers and health policy experts believe that centralizing specialty services not only results in cost-savings, but also addresses quality deficiencies in independent hospital care. Consolidating inpatient hospital services, experts say, allows a health system to provide for more uniform and coordinated care, all while cutting duplicative services — such as pediatrics — at the other outlets in the system.

But a healthcare provider must factor a number of ethical considerations when making decisions about which services to consolidate and how to do it, said Dr. Clarence Braddock, a bioethical healthcare consultant and vice dean of education at UCLA's David Geffen School of Medicine. The question of access, he said, is one of the main considerations for a healthcare provider when planning to consolidate services. As long as consolidating a service in one location isn't burdensome financially or geographically on persons seeking medical care, consolidation is ethically justifiable, he said.

Kaiser's decision to consolidate pediatric services is, in theory, also ethically justifiable, so long as Kaiser provides basic, primary care to the community. Although Braddock explained that, within the field of biomedical ethics, there is an intense debate over what "basic" service means, California state law only requires acute care hospitals to provide eight basic services — medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary — according to the California Department of Public Health, which issues hospital operation licenses based, in part, on these criteria.

Pediatrics is not included.

Kaiser's new Oakland Medical Center is a twelve-story, $1.3 billion facility, complete with large interactive touch screens that tell visitors and patients exactly where they need to go to receive services and obtain educational resources. Some screens are positioned low enough for young guests (and patients), and other screens display art created by children from the pediatric ward.

A day before young patients from the old Kaiser facility in Oakland moved into the new building on July 1, Kaiser officials gave me a tour of the new pediatrics unit. Guiding the tour was Dr. Jorge Gutierrez, assistant physician in chief of pediatrics of the Kaiser Oakland Medical Center. He said the unit offers a full range of pediatric specialties, including pediatric neurosurgery and pediatric cardiology.

Gutierrez also said the unit offers "family -centered rounds," during which parents are given information about their children in layperson's terms. This is intended to improve openness and communication with parents, and ultimately to reduce their anxiety about their children's care.

The unit's spacious, single rooms are each equipped with a pullout bed for families who need to stay overnight, as well as what Gutierrez called a "Care Board," a keyboard that allows patients to interact with an LCD screen that has a menu offering newly released health and safety information — and even room service.

Most rooms have sweeping views of the Oakland hills or the city below, because the unit is located on the eleventh and twelfth floors — but it wasn't always that way. When the hospital was being designed, the pediatrics unit was originally divided between the sixth and eleventh floors. According to Gutierrez, this left a large, five-story gap in the unit. "It would have been too unsafe," he said. "I felt it would take too long to respond to kids who were decompensating."

Decompensation is a medical term for organ failure — like what happened to little Jenevieve. Gutierrez may have only been referring to the arrangement of the new Oakland hospital, but in doing so he inadvertently revealed the apparent misaligned intentions of Kaiser's decision to close its Hayward pediatric unit and require families from central and southern Alameda County to transport their seriously ill children to Oakland: Children decompensate very quickly, and when pediatric resources are separated by distance — whether it's five hospital floors or twenty miles on a congested freeway — it can be dangerous.

Kaiser was able to close the gap in Oakland by simply moving two units to adjacent floors. But a wide gap remains for the rest of the East Bay.

After Jenevieve slipped into a coma, doctors at Kaiser Oakland sat down with Olguin and Dagatan and explained their options: Jenevieve would likely eat from a tube for the rest of her life, some of her limbs would be amputated due to blood infection, and she would likely suffer from mental retardation. Olguin said a doctor pulled her aside and told her to think about her three-year-old son, who was healthy and would need her attention.

It took eight days for Olguin and Dagatan to make a decision. During that period, Kaiser medical staffers gave Jenevieve a battery of tests — including CAT scans and ultrasounds. An MRI confirmed that the meningitis had inflicted severe damage on the little girl's frontal lobe. "When I held my daughter, they had to rotate her body because one side of her body was so swollen you could see fluid moving around," Olguin recalled. "That's when I knew.


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