Emergency room physicians at Providence Medford Medical Center worry that a new staffing model, which would call them away from ER patients to assist in the hospital’s intensive care unit, could lead to patient harm.

From 7 p.m. to 7 a.m., ER physicians are now expected to leave the emergency room to help the ICU’s nurse practitioner perform intubations.

This procedure — still handled during the day by an ICU intensivist — involves putting a tube through a patient’s nose or mouth, down the windpipe and to the lungs to help the patient breathe. On rare occasions, the tube enters the windpipe through a cut in the patient’s neck.

Historically, an ICU intensivist would also intubate patients at night.

This month, Providence brought a telemedicine model to the ICU. Nurse practitioners, while managing patients, can turn to the remote intensivist from Sound Physicians for guidance and backup.

But when a patient requires intubation, the hospital’s ER physicians will be asked to support the nurse practitioner, who is credentialed to do the procedure but lacks the same level of training and experience.

ER physicians said their new role could endanger their own patients.

“Anything that pulls us away from the ER potentially puts our patients in jeopardy,” said Dr. Bryce Pulliam, an ER physician at the medical center.

Yet, if Pulliam and his colleagues can’t leave the ER, this could put ICU patients at risk, he said.

“If Providence feels that they cannot safely staff the ICU without the expectation being that the ER doctors will respond to support critical procedures in the ICU, our feeling is that the ICU is not appropriately staffed, or not safely staffed, as the patients in the ICU deserve,” he said.

Dr. David Levin, an emergency physician at Providence, started working at the medical center about a dozen years ago.

“One of the things I was specifically told in my interview was that we do not provide procedural backup for the ICU. That’s their issue, their deal,” he recalled. “Our responsibility is the ER patients.”

Pulliam said he has been told the same over the years by Providence’s various ER medical directors.

Concern for patient safety is one reason Pulliam, Levin and their fellow ER providers at the medical center unionized in April.

Calling themselves the Southern Oregon Providers Association, the group said that the medical center’s low staffing levels could lead to employee burnout and compromise patient care. They said Providence has been asking ER physicians to take on extra duties outside of their department.

Now, even during the nightly hours when one physician is on duty, that person will be responsible for ER patients and, potentially, ICU patients.

Pulliam said that while staffing in the emergency department has been remarkably stable in his 10-plus years at Providence, he has witnessed a high turnover and a lack of retention in other departments.

“As a result, ER physicians are being asked to do more and more to support the hospital,” he said.

In a statement for the Rogue Valley Times, Chris Pizzi, chief executive officer at the medical center said:

“Emergency department physicians have historically provided intubation and other support to patients in our ED and other units of Providence Medford Medical Center. The need may arise in certain rare circumstances when additional support is needed to help protect patient safety; for example, when there is a more complex intubation.

“Physicians supporting other providers in the hospital is a common practice to ensure safe, high-quality patient care,” he continued.

Pulliam said in an email that while he and his ER colleagues have responded outside their department for emergencies such as cardiac arrests, “we have never been expected to be present at the bedside for routine procedures, including intubation.

“Just as we do not supervise anesthesiologists performing routine intubations in the operating room, because they have been credentialed and trained to be able to perform these procedures, we have never supervised ICU providers performing routine intubations,” he wrote.

The American College of Emergency Physicians, a Texas-based organization that advocates for the profession, says in a policy statement that the “emergency physician’s principal legal and ethical responsibility is to patients who present to be seen and treated in the emergency department.”

The organization argues that an “emergency physician must be available at all times to respond to emergency department patients in a timely and safe manner while formally assigned as an attending in the ED,” and that it’s “the responsibility of the hospital administration and the organized medical staff to ensure adequate medical care for those emergency situations that occur in other hospital departments and areas.”

In addition: “Hospital medical emergency response plans and teams should be organized in a manner that is not reliant upon an emergency physician unless the ED and its patients’ medical needs can be safely provided for at all times.”

The group brought their concerns about the new staffing model to Providence administrators and did not get a response, Pulliam said.

On May 31, Claire Syrett, the association’s labor relations representative, sent a formal cease and desist letter to Jason Kuhl, the medical center’s chief medical officer.

The letter reminds Kuhl that the ER providers did not agree to the new working conditions. “You are required to maintain status quo for the members of this bargaining unit at this time. Any proposed changes in working conditions are subject to negotiations,” Syrett wrote.

The letter alerts Providence “to the potential of an unfair labor practice should you choose to continue to ignore our communications on this matter.”

Pulliam said the medical center has not changed course.

The number of ER patients who come through the hospital at night varies. Pulliam estimates an average of one to two, sometimes three an hour during a seven-hour shift. The number is rarely fewer than eight, and typically between 12 and 15. The most he’s seen is 26 patients in seven hours, he said.

That is the nature of the emergency room, he said.

“We can’t predict: Is this going to be a slow night, or is this going to be an incredibly busy night? Are patients going to all have coughs and colds, or are patients going to have heart attacks, strokes? Are they going to be septic? Are they going to be dying?” he said. “We have no control and no way to predict what’s going to come through our doors.”

To Pulliam’s knowledge, an ER physician has not been asked to intubate an ICU patient per the new staffing model as of Thursday.

If that time comes, the available physician will step up, he said. The association then expects to file an unfair labor practice complaint with the National Labor Relations Board.

The association also expects to file a report through the medical center’s internal system for reporting unsafe practices and conditions, Levin said.

“Frankly, it’s dangerous,” Levin said. “We have our hands full in our own department. … Our job is to be available for those ER patients. I can’t be in another part of the hospital and not know what’s going on in my own department.”