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Sunday, August 22, 2010

Who is the captain? Are we there yet?

Being a hospitalist I often see patients sitting in the hospital for days at length for no reason other than poor planning. Sometimes I feel that physicians who are involved in patient care are oblivious of each other. Everyone is in their own domain rather than working as a team. Increase length of stay in the hospital not only increases the cost of health care but also adds to the risk of medical complications including hospital acquired infections and medical errors.

There are several factors which contribute to poor outcomes, errors, poor plan of care and increase in patient length of stay. Some of the leading causes which I have observed are;

  • For the most part lack of leadership role by physicians involved in patient care.
  • Delay in patient-admitting physician contact from the time ER admits a patient to a 1:1 contact by the admitting physician.
  • Lack of proper follow up. For example patient is ready to be discharged but there is no confirmed follow up for labs like sub-therapeutic INR, low potassium levels, pending culture results etc. Some of these patients are doing nothing but waiting for labs which will not change management. These patients can very well be discharged with responsible follow ups.
  • Some patients need transfer to rehabilitation centers. However, if they have Medicare as their primary insurance then they can not be transferred as per Medicare rules.  They need to stay 3 days in the hospital before they are eligible for discharge.
  • Unfortunately few physicians may be pressed for keeping their patients in the hospital for monetary gains.
  • Lack of nocturnist hospitalist.
  • Lack of support staff for procedures and test over the weekends.

For example, Mr. Delay In’Discharge presents with chest pain and admitted at 5 pm. He is not seen until the next morning by the admitting physician. He was ruled out for myocardial infarction but has an abnormal nuclear stress test and this requires a cardiac catheterization. In the mean time a CT of the chest with contrast is performed to rule out pulmonary embolus. This comes out negative; however, the patient develops contrast nephropathy and acute renal failure. He also develops Foley catheter related urinary tract infection.

This is a typical patient encountered on a regular basis. This patient may end up with an army of consultants. So in this particular patient you would have an admitting doctor either a Hospitalist or an Internist, a Cardiologist for chest pain, a Nephrologist for renal failure and an Infectious disease consultant for urinary tract infection.

From here on a cardiologist would write in progress notes that he will perform cardiac catheterization when Mr. Delay In’Discharge kidney function improves, infectious disease consultant would like to wait until urinary tract infection resolves. On the other hand nephrologists could have already cleared the patient for cardiac catheterization but this has not been conveyed to the rest of the team. Hospitalist writes his daily notes but never takes the time to call and inquire about the plan. Now comes the weekend, no procedure could be done over the weekend. By now 6 to 7 days have already passed, where patient is stable and ready to move on to the next phase but as no one has reviewed each others notes, all is at a stand still. Regrettably, no single physician is ready to take a leadership role and everybody is just going with the flow.

Leadership role in patient care plays a significant part in appropriate patient management. Majority of the times we rely on the other person to take the initiative. I remember once I called a specialist who saw the patient at 9 AM to ask his opinion about starting plasmapheresis on a patient of thrombotic thrombocytopenia, the answer was “I was thinking about it but I will ask the surgeon to put the line in the morning, as it is already too late in the day (It was 7 pm)”. The problem with this statement is 1) This is a medical emergency which require immediate care. 2) If he was really thinking about it why was it not conveyed on time. 3) This is delay in care which increases the risk of developing various fatal complications.

I witness this many times that a physician comes up with a plan however, it is not communicated properly to the rest of the team. A lead physician needs to formulate a plan, communicate with other physicians in the team and decide what needs to be done in the hospital and what could be done outside the hospital. I think considering the position a hospitalist is in, they should take that leadership role as they are eventually responsible to review not just one area but all aspects of patient care.

Hospitalists are known to rely on too many consultants. Every time a patient comes there could be 3 or more consultants asked to see the patient. I respect the need for specialists and their expert opinion. I do rely on their recommendations, especially in this day and age of medico-legal medicine. But on the other hand all kidney failures do not require a nephrologist, all anemia do not require a hematologist and requesting an oncology referral without a tissue biopsy results in waste of their time.

So what are the solutions for these problems?

  1. As we are moving more and more toward the era of electronic medical records (EMR). A physician should be able to task other physicians, just as they can do it in the office utilizing EMRs, We can debate if these task should be part of medical records or not. This could substitute physician’s hesitation to call other physicians and allow all members of the team to review the proposed tasks for the day.  Whenever a physician opens the chart of a patient they should not be able to close the chart or sign out their orders or progress note unless those tasks have been reviewed or answered.
  2. There should be training workshops for physicians regarding the significance of leadership role in patient care.
  3. We should hire full time “discharge planners” who can assist in scheduling (confirmed) follow up visits with out-patient doctors and arrange for desired labs. These planners should be given access to add notes in EMR so concerned parties can review their work flow. (We could argue that case managers should do this job, but most of the times they are consumed with utilization review or with nursing home discharges; they do not have time to keep a track of these things). These discharge planners needs to be certified in a curriculum which provide them complete comprehension of these task and needs of patient and physicians.
  4. We should have more services available over the weekends for patients.
  5. Reformation of Medicare 3 day rule regarding transfer to rehabilitation centers.
  6. Review time between ER encounter to patient-physician contact.
  7. Utilization of Nocturnist as a routine in all hospitals programs. (It will be very difficult for private groups considering the cost involved and decreased revenues generated by them)

In all honesty we have not been successful in implementing all of these measures in our hospital. However, we are making an effort to reach these goals. I will provide an update monthly once we achieve goals.

We will keep on trying them like I told my daughter a little while back that failure is an integral part of success.

About the picture:  I took this picture from our sailboat in Hudson River, New York
Back to work tomorrow.

1 comment:

Anonymous said...

Excellent post. Paul Levy will tell you that I used to dispute him when he said physicians exhibited lack of leadership, but he has convinced me now. Your solutions seem excellent; keep working at it!

nonlocal MD