Sunday, December 07, 2008

My 94 year old mother was in your hospital

A letter sent by a friend to the CEO of a hospital outside of Boston. While this was not here at BIDMC or at a place where you might work, let's all look at each of her complaints and answer honestly: "Could this have happened at my place? What will I do to make sure it doesn't?"

I feel you need to know about some significant problems I experienced at your hospital. My ninety-four year old mother was a patient there from Nov 28th through Dec 4th, having fallen and broken her leg. Beginning with the nine hours she spent largely unattended by anyone but me in the emergency room and ending with her discharge a week later, the one constant was a lack of any useful communication, particularly given her age and degree of memory loss.

She was logged in to the emergency room an 2:00 in the afternoon on the 28th and finally given a room at 11:00 that evening. During that time she was in a great deal of pain, left without food or drink (in case she was going to be scheduled for surgery, even though it was clear hours earlier that no orthopedic surgeon was going to be available … she had the surgery late Monday afternoon), and although she is incontinent, not given any help or comfort until I intervened.

During her stay, I never heard from her own physician, and when I called him the day she was discharged, he told me that he had never been informed by the hospital that she had been admitted. He told me that he had recently received a letter saying that because he uses a hospitalist there, he no longer had hospital privileges. This may well be a useful policy for streamlining patient care (although my experience does not bear that out), but it needs to be shared with the patient’s family. I assumed, incorrectly, that her doctor had been called and his advice solicited.

I neither met, nor heard from the hospitalist, so I can only guess that he or she exists. The only calls I received from physicians were “witnessed” pro forma calls asking for consent for surgery and anesthesia. If the hospitalist policy precludes keeping family physicians informed, then some form of organized communication with the responsible family member needs to be instituted, particularly when the patient is elderly and mentally impaired. Her own family doctor could have given useful information on her medical history and mental state. The staff seemed generally unaware of her memory loss, her impaired hearing, and that the pain medications were causing her to hallucinate.

It was, all in all, a depressing, disorganized, and generally disillusioning experience. I will be happy to provide any further details about her hospital experience that might help you find ways to remedy these breakdowns in communication.

I look forward to hearing from you.

14 comments:

e-Patient Dave said...

I eagerly await news of how the CEO responds, both in words and action.

Dr. Val said...

Wow, tough letter. :( It's hard to guarantee excellent care every time - but we need to try. Let us know how you handle this, Paul.

Paul Levy said...

Wait, Val, this wasn't at BIDMC...

Paul Levy said...

For one thing, our hospitalists actually talk with the patient's primary care physician, and also with th epatient's family members.

Anonymous said...

I agree that patient care should involve a lot of cross-communication between the people treating the patient, the patient, and the patient's family. It is a shame that the patient's doctor was not consulted, as this could have eased a lot of miscommunications.

Also, the wait time was pretty brutal. I don't like that anyone has to wait that long, especially if they are in a lot of discomfort. Not being able to eat, drink, or take pain medication for that long just adds to the discomfort. Still, the hospital's job is to keep you alive. It isn't to make you as comfortable as if you were in your own home until your name is called.

What I don't agree with is the implied necessity of mind-reading and needs-anticipating on the part of the hospital. A 94-year old, mentally impaired woman shows up at an emergency room with a caretaker. You might be able to forgive the staff for assuming that the caretaker was going to be taking care of any special needs the patient might have.

If the staff don't seem aware of something, inform them. Having to intervene to get some extra help with an incontinent elderly woman is not an insult or an injury made by an inattentive hospital, it is just common sense. When you have special needs, you must call attention to your need for extra assistance.

Anonymous said...

It is a common story. Most people are too intimidated to complain, so they hire malpractice attorneys. We all need to be more sensitive to our patients and surroundings in this brave new world of medical care. Hospital CEO's and hospital trustees should insist on hearing complaints from the doctors rather than declaring them disruptive for caring about their patients' well being and safety. At least this 94 year old did not end up as did this 89 year old, but then again, the 94 year old could not walk:

"Elderly patient found dead on hospital roof
Wednesday, December 03, 2008
By Jim McKinnon and Jerome L. Sherman, Pittsburgh Post-Gazette
An elderly woman who had been reported missing from (redacted) yesterday was found dead on the roof of the Oakland facility this morning.
Pittsburgh police identified the woman as Rose Lee Diggs, 89.
She suffered from dementia and heart problems."

NZ

Anonymous said...

The "system" needs to get its act together since the advent of hospitalists means that eventually there will be "out of hospital" doctors and "in hospital" doctors. Hospitals, and, yes, the doctors themselves need to take responsibility for ensuring methods of communication when the patient goes from one environment to the other. Personally, I fault physicians for passivity and excuses as much as hospital administrations. Do you think the patient's primary care physician went to the hospital and said, "we need to solve this problem for all patients who come into your hospital?" I would be money NOT.
For an interesting perspective from the opposite side, read today's post from "The Happy Hospitalist" blog. I refrain from comment for now.

nonlocal

kevin shea said...

I had a similar experience with my 82 year old mom. Although her care was better, the most significant issue was one of integrated care.

She bounced between hospitals and care facilities for a period of about 3 months. When she was transferred, not much information, if any, transferred with her.

The role of coordinator of care fell to me and my siblings. We ultimately became mom's systems integrator. That is, we pulled together all the issues and problems so that when she was transferred again, we could repeat the history. Often, this history changed the nature of the care provided by the doctors, rehab specialist, etc.

I am a process efficiency consultant and was beside myself at how badly the system works. When a care giver has to become involved in the system to make it work effectively, something is very wrong.

Many HC professionals are "siloed" in their specialty area and the interfaces and interactions between them and their supporting systems are flawed, or not functional. These system failures compound the problem.

The evolving movement of HC towards practices of systems engineering and methods similar to Toyota Production system should help.

Anonymous said...

This is what we have designed, and now we must live with it. The business model of medicine, with its emphasis on efficiency and operational systems, has replaced what the elderly remember and what their children are trying to re-create: some degree of personalized attention. I guided my mother through a similar situation several years ago and my spouse is now doing the same for her 90 year old mother. As an emergency physician in a tertiary care hospital I witness daily the unrealized hopes and expectations of the families of patients like this one.

Anonymous said...

The system does not pay for the kind of personalized, detailed care that most would want for their own families. The hospitalists have to see 15+ patients a day. Ideally, there would be time to call every family member, play phone tag, explain things in detail for every patient, have several care conferences, speak with the nurses and therapists and social workers involved in each patient's care, call and talk to the primary doc, etc. But the hospitalist wants to get home before 10PM every night.

And don't forget the ever increasing paperwork and documentation burden for every one of those 15 patients.

Sometimes you have time for proper communication. Often, you don't. As the previous comment noted, it is the system we have designed, and we have to live with it.

Anonymous said...

Could someone explain what IPC the hospitalist company is? Why is there a company employing hospitalists? This company is on the stock exchange plus have really good profits for their shareholders. Who employs your hospitalists at BIDMC and are they on the stock exchange too?

Anonymous said...

My, My 17 patients at $130-150 a visit reimbusement. Only $550,00 plus a yr. My heart bleeds.
Most, if not all hospitals have never had a good communication system. What with interns and residents doing most of the work and a 10 minute patient visit from a hospitalist, what do people expect. Lack of communications cause death and horrific mistakes, but you poor hospitalists don't have time. Boy, I am so sorry you are doctors. What don;'t you become something else where your lack of time to communicate won't kill.
Your attitudes are terrible. If your patients are such a burden, do something else.

Paul Levy said...

Our hospital employs our hospitalists. We are a non-profit organization and have no shareholders.

Anonymous said...

I am a nurse at a moderately sized hospital. There have been many days I feel like walking out the door and never returning. I return because my patients need me if they were less one nurse then the problem gets even bigger. I am overloaded and treated with much disrespect from families because I could not get to the call bell within 5 minutes. Does it occur to anyone I am with another patient doing a procedure. I am scolded because 'mom' needs fed and I could not be there to feed her within a half and hours time. Why can't the family feed her. Oh wait that not their job. I am juggling many patients and I am one person. There is a nationwide nursing shortage and it is only going to get worse. My patients are not a burden, I take care of them because I care. I take care of them well. But along with the shortage, nurses are getting more and more patients. People are so quick to judge but take a moment to walk in my shoes for the 12 hours I work in a day. I work extra more and more so my fellow nurses are not overloaded. And as far as the case at the UPMC hospital where the women wandered away and died-- my heart breaks for her, her family but mostly for the nurse who had her as a patient. Who knows how many patients she had that day. She (or he) will live with that guilt forever. Restraints are always an option but that is always used as a last resort and trust me --families do not appreciate this. Before ending my post I would like to thank the families that do understand that we (nurses) are doing the very best we can. Until hospitals can mandate how many patients a nurse can handle comfortably, then this will continue. But if that is the case then emergency room wait times will be even longer until the nurse on the floor is able to have the proper number of patients -- they will have to wait for other to be discharged. The patient are never the problem--even if I run ragged in all directions my patient get the care the need and deserve.