Coordination of Care Requires Patient Input

As a general internist with a small concierge practice I have tried to coordinate my patients’ care and dealings within a complex, bureaucratic and dysfunctional health system. Patients have access to me 24 hours a day, seven days per week by telephone, cell phone, email and text messaging.  I do not have an answering service so all after-hours calls are forwarded directly to me.   During the initial patient orientation visit we discuss the need to keep me abreast of their health concerns and problems so I can bring the big picture to their immediate and localized health concern or problem.  Similar information goes out in my quarterly newsletter and is on my web site. I am trying to reach the technologically sophisticated patients as well as the technologically challenged.

I was somewhat surprised to receive a late Friday night call from the local ER to tell me one of my 86 year old cognitively impaired individuals was being evaluated. When I spoke to the charge nurse I found that the patient was brought by the paramedics for intractable nausea and vomiting.   This particularly charming, mild to moderately cognitively impaired, woman had moved with her 90 year old husband from her private residence to a senior facility on my suggestion so that care was available for her as she deteriorated and required more hands-on attention. They were thrilled with the new apartment as well as the care and concern provided by the staff.  I had seen the patient six weeks ago and she was doing fine. There was no mention of problems.

Since her last visit she had developed a dental problem. Unknown to me, her dentist extracted all her left lower jaw teeth and made arrangements for a periodontist to perform three dental implants.  The periodontist pre-medicated her, one hour before surgery, with 1 gram of the antibiotic amoxicillin because seven years ago she had a surgical knee replacement.  She then had the surgery and was sent home on Tylenol and codeine for pain.

She took her second Tylenol with codeine at home, went down to the community dining room, ate some chicken soup, felt ill and vomited several times.  The dining room staff just called 911 and transported her to the local ER.  I was called by the ER doctor after his evaluation to say he believes that between the large dose of oral antibiotic and the codeine, the patient became nauseated and vomited. He was prepared to give her some intravenous fluids and send her home.  After completing the IV fluids she got up to go home, became lightheaded and had another bout of emesis.   I was called back at about midnight and went in to evaluate her.  She looked fine but a bit dehydrated so I decided to observe her overnight while administering fluids and anti-emetics if she needed them.

I had no previous knowledge that this cognitively impaired woman with a limited future lifespan was having such extensive dental surgery.  There is much controversy about whether an individual with a prosthetic knee replacement even needs antibiotic prophylaxis with an antibiotic notorious for causing GI distress.  There were additionally concerns on my part about the choice of a codeine based narcotic for pain control based on her existing medication list.

Had the husband, patient or dentist called in advance to discuss this we could have come up with alternatives that may have prevented this hospitalization.  If the primary care physician is not included in the care plan and kept current, how can one be expected to coordinate care?

After evaluating the patient and making the arrangements for her to stay overnight, I expressed my disappointment to the patient’s spouse about not being informed of the impending dental procedures of this magnitude in advance.  He apologized profusely for not thinking to call me or asking the dentist to call me. He asked me to write about it in my blog to let the other patients know why they need to keep their doctor informed of all their health care comings and goings.

It’s Only a Cold …

As a concierge medical practice we pride ourselves on being available to help our patients with access to the doctor by phone and same day appointments. At this time of year we are faced with daily phone calls regarding cold or flu like symptoms.  Thus, I thought it appropriate to share some topical information which should be useful in helping anyone decide whether they should “ride out the storm” or give their doctor a call.

There are at least 1,500 different known viruses that lead to a viral upper respiratory tract infection sometimes known as “the common cold”.   With these, a high sustained fever of 101 degrees Fahrenheit is rare.  Aches and pains, nasal discharge with runny nose and post nasal drip are common. Dry cough advancing to a barking cough productive of clear, yellow and often greenish phlegm is common as well.  You’ll most likely feel miserable. Your sinus and head congestion make you feel like you are in a tunnel, a sound chamber, or wearing a deep sea diving helmet. Your appetite waxes and wanes. You are exhausted with the activities of daily living.  Getting out of bed to wash your face and groom yourself may seem as challenging as a 26.5 mile race up a hill.

Currently, there is no cure for the common cold. Antibiotics do not work.  A “Z Pack “does not speed up the process. An injection of antibiotic does not make it go away faster. The infection could care less if you have a high school reunion to go to in Philadelphia, a grandchild’s bar mitzvah or baptism, or a flight to Paris for a combined work/pleasure excursion. Frankly, once you have this type of viral infection you will most likely have to ride out the storm.

Furthermore, going to the ER and sitting and waiting to be seen doesn’t make the infection go away quicker. Paying for a visit at a walk in center or urgent care center where you are more likely to negotiate successfully for an unwarranted or needed antibiotic will not help either.

In most instances, your recovery from the virus will take 7-14 days providing you drink plenty of warm fluids, rest when you are tired and use common sense. Cough medicine may ease the cough. Saline nasal solution may clear the nasal congestion. Judicious use of a nasal decongestant under your physician’s supervision may help as well.  It will take time. You are contagious. No you should not go to the gym if you are feeling poorly. Chicken soup, tincture of time, hot tea with honey, plenty of rest and common sense are recommended remedies.

If at any point you still feel you have the plague, dengue fever, the bird flu or the Ebola virus come on in. We will take a look, evaluate your symptoms and likely tell you, “It’s a cold.”

The 20 Minute Rule

To meet Federal patient satisfaction goals, our hospital administration is requiring community based physicians to give patient admission orders before we have a chance to see the patient. Patients who self-refer themselves to the emergency department, are evaluated by the emergency room staff, and who are determined to require admission must be admitted by their community physician within 20 minutes of receiving a call from the ER staff advising the patient requires admission. In most cases, the community physicians have no idea the patient is actually at the ER until they receive that call.

It is bad medicine to issue patient orders on a patient you have not seen, taken a history from or performed an examination on. To complicate matters, the hospital does not require physicians to actually come in and see the patient for 12 hours after admission.   Think about it, diagnostic and care orders are being given routinely by doctors who have not examined the patient. The doctors then have the latitude to not show up for half a day to actually do an onsite evaluation.

One of the cardinal rules of medical training is you should do a thorough history and exam before constructing a theory of the causes of an illness and instituting diagnostic and therapeutic measures. The local hospital rule is a direct effort of the hospital to control all aspects of patient care for financial gain. They are buying up practices, revamping medical staff bylaws by manipulating the rules and, filling the decision making committees and legislative physician groups with salaried doctors they control.

Hospitals perceive community based physicians who are advocates for their patients as a threat to their financial planning.  The goal is to drive out the community based physicians because they act as a check and balance to the designs of the hospital system working as advocates of their patients. Do not believe for one moment that the goals and aspirations of patients in a community setting are aligned with the goals and aspirations of hospital administration.

I recommend that citizens look into the politics of their local hospital system.  If you do not, you may find that your doctor can no longer take care of you when you are sickest and in need of those professional services provided by someone who knows you well. You may find that you are transported from the ER to the floor quickly but you may not get to see a doctor for half a day.

How should this policy be altered to make sense?  Staff physicians should have 90 minutes to arrive at the ER and assume the care of their patients. In critical life threatening situations requiring immediate intervention, hospital ER staff should be providing stabilizing care until the patient’s care team arrives.

Requiring doctors to give orders on patients they have not seen is bad medicine. Giving those same doctors 12 hours to show up is irresponsible.

The Turnovers are the Difference- Medical “Handoffs” Are Continually Fumbled

This is a humbling football season for those of us who root for Florida teams at the collegiate or professional level. It seems that each week after another loss we are listening to the head coach standing at the podium during a post-loss press conference talking about how if the handoffs had not been fumbled, and the ball dropped and lost, his team could have prevailed. It is hard enough to deal with the turnovers and fumbles when rooting for your team. It is far more difficult to deal with it when we are talking about human beings hospitalized and cared for by hospital employed physicians and then turned back to the community without communicating adequately, or at all, with the care team responsible for their continued care at the community level.

Take the case of GH, an 82 year old obese diabetic with high blood pressure, high cholesterol and heart irregularities requiring the use of Coumadin to prevent a stroke. He awoke one morning two weeks after a major auto fender bender and found his underwear stained in bright red and dark brown blood. His wife was unsure if it was coming from his rectum or penis so she called 911 and allowed the patient to be taken to the nearest emergency department.  He was seen by the emergency room staff and admitted to their contracted hospitalist service for presumed intestinal bleeding due to Coumadin toxicity.

Eight days later he was discharged home with an indwelling Foley catheter needed because of the “clots” in his bladder. His Coumadin had been stopped on admission and never restarted. GH could not get out of the bed and walk while in the hospital and he stubbornly refused to go to a nursing rehabilitation center as an interim step until he was strong enough to walk independently.  His frail 80 year old wife, battling a lymphoma herself, was given the task of caring for this obstinate man at home and emptying and caring for his indwelling urinary catheter.

On his first day back home, I received a phone call from his wife informing me of this. She didn’t know what she could possibly do to care for him because he weighed 230 lbs and he couldn’t get out of bed and walk. A nursing service and physical therapist had been requested but had not yet called to schedule a visit.  She was particularly disturbed because 12 hours had gone by since he got home with no urine appearing in the bladder drainage catheter. At the same time his lower abdomen was growing in size and he was feeling pain and discomfort at that spot.  Once again, 911 was called and he was taken back to the same emergency department. Paramedics transport sick patients to the geographically closest facility not necessarily the one his physician sees patients at.

GH was readmitted because his catheter was blocked with clots and needed irrigation and there were concerns about a urine infection. I spoke with the wife and children and asked for the name of his doctor but they could not remember it. They did remember the name of his consulting urologist. I called the urologist who was a bit put out to discuss the case with me. He told me that “our“ patient was bleeding from the urinary tract due to a transitional cell cancer of the bladder that he discovered and treated during a cystoscopy. He felt the prognosis was excellent.

The urologist declined to discuss whether the patient was additionally bleeding from his intestinal tract or if the appropriate evaluation had been done. He suggested I find the hospitalist responsible for the patient’s care. When I asked for the name of the hospitalist he told me he had no idea who it was. “They all look the same to me,” was his actual response.

I asked the patient’s wife to have her husband sign an authorization to release medical records and obtain the medical records of his admissions for my review. She did that and presented it to the medical records department who sent me a brief summary of his second admission. It took three phone calls to obtain the records of the first admission and another to get the emergency department records.  I needed this material because it was quite easy to convince the patient to come to a local rehab facility after this hospitalization with me as his attending physician.  The patient and family had no idea why he was bleeding other than “I had clots” in the bladder. They didn’t know the name of his hospitalist either.  When I received the records it identified the physician. I called the hospital to page her but was told she was “off “for the next few days. Her colleagues on duty did not know or remember the patient.

The patient records finally arrived. His admission diagnosis was bleeding due to Coumadin toxicity, but the INR (a measure of how effective the Coumadin is in thinning the blood) was very low indicating that his blood was not anticoagulated much at all.  An INR of 1.4 doesn’t cause bleeding and is not toxic. The medical record said he had hematochezia (blood in his stool) but there was no documentation that anyone had performed a rectal exam or examined a stool specimen for the presence of gross or microscopic blood.

There was a lab order to type and cross-match the patient for a blood transfusion but certainly no mention that a transfusion had actually occurred. There was a thorough procedure note from a gastroenterologist who looked in his stomach and colon several days after admission and found no source of bleeding. I called the gastroenterologist on the day I received the records but he was gone for the Thanksgiving weekend.  The records indicated the patient’s blood count showed hemoglobin of 9.3 on the day prior to discharge and 8.3 on the day of discharge but there was no mention of an investigation of why the blood count dropped and why he was released with a dropping blood count.  A chest x-ray report on his first admission showed a right lower lung infiltrate but there was no follow-up performed or reported.

The patient arrived at the local rehab facility on Thanksgiving morning. I saw him and performed a thorough history, review of his records and an exam.  He was no longer bleeding, with no black stools noted on my rectal exam and no microscopic blood on the stool occult blood slide test I performed at the bedside. His Foley catheter was draining clear non bloody urine and the patient looked pale but well.

It was really very easy to convince this patient to come to rehab to learn to walk again once I became aware of his hospitalization and condition.  After my initial exam I sat down with the charge nurse and we constructed a care plan for the next few weeks at the rehab facility and explained it to the patient. Then I told the patient he had bladder cancer with a good prognosis. He was completely unaware of that diagnosis until we had the conversation.  I called his wife and children separately and reviewed the diagnoses and care plans for follow-up.

GH entered the hospital on an emergency basis as an unknown. He was appropriately taken to the nearest receiving facility by the paramedics when he was found to be on a blood thinner and bleeding actively.  His inpatient hospital employed physicians prevented a catastrophe and did what was necessary to make sure one was not ongoing. They did little or nothing to insure the loose ends of his medical problems resulting in hospital admission were addressed or understood by the patient and family.  Little or no effort was made to insure continuity of care and appropriate follow-up.

Judging by the editorials in our peer reviewed medical journals, this has become the norm not the exception in our insurance company / employer driven health care system. The devil is in the details. Unless the loose ends are planned for , understood and addressed, patients like this will continue to be bounced back to the hospital as an “emergency”, unnecessarily spending money we do not have and do not need to waste.