Patient Hand-Offs and Communication

document businesspeople 1I was finishing tying my shoes as I got dressed to take my lovely wife out to dinner for our 41st wedding anniversary. It was 7:30 p.m. after a hectic day at work and we had a wonderful dinner planned at a local restaurant.

The telephone rang with the caller ID identifying a call on my office work line. “Hello this is the Emergency Department, please hold on for Dr S.” Before I could get in a word edgewise I was put on hold. Five minutes later Dr S. got on the line. “Steve this is Pete. “Dr. Rheumatology” saw your mutual patient Mrs. T this afternoon and she was complaining of shortness of breath beginning three weeks ago. She complains of overwhelming fatigue. He sent her here for evaluation. Her exam is negative. At rest she doesn’t look short of breath. Her EKG doesn’t show any acute changes but I do not have an old one to compare it to. Her chest x ray is negative and her oxygen saturation on room air is 97 % (normal is greater than 90%). She has lupus and multiple autoimmune problems and is on many immune modulators. Maybe she has a constrictive cardiomyopathy or restrictive lung disease. I called Dr. Rheumatology and he said this isn’t his department to call the PCP (primary care physician) to admit the patient and you are the PCP. “I told the ER physician I had not seen the patient in over six months or heard from her but I would be right in to see her”.

I explained to my wife that duty calls and there was a sick patient in the ER. She was extremely understanding. On the drive to the ER I called the Rheumatologist to ask him his clinical impression because he had been seeing her every two weeks and had examined her just that afternoon. He returned my call and we discussed the clinical aspects of the situation and his thoughts. Then I told him that I thought he should have called me when he sent the patient to the ER if he expected me to assume care. If he did not call then he most certainly should have called me when the ED doctor called him to report on the findings and he said call the PCP. Hand-offs should be direct especially in an acute situation and especially if you sent the patient to the ER and do not intend to take ownership of the situation you sent the patient to the ER for.

He told me that in 30 years of practice no one had ever criticized him for this and he does it all the time. He told me he had been working long hours and did not have time to call referring physicians. I told him that was no excuse and if he was working that late maybe he needed to restrict his patient volume so he could communicate in a professional manner.

I arrived at the ER 20 minutes later and learned that the patient had been there for three and half hours already. She had been in the ER while I had been at the hospital earlier that afternoon checking on another patient. Had I known she was there I could have easily seen her, cared for her and still made my anniversary dinner.

A review of her old EKG and comparing it to the new one, plus taking a thorough history and exam, revealed the problem. She was having a heart attack. Her bouts of shortness of breath with activity with overwhelming fatigue were her equivalent of crushing chest pain.

Getting called to the hospital during “off” hours is part of a physician’s way of life. Having a colleague take your role and time for granted at the expense of the patient is disturbing and unprofessional.

All too often today physicians, both specialists and primary care, don’t take the time to communicate directly and clearly with their colleagues about patient care.  When this happens, clearly the patient is negatively impacted.

ACO’s and the Patient Centered Medical Home will not cure this. Only courtesy, respect and putting the patient first will change things.

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.

Hospital Administration: Spending Your Tax Payer Dollars / Shorting You on Benefits

Last summer my 86 year old father awoke in the middle of the evening with profuse rectal bleeding. He felt weak and dizzy and called 911. The paramedics transported him to the local emergency room at a hospital close to his home – about one hour south of my home.

I call my parents daily to check up on them and learned of the trip to the hospital during one of these calls.  Mom is 84 and wheelchair bound with multiple structural and cardiovascular issues. Dad is 86, a WWII decorated paratrooper with dementia and orthopedic issues that dwarf his other chronic problems. They have an aide for several hours a day that is the glue that holds their lives together in their own home.

No one was home when I called and of course my folks had their Jitterbug senior special cell phone turned off so they were unreachable.   I left several messages and finally about 8:00 p.m. my mom answered the phone, denied that the cell phone was turned off, denied that I had left any messages on her answering machine and told me that dad was in the ER at Memorial Hospital. Her description was quite vague as to what was going on but I did learn that their long-time physician was unavailable and the hospitalist service was caring for him.

I phoned the ER and spoke to a nurse who was nice enough to tell me that he was stable and they were holding him for observation. He had not yet required blood transfusions and they did not know the exact source of the bleeding but he was still in the emergency department and comfortable.  I drove down that evening and saw dad in the ER. The next evening, unable to find his doctor, I drove down as well and saw dad in his hospital room on the medical floor.  He was weak but in good spirits.  I left a note with his nurse to please ask his physician to call me at his convenience and left my office and cell phone numbers.

Two days later I received a phone call from his long-time physician, who had returned from visiting her family to explain what was going on. She said that his gastroenterologist had been in to see him and he was doing well. The next day after some “tests”, dad’s liquid diet was advanced to a soft diet.

At 5:00 p.m. I received a harried phone call from my mother. She told me that dad was being discharged immediately and that if they stayed longer Medicare would not pay for it and my folks would be totally responsible for the bill. Dad had been in bed for four days, had not walked the halls, had not showered or washed himself and had not yet had a bowel movement since admission.

As a board certified geriatrician I realize the importance of these benchmark pre-discharge steps being achieved BEFORE you send a patient home.  It was too late for dad who was out the door and home.   His aide was upset because she leaves at 7:00 p.m. and she felt dad was too weak to get out of bed and walk to the bathroom without falling. I hired a night nurse and put in a call to his doctor.  I demanded that he be evaluated for a stay in a rehab facility until he was able to ambulate or at least send in a physical therapist to help him regain his strength and ability to walk. A few days of bed rest completely de-conditions most senior citizens and the complications of falls, and their prevention, must be addressed to prevent a bad situation from becoming worse.

His physician told me that “he did not meet criteria for home health assistance or rehabilitation stay” because he had been in the hospital for less than three full days.  I was astonished. He had been in the hospital for five to six days by my count.  She told me his first two days in the hospital were not as an admitted inpatient but as an outpatient observation.   By discharging him at 5:00 p.m. he had missed being an inpatient and qualifying for benefits by several hours.

Outpatient observation status is a game hospital case managers and administrators play to bill more money. When a Medicare senior citizen is admitted as an inpatient the hospital receives a bundled total payment based on the diagnosis or DRG.  If the patient is kept in observational status the hospital is no longer limited to receiving a flat rate but can unbundle the charges and bill ala carte for each service rendered.

The Center for Medicare and Medicaid Services (CMS) in its 12/03/2009 bulletin on page 3 defines outpatient observation services as “the use of a bed and possible monitoring by nursing or other ancillary staff, which are reasonable and necessary to evaluate the patient’s condition for possible inpatient admission.”   The decision as to inpatient admission status or observational status is supposed to be made by the patient’s doctor.  The problem is that is as far as it goes. No one at the CMS level has actually delineated criteria for an inpatient or traditional admission or for outpatient observation.

At the hospital level, administration now places a document on each patient chart requiring the physician to defer that decision to the hospital employed case manager who is not a physician. Over the years, hospital administration has diminished the political power of the individual physicians and medical staff to be advocates for their patients by destroying the medical staff bylaws and infiltrating medical staff governing bodies with physicians loyal to, and employed entirely by, the hospital.

The result is a tremendous conflict of interest with no one watching out for the patient.  The hospital then controls the rules and regulations and can even bully staff members into relinquishing decisions on admission status to the hospital employees rather than the patient’s physician.  One of the reasons hospitalist medicine has become so popular is that hospital administrators love the idea of controlling the physician side of care, something that acted like a “check and balance” in favor of patient advocacy when physicians were independent.

I bring this up because at my community hospital, where I care for my patient’s administration, is now attempting to influence doctors to give up the decision-making on admission and cede it to their case managers as well. A note was sent to the entire staff instructing us to not admit patients who do not meet “interqual” criteria for admission but to let their case managers assign them to observational status.

When I inquired about what interqual criteria were, and where “interqual” criteria were listed in the CMS bulletins or Federal Register, I was told they did not exist there.  Once again the fox is watching the hen house.

In these times of deficit spending and economic crisis hospitals are using our tax dollars to bill ala carte at a higher level and limiting senior citizens right to qualify for necessary post-hospital rehabilitative care by making much of their hospital stay “ observational” as opposed to traditional inpatient status.

I wrote a letter to Memorial Hospital about my dad’s stay and asked to see their criteria for inpatient admission.  Just like my local hospital could not produce criteria, neither could Memorial Hospital. I wondered how a frail 86 year old, dizzy, bleeding rectally and on anti-platelet agents to prevent clotting did not meet criteria for hospital admission?  I received a phone call from the Chief Medical Officer at Memorial Hospital months later saying he had reviewed my dad’s case and he was comfortable with their decision-making.

The issue needs to be addressed by patients, family members, legislators and concerned physicians. Hospital administrations are bullying physicians into relinquishing their advocacy and decision making so that they can charge more using the observational status rather than the inpatient admission status. By using this technique the patient does not meet the three day minimum hospital stay to provide post hospital care and treatment paid for by Medicare and the patients supplemental insurance policies. Once the patient’s personal physician relinquishes decision-making power to the hospital employees, they have created a conflict of interest which, if left unaddressed, will raise health care costs and affect quality of the patient’s care.

Hospitalists and Community Physicians- It’s All About the Handoffs

I referred my second patient to a specialty surgery department at a local university center last month. The patient is a practicing physician with severe lower back disc disease and structural abnormalities. He saw a highly acclaimed surgeon who won the patient’s confidence.

I performed the required preoperative evaluation requested by the surgical team, called the surgeon to make sure we were on the same page, and made sure all the appropriate records and labs arrived at the center prior to the patient’s surgical date. Three days after the scheduled procedure I received a phone call after-hours from a nurse at a local rehabilitation facility telling me my referred patient had been transferred from the university center after discharge and requesting confirmation of  admitting orders to their facility for postoperative rehabilitation.

I had not received a phone call from the surgeon or his staff to discuss how the surgery had turned out. I had received no phone call, fax or email telling me when they planned to discharge the patient. I received no communication discussing discharge instructions and medications.  The surgeon is a chief of a department responsible for teaching fellows, residents and students how it should be done. He fumbled the handoff and sent a patient on his way with a bunch of handwritten chicken scratches on a form filled out by a case worker. In the era of cell phones , smart phones , email , faxes , instant messages and tweets it seems like communication between practitioners has gotten worse not better due to lack of effort and failure of practitioners to acknowledge that it is their job to take the time to make the transition smooth and seamless.

The hospitalist program at my community hospital is no better. Physicians employed by the hospital were supposed to “move “patients and facilitate discharges helping the hospital’s financial “bottom line.”  Hospital administration contracted with non-fellowship trained hospitalists to admit patients who arrive through the ER and have no doctor. The hospitalists are only too happy to admit patients of staff members who do not wish to attend their patients in the hospital.

The problem is that the hospitalist do not enjoy coming in at night. When a patient with a hip fracture shows up at our ER, the orthopedic surgeons on call for the ER now believe they are consultants not doctors. They will not admit a surgical case. They want the PCP or hospitalist to do it for them. If a broken hip case arrives after 7:00 p.m. “the hospitalist “admits the patient sight unseen over the phone and then comes in by 7:00 a.m. to see the patient.

Our hospital has some patient unfriendly bylaws. If the ER doctor calls you and says your patient requires admission you have 30 minutes to provide admitting orders over the phone or in person but you have 12 hours to arrive and actually see the patient.  Showing up 12 hours later often pushes the surgery back a day negating the main reason hospitalists were hired. When the patient is ready to leave the hospital it is rare that the facility has introduced the patient to an outpatient physician for follow-up care.  If the patient actually has an outpatient physician it is even rarer that the hospitalist contacts them to discuss the hospital course and discharge medications and instructions.

The system in the Intensive Care Unit is no better. After years of debate and disagreement based primarily on economic issues and turf and privilege battles, administration contracted with a pulmonary group on staff to provide fulltime intensive care physicians. They went out and hired a bunch of young ICU specialists and salaried them.  These physicians run the critical care areas.

I have always favored fulltime ICU physicians in our community hospital because with no interns or residents there are no physicians in the facility after hours. I was a bit surprised when the contract allowed the ICU doctors to go home at 11:00 p.m. leaving no one in the units until the next morning. My first contact with the intensivists came after a weekend away during which my associate covered for me.  He admitted a patient to the hospital with a raging pneumonia.  Since the patient was taking an anticoagulant Coumadin he had to specifically choose an antibiotic that didn’t alter the affects of the blood thinner. Later that first night the patient had some respiratory distress so my associate came in and transferred the patient to the ICU. He called the intensivist and discussed the case in detail.  He made rounds the next day and reviewed the chart and pointed out to the ICU specialist that the antibiotic he had switched the patient to potentiated the Coumadin effect. He suggested checking the clotting study and adjusting the dose of the Coumadin.

When I came in on Monday I found the patient lying in a pool of blood from the rectum. His PT/INR had been elevated the day before and required lowering the Coumadin dose. No action had been taken. His PT/INR on Monday was even higher.  I called the charge nurse and barked out some orders. She reminded me that the intensivist was in charge. The intensivist that morning was a young woman in her early thirties. When I asked her why the monitoring of his Coumadin dose was left unattended she took great offense and answered, “I wasn’t on call this weekend, why don’t you take it up with the doctor on call.  He’s asleep now so I would give it a few hours before you call him.” I gather she wasn’t willing to “take one for the team.”

Within the last six months an editorial in the Journal of the American College of Physicians was critical of hospitalist programs for the poor communication when a patient leaves the hospital and returns to his doctor in the community without communication occurring.  A recent research article in the same journal revealed that patients treated by hospitalists require re-admission to the hospital for some complication of the original problem far more often than if their personal physician cared for them. The ultimate cost to the system was higher. The problem is the communication and handoffs.

Part of the problem is that physicians no longer feel it is their responsibility to contact their peers. In the past, physicians had close knit referral circles and patterns using physicians they trusted and worked well with. Insurance company managed care programs destroyed those referral patterns forcing physicians to use the doctor on the panel or else they would not pay the bill. Often the consulting doctor on the panel was resentful of receiving a consult from a doctor who had never used his services but would now use them at the panels discounted rate. They felt no strong compulsion to contact the referring physician and discuss the case. T

The referring physicians are not without blame either, often sending patients to physicians they have little contact with accompanied by little if any information as to why they were being consulted. A culture of communication and sharing of information professionally became a culture of “I am too busy to make a call.” The one that suffers is the patient and the people paying more for care because of communication breakdowns.

The American Medical Association and the American College of Physicians have supported the development of the specialty of hospital medicine long before I believe they should have. These organizations are heavily dominated and supported by specialty physicians who are paid handsomely to stay in the operating room and perform procedures rather than care for the patients.  Having hospital employed physicians to be their “scut “workers and take care of the patients with their nurse practitioners and PAs makes sense to them. It breaks the link of good continuity of care and just isn’t very good for patients or overall costs.

Legislators, politicians, employers, insurers, medical school faculty keep looking for ways to overcome the shortage of primary care physicians and the large gap in payment between cognitive services and procedural services. The solution to the problem is to pay the primary care physicians well for their evaluation and management services, train them thoroughly and completely and allow them to care for their patients in all our health care venues.