Hospital Discharges and the Handoffs

Fred Pelzman, M.D. is an experienced internist who practices in the NY Metropolitan area and trains young doctors at a well-deserved renowned academic medical center. His corporate behemoth medical system tries to engage in the latest and greatest business practice models for care, using technology and staff generally unavailable to the mom and pop medical practices that once dotted America.  Meanwhile, Dr. Pelzman cares for people compassionately while training his young disciples in an ever changing and complicated health care environment. I love reading his blog posts discussing his thoughts, concerns and efforts.

This week’s article or “post” is about the difficulty and danger entailed when a patient leaves the hospital, after being cared for by hospital based physicians, and returns to their homes and the care of their outside doctor’s. I give Dr. Pelzman much credit for taking ownership of the problem and attempting to solve it. I think there is a much simpler solution to his problem than creating a fast track computer program for patients who need to be seen quickly post discharge. It is called the telephone.

There was a time when physicians actually picked up the phone and called their colleagues and discussed the transfer of care before initiating it. During my internship and residency at the University of Miami Jackson Memorial Program; when a patient was being transferred, the receiving physician received a page resulting in a phone call from the transferring physician to discuss “the case.” The transferring physician wrote a transfer summary in the chart to be reviewed by the receiving physician. When patient’s went home, especially non-private patient’s, the handoffs were inadequate since often there was no receiving physician to communicate with.

After finishing my training and entering private care in a suburban community, the transfer of care was quite simple because most physicians cared for their own patients in the hospital and in the community so the transfer of care was smooth and seamless. This changed with the institution of “managed care” run by insurers at the request of employers and by the development of hospitalist physicians.

Employed hospital based physicians were the idea of Robert Wachter, M.D., the father of hospitalist medicine and the current director of hospital physician training at University of California in San Francisco. When he was completing his training in internal medicine he noticed that general internists in private medicine were not being paid very well in the field. He also noticed that his academic teachers, who were required by Medicare and insurers to actually spend time taking a history, doing a physical exam and writing a progress note on each patient on their teaching service if the facility was going to get paid for their care hated actually interacting with patients. They preferred to be in their research labs or teaching students and future doctors.

Hiring someone to do that work and creating a specialty gave them the freedom to go back to what they wanted to do. It also gave administration a certain amount of control over the tests ordered, medications ordered, length of stay and costs. At the same time this was occurring, “administrative and management experts” were out in the community, convincing private physicians that the solution to their low reimbursement was to stay in the office and see more patients and give up caring for hospital patients. It was deemed inefficient to cancel or delay patients in your office or clinic so you could run to the hospital or emergency room to see an acutely and seriously ill patient.

As hospitalist medicine took hold, medical and surgical specialties decided it was more efficient to use their services than to take the time to admit the patients with issues they were best trained to care for. Orthopedic surgeons stopped admitting patients to the hospital with fractures that needed surgical repair. They asked the hospitalist to do it. Oncologists stopped admitting patients with fevers and infections and abnormal blood counts as a consequence of their cancer or treatment of cancer. They asked the hospitalist to do it. Gastroenterologists stopped admitting acute gastrointestinal bleeders who needed endoscopy and cardiologists stopped admitting acute heart failure and pulmonary edema and heart attacks. These specialists preferred to be “consultants” and let the hospitalists perform the tedious medication reconciliation, admitting orders and mandated quality metrics forms and the deep vein thrombosis prevention forms. The hospitalists became their interns and medical students performing the time consuming , bureaucratic, labor intensive low paid administrative work so the specialist could arrive like the cavalry and just do their procedure and leave.

The problem is that the hospitalist didn’t know the patient. The referring doctor never called the hospitalist or ER physician to send the records and explain why the patient was coming and there was little if any communication. The same occurs when the patient leaves the hospital and is sent for post hospital care. No one coordinating care in the hospital contacts those responsible for the patient’s outpatient care to discuss a care plan. The fault lies with both the inpatient and outpatient physicians who don’t take the time to communicate.

Above anything else, the patient must come first. Picking up the phone and calling the receiving physician and discussing the nuances of the necessary care and creating a plan which is explained to the patient is in the patient’s best interests. All care givers need to remember this and create local environments, climates and systems that encourage communication between hospital-based physicians and community physicians.

Advertisements

Primary Care Docs Outperform Hospitalists …

A study published recently in JAMA Internal Medicine looked at 650,651 Medicare patients hospitalized in 2013. It showed that when patients were cared for by their own outpatient physician they had a slightly better outcome than when the patients were attended to by full-time hospital based specialists who had not previously known them.

As an internal medicine physician who maintains hospital privileges, as well as caring for patients in an office setting, this study supports the type of medicine I have been trying to practice for the last 38 years. However, I am not naïve enough to believe it entirely.

In recent months similar studies have touted the benefit of female physicians over their male counterparts, younger physicians over older physicians and even foreign trained physicians over those trained in the USA. Based on these studies, one might conclude you should be treated by a young female outpatient physician who trained in a foreign country. While the JAMA study shows the success of the outpatient primary care physician, those in hospitalist medicine could similarly produce their own studies showing the benefit of using a hospital based physician or hospitalist.

I do believe having a familiar physician, you know and trust, adds a major level of comfort when you are ill. Having that physician consult within his or her referral network of physicians who know how that doctor expects the communication between doctors, and care to occur, is an additional benefit.

The fact that your personal physician knows what you look like in health gives them a distinct advantage in recognizing when you are ill. They know you and all about you and that helps. It especially helps patients with complex medical issues who require more time and thought. Being able to review the old records and previous specialty consultations which you were a part of seems to impart an advantage that someone just joining the care team does not yet possess.

This study does not say that outpatient primary care docs are better than hospitalists. It only points out that in a senior citizen population in 2013, patients cared for by their own primary care doctor had a better 30 day survival after a hospital stay.

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.

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.