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.

Care of Senior Citizens – Fewer Rules Needed

Last month I had the pleasure of seeing my younger daughter get married. The morning after the service I found myself having coffee with the uncle of the groom, a very successful trial attorney who makes a great living suing doctors and health care institutions.  I asked him how his mom was feeling. She had come to the function feeling ill and had returned home with her caretakers immediately after the service feeling too ill to stay for the reception. She had looked elegant, as a great lady should, and would not miss seeing her grandson marry even at the expense of her health. I asked him what was wrong with his mom. Among her many severe and chronic problems was a new bed sore on her buttocks. Despite living in a luxurious condominium on the Florida waters, having the best in round the clock medical help and equipment, her frail and thin skin had broken down in what the lay press calls a bedsore. It was all the more perplexing because everything had been done correctly. “I sue people for having problems like this develop in their loved ones,” he said only adding fuel to his frustration and anger. It was a stark and painful awakening for this gentleman that sometimes everything is done correctly and as the bumper sticker says “ shit happens” because the patient is frail, vulnerable and nearing the end of the circle of life.

As I went back to my room I saw a public bus pass outside bearing a large banner advertising a law firm representing the elderly in nursing home senior abuse cases “for the injured.”   I turned on the TV and there was another advertisement for another trial attorney firm claiming to represent those “wronged” by the health care system.  It was the morning after the wedding and I wanted to give my wife some flowers so I grabbed the local Yellow Pages to look for a florist only to be greeted by an ad on the back cover from a large law firm seeking clients injured in nursing homes.

I currently practice internal medicine and geriatrics and give my patients my cell phone number. My associate was on call the weekend of the wedding, but it is not uncommon to receive a direct call from a patient or institution even if I am “off”.  The phone rang at 8:45 a.m.  It was a local skilled nursing facility calling to tell me that my 94 year old cognitively impaired patient had brushed against a cabinet in the dining room and had a minor scrape. They wanted permission to wash it with soap and water and peroxide and put on a bandage. They are required by law and protocol to call the physician and notify him and get permission.

If the patient had indigestion and asked for a glass of ginger ale or some over the counter antacid they are required to report that too. In fact they are required to report everything that occurs. Simple first aid and minor ailment solutions that the patient would perform themselves if they were home require a call to the doctor and orders before the nursing home can treat the problem. Once you receive a call you will receive a copy of the phone conversation with small order sheets in triplicate in the mail within 72 hours for you to review, sign and send back.

With current staffing ratios in the evenings and weekends leaving one registered nurse caring for forty or more seniors , it is amazing that any “ caring “ occurs while the staff is busy reporting as per protocol. If you don’t report it then you may be sanctioned. Sanctions vary by state and locale and involve fines and even loss of license and they are posted on an Internet website for all to review.  The rules for running these places are so numerous and complex that the cost of caring compassionately for an individual is compromised by the time and cost of documenting and fulfilling the large number of rules and regulations. Instead of staff being hired to provide hands-on care, they are hired to dot the “I’s” and cross the “T’s” to remain in compliance.

Not many internal medicine generalists or family practitioners follow their patients in these facilities anymore. It has become too problematic. For one thing it is no longer sufficient to be licensed in the state you are practicing in and be in good standing. Based on regulations the SNF must follow, you must now be credentialed at the facilities you wish to visit to see your patients. You may have been seeing patients at that facility for 30 years but now you must provide them with proof of medical malpractice coverage in amounts they are comfortable with. They need your physician NPI and UPIN number, your DEA license, your resume or curriculum vitae, several personal and professional references, proof of recent continuing medical education credits and courses. All this of course is required by law to maintain your state license and renew it every other year.

You could make the assumption that if you have a current and active license in your state you already meet these criteria. With so few general internists and family practitioners willing to go out and treat patients at these facilities you would think they would make it easier not harder to stay on staff.  In addition, most of these facilities now have a full time medical director. The medical director is paid a salary to sit in on meetings, provide oversight and sign forms so that the facility stays in compliance with numerous local, state and federal organizations. It is common for the nursing staff, and administration at these facilities to try and steer all the new patients to the medical director regardless of how long the patient has been seeing their community medical doctor.

The change in physician recommendations are done repeatedly and often by nursing staff and administrative staff who find it easier to reach the medical director on site then wait for the community physician to return a call about a non critical matter.  Losing continuity of care and all its advantages never enters into the facilities thought processes, just convenience and availability.  How many phone calls in the middle of the night do you have to receive that awaken you and the family while you hear “This is Shady Oaks Rest Home calling. Your patient Mr. Jones was found sitting next to his bed with no apparent injuries. We are required to call and apologize for the hour but how would you like us to proceed.”   This is actually preferable to hearing, “Mr. Jones was found on the floor next to his bed, and he has a grapefruit size lesion on his scalp but appears to be ok. We called 911 and he is on his way to the ER for further evaluation.”   In a logical world Mr. Jones would receive an ice pack to the bruised swollen area, some Tylenol for the aches and pains, and if the nurse feels there is nothing seriously wrong, be observed by the staff using the standard recommendations for observing an individual after head trauma.  There is however no room for skill or nursing in a skilled nursing facility anymore. The rule of the road is always “Call 911 and copy the chart for transfer to the Emergency Department.” With a high ratio of patients-to-nurses there is little time for the nurses to do much more than pass their medications out before their shift is ending let alone observe and care for patients.

If we look at the clientele at these facilities they are generally two types. There is the chronically ill cognitively impaired individual placed there for long term custodial care because they are too difficult to care for at home. They are demented, some unknowingly angry and aggressive, incontinent of body fluids, with little or no hope of recovery and rejoining society.

The other group is the rehabilitative patient recently out of the hospital after an injury or surgical procedure and requiring therapy before they can perform the activities of daily living and be successful at home. This group is generally too frail to be admitted to a true rehabilitative hospital and have been turned down by the rehab hospital leaving the Skilled Nursing Facility as the only other option.

Most facilities have excellent therapy departments and clinical social workers to assist you in your care. I follow my patients from their homes to the hospital and into the skilled nursing homes.  I do it because I believe in the benefit of longitudinal care and having continuity of care. Most physicians do not follow their patients into the facility or even the hospital anymore. They either turn the patient over to the “house doctor” or send their nurse practitioner to provide the care. The hassle factor makes it too difficult and unpleasant for them to come to the facility and care for their patient.

As the national shortage of primary care physicians grows, and the failure to compensate physicians for evaluation and management services adequately continues over time, there will be fewer and fewer doctors travelling to these facilities.  Tragically, the shortage of primary care physicians is occurring at the same time that our baby boomers are turning 65 – creating the ingredients for the perfect health care storm.

The loss of continuity of care is problematic. For example, Mrs. Jones is recovering from hip replacement. Upon admission to the hospital after suffering a fall and fracture, the hospital pharmacy makes therapeutic substitutions to the patients medicines based on the hospital formulary and their buying costs. Orthopedic surgeons in my community no longer wish to attend to and admit surgical cases. They want the medical doctor to do it. If the community based physician has a problem with that, the hospital wants the medical care provided by their employed hospitalist. The surgeon may or may not directly provide informed consent. They are supposed to by law but it doesn’t usually happen.  Many times the surgical nurse or his nurse practitioner does the talking, explaining and the pre-op exam. The surgeon operates and then turns the bulk of the postoperative care over to his nurse practitioner or physician assistant.  The surgeon may not see the patient until weeks after the surgery in his office to check the wound, the alignment and to remove sutures. After two or three days in the hospital the patient is transferred to a skilled nursing facility for rehabilitation.

In all probability the surgeon has not seen the patient since immediately post operatively in the recovery room. When the patient arrives at the rehab facility, they are turned over to the house doctor.  The pharmacy contracted to provide medications for the facility reviews the in patient hospital medications and then again changes the medication to fit their formulary and buying preferences.  If you actually provide the medical care in the hospital and then wish to follow your patient into the SNF you are most likely writing and reviewing the patient discharge and transfer orders. You may see the patient on rounds at 7 a.m. that morning with the transfer to the SNF occurring later that day. When the patient arrives at the SNF you are supposed to write an admission note within 24 hours of admission even if you have just seen the patient that morning and the level of attention required does not merit another visit that same day. You must fill out another complete history and physical form in the format of the SNF even if you bring the hospital history and physical, daily progress notes and discharge summary with you and place it on the chart. It is not sufficient to write a short progress note documenting your continuing care at this new location. Failure to rewrite your history and physical can result in sanctions and fines against the institution.

The medication list at the SNF is transcribed onto their triplicate copy form. If you actually go to the SNF that same day and try to review the medications with the staff, they are not prepared to review the medications because the contracted pharmaceutical firm has not produced the medication order sheet in triplicate yet. They would much rather wait until their documents are ready and then  read you a list over the phone and have you confirm it even if you are no longer at the office or have the medical record in front of you. It makes no sense but complies with their rules and regulations.

The skilled nursing homes have their own list of specialty physicians they like to refer to. When they call you with a minor non critical issue and they do not like the speed of response or the therapy suggested, they immediately call the family to suggest that they call in a specialist.  “Hi Dr Reznick, this is Brenda at Shady Oaks, your patient Mrs. Jones has some skin lesions on her back and a rash. I have spoken to her daughter in Atlanta and they want her seen by a dermatologist.”  The skin lesions may be benign cherry angiomas that you have known about for years. Once the call is made you can bet the dermatologist will be called.

Last year at a fine facility in Delray Beach, I made my monthly visit to an 87 year old severely demented gentleman who had a cough. When I pulled his shirt off to listen to his lungs his back looked like a minefield that had exploded. There were 27 excisional biopsies that had been performed by a visiting dermatologist the day before.  Due to his dementia, this gentleman had not recognized friends or family for years. He was eating a honey thickened puree diet. He sat in a chair or bed all day in front of a TV with no acknowledgement of what was on the screen. . He was in no pain or discomfort. Did he really need 27 biopsies at this stage of life?  They all came back benign lesions or simple basal cell carcinomas. To make matters worse, he ordered numerous creams and salves for the patient as a verbal order over the phone and the nursing staff sent the small order papers in triplicate for me to sign as if I had given the order. When I explained to them that the dermatologist had ordered these medications and should be the one to sign for them, they became annoyed at me.

Speaking to the administrator or head nurse about your issues is of limited value. Most of their staff changes in a calendar year. There is close to 100% turnover per year. This is not surprising. The physical work is hard. The patients do not always have the mental capacity to voice their appreciation. The patients have issues of urinary and fecal incontinence requiring constant attention, changing and cleansing. The pay is low. It is surprising to me just how caring and compassionate the workers are under these circumstances and it is a credit to their kindness and humanity that they continue this work.

As the Baby Boomers age, we need to make it easier for physicians to follow their patients in the hospital and into nursing facilities – not more difficult.

  • We need uniform order forms (preferably computerized) to make prescribing medications and therapy easier and more accurate.
  • We need sensible credentialing rules that allow a practitioner in good standing in his state and local hospitals to follow his or her patients without expensive and costly re-credentialing procedures.
  • We need to reform the tort laws to eliminate the fear these institutions have of costly and frivolous law suits and allowing them to put more caregivers on the floors rather than compliance officers.
  • We need to appreciate the benefit to the patient of continuity of care rather than fragmenting their care asking a new provider to start over and assume care in each location.
  • We need to get healthy teenagers who are considering a career in health care and healthy senior volunteers into these facilities to assist the under staffed employed staff.
  • We need to get young doctors and nurses into these facilities as part of their training requirements, so that simple care can be provided on site rather than continuing the “call 911 and copy the chart for transfer” carousels jamming acute care hospitals and emergency departments and freeing the emergency responders to respond to true emergencies.
  • We need less regulation at these facilities so that the patients can receive more care.