In our last post, Dr. Bruce Leff talked about Hospital at Home. When someone becomes acutely ill or injured, hospital care is needed to treat the problem. But hospitalization causes its own problems. One of Dr. Leff’s patients described the hospital as a “crappy hotel.” I’ll describe three things that make the hospital feel like a crappy hotel.
1. Who’s in charge? 3 different doctors in 2 days???
When a patient is hospitalized at night, the nighttime doctor examines the patient and writes the orders. The next morning, the doctor goes home. Another provider assumes care. However, hospitalists work on rotations. Work starts at the beginning of a rotation and transfers to the next provider at the end of the rotation. If it’s the last day of a rotation, yet another person will be in charge the next day. This is a common situation which results in 3 doctors in 2 days.
When a family member wants information, the doctor who first wrote the orders is gone during the day. If providers are rotating over the next several days, a family could be told: “Let me see who’s working today.” On the first day of a rotation, every single patient may be new to the hospitalist. An honest answer to questions is sometimes: “I don’t know, this is the first time I’m seeing your mother."
Who’s in charge? Is Mom getting good care?
The direction of care is initiated by the first hospitalist. What happens at that point can vary greatly depending on the hospitalist. The PCP who knows the patient best is seldom involved. A hospitalist can decide that aggressive care is needed. In that case, the patient could end up in the ICU. Another hospitalist may decide that aggressive care is unlikely to be of benefit. The patient could end up on hospice. Loved ones ask: “How did that happen?” The provider who set the direction is often unavailable.
Who’s in charge? What’s going on?
Sometimes there are too many “cooks” involved. Families are told one thing by one provider and something else by the next. Sometimes therapies change mid-stream. This is especially true when a new rotation starts.
2. Hospitalization can be a nightmare
The hospital is designed with the goal of reversing an acute severe illness or injury. It is not designed to meet the needs of older patients. Many patients say they never want to go back. There are good reasons. The following statements are commonly heard in the hospital.
“I need to go to the bathroom!!”
Patients are placed on IV (intravenous) fluids given via a tube and a needle in the arm. These fluids usually result in more urine production. Older patients have more bladder control problems. IV tubing also makes going to the bathroom difficult. Sometimes a urinary catheter is inserted. The patient is told: “You don’t have to go to the bathroom, you have a catheter.” In the worst-case scenario, a weak and confused patient tries to get out of bed to go to the bathroom. Then the patient falls.
“You need to stay in bed!!”
Falls in the hospital are disastrous. People who are weak are at increased risk for falling. One “solution” is to have patients stay in bed. In fact, older patients spend more than 80% of a hospital stay in bed. The result is that weak patients become weaker.
Among elderly patients who experience an acute hospitalization, more than 50% lose half to two thirds of their ability to perform activities of daily living and walking. Often, this situation results in nursing home placement.
“The patient is agitated.”
Vital signs are taken frequently in the hospital and sleep is disrupted. Strangers walk into the room day and night, talk to you, handle you, give you instructions and leave. Lights come on and off. Noises come from the hallway.
A patient may be described as agitated for many different reasons. One reason might be attempts to get out of bed to go to the bathroom. Another reason is frequent calling for help from the nurse. A patient may be terrified in a nightmarish environment. If a nurse calls a doctor at night, the doctor wants to avoid further calls. One temptation is to use medications to “quiet” the patient. These medications can result in increased confusion and weakness.
3. Mom is Being Discharged Today?? She’s too weak!!
Hospitals are financially motivated to keep hospital stays short. Hospitals are not paid more for longer stays. In the United States, the average length of hospitalization for a person age 85+ is 5.1 days. The goal is to treat acute illness or injury efficiently. It is NOT to maximize the strength and recovery of the older adult.
In fact, hospitalization and bedrest result in weaker patients who need more care. Hospitalization is risky. The result can be a one-way ticket to a nursing home. 36% of patients age 85+ are discharged to long term care services.
I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.
PS: Please let me know if you'd like to see reference sources for the data in this post.
The Hospitalist Movement
Who takes care of you in the hospital?
Thirty years ago, the Hospitalist Movement emerged. The movement has grown rapidly. Hospitalists are now used in 90% of U.S. hospitals. Hospitalists are doctors, nurse practitioners and physician assistants. They work full time in the hospital. This has definite advantages. If a patient becomes worse, the hospitalist is readily available. Hospitalists are also very skilled at managing severe acute illness.
But there are some disadvantages. The PCP (Primary Care Provider) seldom sees the patient in the hospital. In most cases, the hospitalist does not know the patient and family as well. The PCP may know things about the patient’s history that the hospitalist doesn’t know. In addition, continuity of care is not as good. The person who sees the patient last writes the hospital discharge summary. This person may or may not know the case history well. Plans made in the hospital may not have good follow through in the outpatient setting. Sometimes the PCP decides that the treatment plan needs to change.