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How Inpatient care FEELS today – and what might be done about it.

My Mother had a stroke.  It is serious.  It is scary.  My mom takes really good care of herself but her physical condition is complex and fragile as she is in her eighties.  The care she and we have received has been excellent.  From 911 and the Emergency Medical Tech response, to the Emergency Medicine and Neurology service in that critical first hours of care, then ICU, then the Neurology service floor, now rehabilitative care.  Everyone has been well trained, focused, attentive, responsive and genuinely caring of my Mother and all of us, her family.

This is not my first experience of hospital care either as a patient, a family member or a friend of someone going through an encounter with “the system”.  Not by a long shot.  My advice to family members who are part of “handling” a medical event has become:

  • Stay close to your loved one and visibly engaged with nurses on every shift and with physicians from every service.
  • Be respectful and appreciative of clinical professionals, but ask questions, request services, pay attention to medications, tests, orders, therapy visits and all the rest.
  • Make sure that everything that is intended to be done for your patient is done, ideally in a timely manner.  Respectfully, of course.

This is a lot to ask of a patient’s family.  There may not be a family member that can provide this level of safety net for assuring that a patient receives all the treatment and support that should be expected.  Even in our best facilities, with well trained, well intentioned, motivated, caring professionals, gaps can and do occur.

As I have said, my Mom’s care was and has been excellent.  However, our experience of care often felt random and chaotic.  I found myself concerned that some order, therapy or evaluation was going to be missed.  Tests which required transport could result in Mom disappearing for hours without any clear response from Nursing about what to expect.  Doctors stopped in randomly throughout the stay to review her condition, evaluate charted lab and other test results, then adjust medications or therapies.  Sometimes expected clinical data was fresh, current and available but sometimes not.  Therapy services (swallow, speech, physical, respiratory) showed up at the same time or not at all.  If a physician was with my mom, therapy staff usually went on to their next patient.  Understandable perhaps, but when asked, Nursing generally would just reassure that therapists would return before end of a shift.

Remember, this is a quality facility.  There is clear evidence of organization, process and procedure in the practice displayed by every service we encountered.  But this is where sound, organized, operations end, within each service.

Each service is on its’ own schedule.  It appears common that a service team member is provided a list of patients, locations, and specific orders for care they are expected to complete before their shift is over.  Maybe there is an inherently cyclical nature to certain therapy services, like there is for Nursing.  Perhaps this is established by the order (three times per day, et cetera).  I suspect that most practitioners attempt to “walk” their list in the physical order that patients will be encountered with minimal walk arounds.  However, as the day goes on, this practice must tend to become increasingly random and inefficient.

So how does this look from a patient’s perspective?  Uncoordinated? It is, across multiple providers: lab, imaging, respiratory, dietary, housekeeping, nursing medications/vitals/general care, physician service visits.  The only service “dedicated” to a patient is Nursing.  While nurses knew what was ordered and expected for a patient, they did not have any idea what my Mom’s schedule of care for the next 4, 12 or 24 hours was expected to be.  If we did not want to miss a physician consult or therapy session, we had to have someone in the room at least from 7 AM to 9 PM.  We might get a general impression of a time frame, clearly based on historical experience.

Hospital care is inherently a service that requires flexibility to respond to random, urgent events and needs throughout the day.  I get it.  But many services are not that exposed to disruptive demand.  They may be disrupted by those that are.

Today’s facilities are supported by pervasive automation as never before.  Every patient service is a digital event tracked for delivery, cost, and, in many cases, outcomes.  They are or can be assigned to an accountable, appropriately skilled professional for execution.  Perhaps there is even a schedule of expected completion being used by service management to assure performance.

What if these investments and practices were taken a step further?  Develop a “view” of house wide activity from the perspective of each patient.  Publish a patient’s “availability” to all care givers and service staff.  Alert scheduled care givers of a change in patient availability status to enable proactive coordination of care delivery.  Enable Nursing to see every unit patient’s schedule, who is expected, when they are expected, what they are doing.  This will enable nurses to respond knowledgeably and confidently to questions from family or patients themselves.  There might even be an attempt to schedule or respect quiet time, so patients can get rest!  Talk about real “patient centered” care.  The experience of care might catch up to the great intent of every care giver to support the patient in recovery.

Let’s switch gears for a bit to talk about doctors.  I am a big fan of Hospitalists or Intensivists or whatever they are called.  Having qualified physician staff dedicated to rounding and reacting to changes in patient condition swiftly is a winner.  Key specialties still need engagement.  Most patients, and virtually all seniors like my Mom, are complex patients presenting challenges for several specialists.  My Mom has cardiac, pulmonary, and neurological issues to contend with.  So, she had three different services actively engaged in her care, each focused on their own “system”.  They are sharing the same chart, tests, results, orders, medications and vitals.  They visit Mom separately.  They comment on Mom’s status, prognosis and course of treatment or support for heart, lung and brain function individually.  There is some inference that they are talking to each other about Mom’s overall course of treatment, the interactions, interdependencies of various options on each other’s area of specialty but you better listen hard and ask questions to maintain any sort of clarity of understanding.  This is not intended as a complaint as much as a report of how physician engagement can “feel” from the patient/family side of an encounter.

I asked for a meeting with all three service physicians at the same time.  Our nurse agreed to make the request but did not seem very confident that it could be organized.  This was two or three days into Mom’s inpatient care.  There had been some discussion of procedures and courses of treatment that could be described as aggressive, but it was all done “serially”, one doctor at a time.  Here is what we got: Mom’s pulmonary physician, a great nurse practitioner from Neurology (no offense to the doctors, but I preferred her) and no one for cardiology (they did not have time).  We had a focused (everyone was on a tight schedule) 20-minute discussion with most family members present.  We heard answers and judgement with context and assurance that everyone (almost) was on the same page, at the same time. We left reassured that Mom was getting the best, appropriate care, taking all her conditions into account.  What a reassuring outcome!

Physicians have huge demands on their time.  They, more than anyone, can plead a case of being at the mercy of patient demands while on shift.  However, might it be possible to schedule a “conference hour” once or twice a shift across all services to allow for consultation on shared patients, coordination of treatment plans, presentations of options to families and a clear sense that care is being delivered by an actual team of engaged professionals and not a collection of narrowly focused specialists?  This is the sort of practice that “name clinics” like Mayo and Cleveland have built reputations on.  If team-based care is truly a best practice, then perhaps more institutions should strive to promote it.

By any current standard, Mom’s care has been of high quality, delivered by caring professionals.  We are having the best outcomes we can hope for, given the nature and seriousness of the event.  There was a LOT of patient care in evidence.  Patient centeredness still

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