This section again emphasizes communication, but in another way, which the author calls “care transitions.” Many transitions or “hand-offs” occur during modern surgical care.
A patient with 3 days of right lower quadrant abdominal pain comes to an emergency department (ED) with fever. The PCP alerts the ED by telephone with the clinical impression for perforated appendicitis. Besides the Financial interviewer, the Receptionist asks for the complaint, enters it in the computer, and then determines priority for Triage, who then determines the priority for ED examination. The PCP’s impression might or might not be given weight.
This information might be verbally communicated to the next caregiver or the system is set up for the next caregiver to pick up the information electronically from the computer when there is time to look. There might be a Signal or just the expectation that someone will look. Waiting times can be lengthy. In the ED, a senior ED nurse performs a Clinical Interview including vital signs and again determines Clinical Severity and Priorities and enters the information in the Electronic records. This includes an overwhelming checklist of exclusions; like patient is not at risk for falling, suicide, etc. “Cut and Paste” from previous impressions is used for some information. The rules are established administratively by the ED Director with some usage of National Guideline. Information is entered in the Electronic Medical Record (EMR). Bloods are drawn according to protocol. If this sick patient looks sick and satisfies numerical ranking or intuitive criteria, he (or she) is moved at varied speeds into the ED flow system where a Physician (MD) or a Physician Assistant (PA) will see them as a patient. At some point the responsible ED physician will be briefed and will examine the area of concern. Some sick patients are stoic, look well and are in a physiologic compensated state and thus evaluation can be delayed. Any provider can either accept the patient’s claim or make their own determination which is influenced by relative ongoing ED demands. The care in the ED then toggles between nurses, MD’s, PA’s, Residents, and consultants. Only the Surgical Residents are specifically specialty focused. All participants are subject to breaks, changes in shifts, demands at other places, and other patients in the ED. Frequency of breaks is determined by unions and administrative rules. The EMR is piled up with comments, times, positives, negatives, various laboratory and radiologic results, orders and many standardized negatives. Frequently, radiologic studies are ordered before physical examination and return when another provider takes over care and decision making.
Laboratory and Radiologic results are sent back to the EMR electronically and await “fetching” by someone in the ED. Frequently the EMR replaces verbal communication. Results are transmitted via computer although there is a standard that obviously dangerous findings should be personally communicated to someone. Sometimes decisions are made based on the written report without personally viewing Radiologic images or performing sequential status reexaminations and correlating visual findings with the clinical picture.
Radiologic priority is determined by an expeditor based on limited written requisition information. This person has varied medical and clinical knowledge and might not comprehend the dangers presented by varied diagnoses of different specialties. In fact, this limitation of specialty knowledge and experience applies in some degree to most of the ED providers who were trained in Emergency Medicine or Internal Medicine. It takes many years of ED experience to be able to make acute diagnoses in many specialties and appreciate the relative risks and consequences of each diagnosis.
When the diagnosis is made of advanced appendicitis, then admission and a treatment plan is required by the Specialty consultant or the Surgical Resident. The patient is assigned to the Surgical Service and care of the surgical team. The patient might be “Boarded” in the ED awaiting admission or access to the Operating Room (OR) or a surgical care unit. Although physically present in the ED, the responsibility for care is “Handed off” to the Surgical Service. ED nurses still follow orders now written and rewritten by a Surgical Specialty Resident who now has responsibility for this patient in the ED although the Resident and Patient are virtually not part of the ED (The Surgical resident is also responsible for care at other sites; on Surgical Units and consultations on Medical Units. His time in the hospital is limited by NYS law to 80 hours/week, and therefore, he too must” hand off” care.).
When admitted to a Unit, sooner or later there is again a “handoff” between Physicians and Nurses and the requirement to redo “intake” information and review the EMR from the ED. Nursing staff and time is limited. Nurses and Nursing assistants are also subject to mandatory breaks, shifts, more delays, and “handoffs.”
Then, in the Operating Suite, “Handoff “to preop nursing staff and to the anesthesiologist. Anesthesiologists might finish their shift after evaluation and before OR time become available – another “handoff.” The surgeon should be a consistent participant but is also subject to other calls and substitution by other full time “hospital physician partners,” for night or weekend coverage. In the OR there is a careful “’TIME OUT’ or ‘Huddle’ reviewing and reconciling the procedure, patient status, allergies, methods and objective.” This makes a lot of sense. However, if the procedure crosses over the timing of breaks and shift, there are new staff substitutes. In the best of world, another “timeout” should occur. Nursing, however, is managed by Nursing Administrators, not by surgeons, and the substitution frequently occurs without advising the surgeon who is focused on the procedure, possibly a critical step. The substitution might or might not be to a nurse with the same specialty knowledge and experience.
There is no dependable solution for the potential problems that might be caused by these transitions except to minimize “handoffs.” The Surgeon is generally held accountable for everyone else and is generally tenaciously attentive to pitfalls of transitions and handoff. However, surgeons also have shifts, time off, and other demands and handoffs occur in their absence or he/she may be completely absorbed and concentrating at a critical moment in performing surgery, or looking into a wound or a television monitor.
Patients and family involvement is protective. They must be alert to miscommunications and inconsistencies and promptly ask for clarification and corrections of inconsistencies. Families, however, also are subject to transitions in support. So, written notes by the patient and a family member are helpful. Pain is treated by drugs that cloud patient’s mentation. What is the diagnosis, the plan, the options, the reasons, the clarity of explanations, the timing, the risks, the caregiver, the team, the expertise, and the support system? Are there counter intuitive inconsistencies in any of these items? Has the explanation been logical, comprehended and fostered confidence?
5-“DISMAL DISCHARGE PLANNING”
Medicare penalizes hospital for readmission within 30 days of discharge. Medicare is more liberal with length of stay than insurance companies and has an “appeal” procedure. However, Hospitals prefer earliest possible discharge and maximum “throughput.” Insurance companies actively set limits to hospital stays, but still allocate responsibility for decisions to MDs. Hospital “case managers” also strongly encourage and monitor early discharge but also hold physicians accountable. “Utilization reviewers” continuously put pressure on Residents to encourage rapid discharge. Residents at early stages of training are susceptible to these pressures. They manage patients after multiple “handoffs” using short notes transmitted between shifts. Nurse “case managers” are employed by Hospitals to catalyze short Length of Stay (LOS). Employed MDs, PAs, Residents are influenced by these Managers and employee utilization Reviewer’s inquisitions. Patient stays become abbreviated. Criteria like normal white blood count, no fever, normal bowel function, diet, oral medication intolerance, and stable physiology might be sub-optimally appreciated.
Readmission can occur for many reasons: complications; diet is not tolerated; uncontrolled pain continues; fever, infection or wound problems occur; cardiopulmonary problems like pneumonia, pulmonary emboli or arrhythmias occur; physiologic bowel dysfunction causes distension and vomiting, and bladder dysfunction persists with urinary retention. All of these issues can result in readmission and delay in solutions more than might have occurred earlier if identified as an inpatient.
On discharge, patients and family should understand symptoms and events that are of concern, methods of communication to an involved person, and a backup plan. If the MD, patient, or family feel that the discharge plan is premature there should be insistence that discharge should be postponed. This request might result in the intimidating admonition that Insurance might not cover the “extra” day(s). Generally the extra time will be accepted by the non-physician participants reviewers if the MD documents reasons and communicates. Management and Insurance companies will demand time consuming explanations for reasons that seem obvious to patients and physicians. The discharge decision maker might no longer be on duty. Patients and Hospitals are also intimidated by the fear that Insurance companies will deny or “carve-out” payment for so-called extra days beyond those prospectively allocated by the listed generic code at the time of admission and the expected average experience.
PART 3 TO FOLLOW.