Last week, while on vacation, I had the opportunity to experience an example of healthcare up close and personal, as they say. Let me qualify what I am about to address by saying that this may have been an isolated incident. My fear is that it is not, and that is why I chose to write about it.
I should like to describe what happened, and then highlight where I think the system broke down.
While in Florida visiting a 90-year old family member, she managed to slip and fall the first night of our visit. She has difficulty walking and was using a walker at the time. The walker caught on something, and down she went! She complained of soreness but was able to get back up with assistance.
The next morning, she was no better, and she opted to be taken to the emergency department of a nearby hospital – by ambulance, as we were unable to move her. Upon arrival, she was placed in an emergency room bay and attached to vital sign monitors. At some point a nurse came in to take her history, draw blood, and insert additional lines. She was given a pain pill, after initially being told she could not have anything to eat or drink, as she might require surgery.
Eventually, she was taken to Radiology for an X-Ray of her hip, which came back negative, except for a possible fracture of her pelvis. The staff indicated that she would need an MRI, and they were waiting on the physician to order one. Eventually, they came to pick her up for a CT! OK, so they changed their mind and ordered a CT instead of an MRI. About one hour later, she returned. The technologist indicated she refused the CT exam! So much for informed patients who listen to the press regarding dosage issues with CT!
After another two hours, she was finally taken to MR for an exam, and then taken up to a patient ward, where she was kept overnight. All told, over seven hours in the ER!
We were met the next day by a case worker who was to assist us with her disposition. We quickly learned that in Florida (and as I have come to find out, is also true in many other states), as long as the patient is in control of their faculties, they make the final call on their course of action. We had felt the best thing for her would have been a continuous care facility, but when confronted, she indicated she wanted to go home – no surprise there! The case worker indicated that she would take care of making all the arrangements with the proper agencies, and she would be released later in the day. At some point we learned that she could not be released without these arrangements for in-home care.
Needles to say, when she arrived by ambulance back at her home at 5 PM, we were met by the care giver. When the care giver was asked if she was OK with getting up with her several times during the night, she replied “no, I need six to eight hours of sleep at night, and no one said I would have to get up.” She was summarily dismissed, and after another two hours of negotiation with the agency, we were able to secure someone who was willing and able to care for her 24/7. I am happy to report that she is doing better, but still confined to a wheel chair and unable to walk.
Now, for the issues with the process:
1. The hospital was extremely up-to-date, having an automated ER tracking and documentation system, CR and PACS in Radiology, and mobile documentation carts on the nursing floors (can you tell I was meddling!).
2. A key element of patient history was missed by the nurse when taking a history – she has IBS. This fact was not communicated to the nursing ward that we know of, and was certainly not made known to the in-home care agency. The nurse that took the history was never seen again!
3. There was no known reason for spending seven hours in the ER, other than delays in the CT and MRI scheduling, and supposedly, availability of a bed. When we inquired, we were told that the ER had placed an order with the floor and were waiting to hear back.
4. At no time in the ER was she ever examined by a physician. They were waiting on the results of the CT or MRI. Eventually, after we had left, she was seen later in the evening after visitor hours by a member of the orthopedic staff, and advised that the MRI was negative and there was no fracture.
5. When it came time for discharge, no one from the hospital followed up to insure that a home care person was available to accompany her. (Someone else was there at time of discharge, as we had to be at her place to receive the wheel chair that had been ordered for delivery earlier in the day).
My key issue? Despite all the technology available to this facility, it played little in the overall quality and timeliness of care that this patient received! I could write it off to staff indifference. After all, there did not appear to be any incentive for the ER to see that she was informed or expedited to a room. Similarly, the case worker seemed more intent on getting her discharged than on any care that she might receive. It was not the hospital’s fault that she refused the CT exam, although, had the staff spent any time explaining it to her, perhaps she might not have refused it when they were about to do the exam!
Instead, I have concluded that the root of the problem is a breakdown in communication, and “departmentalization,” and that no amount of technology could fix the problem. Perhaps it was the way technology was deployed at this facility on a departmental level, or the lack of either an information system application or personnel to oversee the process. This has me wondering if other facilities mange patients from an institutional level?
Yes, there were time alerts in the ER indicated by the color of the indicator on the large flat panel display screen, and on an in-room monitor, but did anyone care? Apparently not, as I observed several simultaneous entries that exceeded five hours! But, more importantly, had there been some way to manage the reasons for the delays from the “bigger picture,” there might have been some effort for improvement, and greater patient satisfaction.
So, I ask myself:
How could technology have been better employed to track and alert staff throughout the entire length of stay?
Is this a reasonable thing to ask for?
Has technology been “pigeonholed” (in this facility and in general) to departmentalization, or are there mechanisms that could have better managed the patient from an institutional level?
Was this just a poorly managed random case?
I’d be interested in your perspective – isolated example, or a real issue? Please feel free to comment. I’m particularly interested in whether technology is too departmental, or whether it can be institutionalized to better manage the patient. I look forward to you