A night doctor’s dilemma
Five years ago, I was practicing medicine in a rural hospital in North Carolina as a nocturnist, when I received a call from an Emergency Room (ER) doctor. “Hey, it’s Blake. Room 7. Demented. UTI,” he says, and hangs up.
I was struck by the abrupt and sparse communication—no detailed report. Not even a name. Charged with admitting and caring for patients, I head downstairs and find myself in room 7 where an elderly woman with a blown IV and no family around is writhing under bright fluorescent lights. Sent over from a post-acute care facility, she’s confused and completely vulnerable.
Frustration begins to rise in me as I look for her name and find myself thinking, it’s 2:30 in the morning and I’m about to admit this poor lady upstairs. We’re going to probably have to restrain her to the bed. This three-day stint in the hospital will cost society $20,000 and all we’re managing is a simple UTI.
It’s not right. Our system has failed this patient.
Why didn’t the nursing home doctor treat the UTI? Why did the nursing home send her to the hospital? As I proceed to administer care, I am hit with a painful realization.
I don’t have it in me to spend my medical career doing this to people.
What’s going on in nursing homes?
The following day, I reached out to my business partner and we agreed: we’re making good money, but the situation I’d encountered the night before was all too common. It was not a career in medicine we would someday be proud of. Avoidable hospital readmissions. Frail and vulnerable patients forced out into the night for a trip to the ER.
We needed to find a way to truly help these patients.
Our first step: figure out what was happening in nursing homes. Most emergency room readmissions take place at night or on weekends when nursing home staff is limited. Like many in healthcare, I suspected third shift nurses, trained in only the basics of patient care, didn’t have the right support and saw the ER as the only option. This was a main source of the problem.
I reached out to a few local post-acute care facilities and was granted permission to observe and try to understand their work environment.
Late at night, I watched as nurses paged physicians and waited almost two hours for a response. I watched as nurses were yelled at for paging. I overheard a doctor’s wife answer the page meant for her husband, only to tell the nurse to stop paging him on their anniversary. I observed as a nurse put a page out for Dr. Miller and heard back from Dr. Thomas who told her, “I don’t know anything about these patients, I’m just covering. Send them to the hospital and don’t bother me for the rest of the weekend.”
I watched as trained, well-intentioned nurses tried to advocate for treating their patients in place but were ignored, demeaned and systematically prevented from working at the top of their license.
And, inevitably, I watched as patients—much like the woman I’d met in my hospital—were strapped to a gurney and sent to the ER with conditions that could have been assessed and treated at the nursing home.
No captain of the ship
In these late-night moments of observation, I saw what many in healthcare don’t often see—the antithesis of the imagined bottom-of-the-barrel, unmotivated, third shift nurse. As their pages were met with rudeness, and their patient’s needs met with indifference, these nurses stood by looking defeated and powerless, and finally, I understood.
I reached out to my partner again: “What we have here is not a ‘nursing home nurse problem,” I told him. “It’s a ‘no captain of the ship problem’.
I discovered that there was little sense of accountability among post-acute care physicians. While a nursing home may have the capability to assess and treat a patient in place, with antibiotics and other medications on hand, no one at the nursing home is held accountable to do so. Rather than looking to front-line, in-house resources, nursing home doctors, and sometimes overworked nurses, simply choose to shift responsibility to clinicians at the hospital.
When a patient is released from the hospital and transferred to a skilled nursing facility for rehabilitation, the intention is for them to return home within a short period of time. Unfortunately, many patients return to the ER instead, sometimes due to the complexities of their condition. Without a captain of the ship at the nursing home, avoidable hospital readmissions occur often, disrupting continuity of care for patients and prolonging their recovery.
A new standard of care
To combat this accountability problem and improve patient outcomes, a stronger provider base is needed in post-acute care settings, made up of physicians who are competent, licensed, and motivated to provide the level of service that nursing home patients require.
Dedicated to a new standard of care, these providers practice old-school professionalism: they reach out to families, answer pages from nursing staff in a timely manner and communicate respectfully with all members of a patient’s medical team to promote seamless transfers.
While they are seldom held accountable by administrators, these clinicians could be incentivized to improve patient care by bundled payments that reward quality care rather than volume of care delivered.
The technology component
Creating a new standard of care begins with improving the provider base, however the pool of available clinicians in rural places is often limited. Once efforts to recruit and improve the local provider base have been exhausted, the next step is to bridge the gaps with technology in the form of telemedicine.
Telemedicine has the potential to solve bandwidth issues for local doctors who are delivering care to multiple facilities and struggle to keep up. It expands the available provider base making post-acute care specialists readily available to support nursing staff and patients in a timely manner.
At the core of the problem of unnecessary trips from the nursing home to the ER, are elderly and frail patients who cannot advocate for themselves. They need our professionalism, our compassion and the very best care our nurses and doctors can provide. New and better standards of care are well within reach—leveraging telemedicine and a commitment to accountability, we can pivot quickly to create systemic change.
About Waseem Ghannam, MD
Waseem Ghannam, MD, is the President & Co-founder of TeleHealth Solution, a company providing a patient and outcomes centered approach to TeleMedicine. Dr. Ghannam is a patient-focused physician with a particular interest in creating ways for physicians and patients to interact and be cared for without geographical constraints. Dr. Ghannam is constantly seeking innovations in technology that can provide unparalleled care.