Monday, August 27, 2012

Part III: Case Study Ellen— Shades of Patient Dumping

Ellen's daughter, Ann, had been told that Ellen would be moved on Monday to a Rehab facility and so Ann had gone to visit other family members in Delaware to discuss the situation with them. Ann felt that her mother was in a safe place--- Georgetown University Hospital.

Saturday at about 6pm I was called by a representative of Georgetown University Hospital (they meant to call Ann) and was informed that Ellen would be moved that evening to the Rehab facility.  I told the woman that I was the friend and not the daughter and thought it was a terrible idea to move her.   It seemed that now that the insurance had been approved that they were going to move Ellen to the Rehab facility. I let the person who called me know that the person she needed to talk to was Ann (Ellen's daughter) and gave her the correct number to call.  

How had this situation come about?  It seems that Saturday during the afternoon a physician called Ann to confirm the DNR that Ellen wanted and Ann said yes she understood that is what her mother wanted. There was no mention that she was going to be moved that evening.

The move on Saturday was totally unexpected and far from good or responsible care.  Ellen was weak, fragile, and readying to go to sleep when she was disrupted with the news that she would be moved.  A person too weak to go home and yet moved on a Saturday night. One can only imagine the enormous amount of stress this put on Ellen.

Is this patient dumping.  How could anyone have allowed that?  This is not the way that patients or their families should be treated.  

Monday, August 20, 2012

Hispanics and the Undocumented.

A few months ago I presented at a conference at the National Institutes of Health (NIH) and was reminded by the comments that people make that too often what people think about Hispanics is framed by their perception of undocumented people.   The assumption is that all undocumented persons are Hispanics and if there are alot of is probably because they are undocumented and shouldn't be getting services anyway.

The numbers are pretty straight forward.  We know that there are 313 million people in the U.S. and about 55 million are Hispanic.  Of the estimated 11 million people in the U.S. that are undocumented fewer than 8 million are Hispanic.  This means that assuming every undocumented person is included in the count of 55 million Hispanics that 47 million Hispanics are in the U.S. legally. But people like having myths and scapegoats.

One of the proposed reasons for the rise in health care costs is that "all those" undocumented persons are using health resources.  The facts according to the Pew Hispanic Center indicate that 41% of undocumented persons have health insurance and those that do not have health insurance either pay out of pocket or tend to avoid the health care system.  The goal of undocumented workers is to work and not be noticed.  That is why going for any type of health service, especially any which may require an interface with a government agency, is avoided.

So do we have a health crisis in the U.S.?  Most definitely.  But don't blame it on persons who are undocumented.

Part II: Case Study Ellen— Water, nutrition, and the right mattress

My 83 year old friend Ellen was admitted to the hospital because she was dehydrated and very weak.  While in the ER I was told that she also had the beginnings of a bedsore. And while I was glad that she was admitted there were some observations that raised concerns:
  • Just like in the ER health care professionals end up spending more time in front of a screen than in direct patient care.
  • On Day One Ellen was given a large container of ice water with a straw so she could drink water.  The person who brought it did not realize she was too weak to either lift the container or suck from the straw.  I asked that she be given water in a cup and it was written on the board.  When I came back on Day 2 there was a pitcher of warm water that she could not lift and the glass. I got her ice water and filled her cup.  During the time I was there she drank 8 ozs of water.  I told the nurse how much she had to drink but I don't think anyone was really monitoring her intake even though the reason she was admitted was dehydration.
  • Ellen had asked for tissues and while I was gone they left her two boxes---unopened.  I had to open one for her the next day when I returned.
  • Since Ellen is very weak she is not able to eat very much.  I asked if they had Ensure and they said yes. I asked that she be given chocolate Ensure because she will usually drink it.  She was given vanilla.  When I inquired I was told, "... they send what they have."  It was not till Day four that she finally got the Chocolate Ensure.
  • Although the beginning of a bedsore was pointed out to me while in the ER, Ellen was not given the special mattress to decrease the likelihood of the bedsore getting worse. 
  • The care team is supposed to write their name but the only ones who did so were the nurses.
Better than most, I understand the stressors in health care, but some small low cost actions ( water, edible food, the right mattress) would definitely make the patient experience one conducive to getting better.

Part I: Case Study Ellen— If It is Weds. Night I Am in the ER

Over the past four weeks I have spent three Weds evenings in the ER with a friend (two times with Ellen and one time with David). One time at Sibley Memorial Hospital (part of Johns Hopkins Medicine) and twice at MedStar Georgetown University Hospital.  I wish that I could say that one experience was better than the other but the reality is that neither ER was what I had hoped.  They both shared some concerning similarities:

  • Both had staff who spent more time in front of a screen than with patients.
  • It was hard to know who could answer questions.
  • Getting admitted into a room required waiting, and waiting, and waiting.
  • There was no privacy...everyone hears all the HIPPA stuff seems irrelevant.
  • Cleanliness did not seem a priority.
  • Getting a glass of water was challenging.
  • The transition from the ER to a hospital room took too long.
The major takeaway is that people go to the ER when they do not know what to do or when there are no other systems to take care of them.  That certainly was the case for the patients who's assessment I could hear through the curtain that separated us: the person who had a problem with alcoholism and was recurring visitor to the ER, the person who would go to a psychiatric unit because she said she had no place to get her  medication, as well as the person who was in a nursing home and prone to falling.  

Everyone waited patiently because it was clear that the ER needed help.