COVID-19 Requires Hospital to Rethink The Patient Experience

Keeping patients and health care workers safe is more than cleaning surfaces and having people tested for COVID-19 four days before they come from a procedure. It also means thinking about exposure, viral load, and ventilation. The time a patient spends in a hospital or health care facilities must be minimized for the health of the patient and all those who work in a health care setting. Procedures need to be recalibrated in real time to take into account the changing realities of COVID-19. It is not about having to wait; it is about the extra time spent possibly being exposed or exposing others.

For example, it is unconscionable that Georgetown University Hospital asks patients to check-in 2 hours before they are taken in to start the prep-op for a procedure. Good management practices would find it unacceptable that the process should take 2 hours. In the case that I witnessed the process actually took less than 20 minutes but the patient had to be there 2 hours before and then ended up waiting an additional hour because the other procedures were delayed. Of course there is paperwork that needs to be done, but much of that can be, and is often accomplished by phone or online.

I contacted the hospital by email about my concerns. The “Patient Advocate” responded in a way that made clear that they were an advocate for the hospital. I eventually called Dr. Michael Sachtleben, President, MedStar Georgetown University Hospital and Dr. Lisa Boyle, Vice President of Medical Affairs kindly returned the call. I emphasized that especially now, under the current circumstances, 2 hours should be unacceptable to all. For certain what is required is timely action and not the process of a committee to agree that 2 hours is too long. The goal must be to reduce time spent in the hospital as much as possible. No excuses. Following pre-COVID-19 standard operating procedures is dangerous to some and fatal to others.

I will see if there is any change as I will be taking my patient back for a repeat procedure. 

Epilogue: Case Study Ellen—Good Policy is Not Enough

These last few months have been so intense.  I have seen health care providers who struggle as they try to care for patients while others acted as if caring for a patient was a burden.  It was at the point of patient care that I saw the greatest variability in how someone was treated.  

I remember the nurse in the step-down unit who had said that the IV should be changed every 72 to 96 hours and became annoyed that after 96 hours I asked how come the IV had not been changed.  Her response was that she was dealing with more pressing patients and she would get around to it.  It was clear that the needs of the individual had become either dominated or subservient to some benchmark or target. This is not the health care any of us want or deserve.

As all this occurred I contacted the leadership at Georgetown University Hospital and they were responsive to my many concerns.  They  made it clear that the policies they had developed had not been followed.  All were apologetic and all apologies were accepted but the bottom line is that the patient suffered and died.

Part IV: Case Study Ellen— Another Trip to the ER

I returned to DC on Monday and my intention was to visit Ellen at the Rehab Center and see how she was doing.  The plan was that she would be there for a while to regain her mobility and then go home.  As I was driving I decided to call Ellen's daughter to see how things were going.  

She let me know that the Rehab Center wanted to call 911 and have an ambulance take  Ellen to Suburban Hospital.  Ellen's white blood cell count was high and they felt she needed to be taken there even though her primary doctor was affiliated with Georgetown University Hospital (GUH).  We were told that the Montgomery County ambulance would not take her to GUH which is located in Washington, D.C.  The only way Ellen could get to GUH was by hiring a private ambulance. And so we did.

So once again Ellen, her daughter, and I were on our way back to the ER.  This time I  let the Georgetown staff know we were coming ahead of time.  We were glad that Ellen was put in the same area designated as Fast Track B. We chuckled about what "Fast Track" means.  

This time Ellen had a wonderful nurse (Jason) who did all he could to make her comfortable.  The 4th year resident (Bobby) had a good disposition and was very patient with her. Ellen had blood drawn, ultrasound of a swollen leg, chest x-ray, and answered many questions. The physician on duty told us that her white blood cell count should not have been alarming as that may have occurred because of some of the medicines she was taking.

In the end they released her to go back to the Rehab Center.  There was nothing wrong with her or perhaps more accurately there was nothing found that could be fixed. Consequently, at 2:20am on Tuesday Ellen was transported back to the Rehab Center by the regular ambulance service.  On Thursday at 1:45pm Ellen died.

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.  

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 everything...so 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.