Optimizing Inpatient Care

November 10, 2008

Being a relative newcomer to the field, I face new medical, ethical, technical situations on a daily basis, a reminder that learning does not end with medical school and residency.

“I take a little white pill in the morning, a pink one at night, two of the blue ones….”

When I was asked to participate in a blog about hospital medicine, my immediate thought was “I’ve only been doing this for two years, what can I possibly write about that wouldn’t be better addressed by a more experienced physician?” But then I thought, “Well, there are some topics I wouldn’t mind talking about.” I hope that by sharing my experiences, thoughts, and concerns, you will get a better idea about the concept of Hospital Medicine, including its critical role in inpatient care along with the limitations that are inherent in this type of practice. I welcome any thoughts, comments, discussions about any of the topics I bring up. Being a relative newcomer to the field, I face new medical, ethical, technical situations on a daily basis, a reminder that learning does not end with medical school and residency. That being said, I look forward to hearing different perspectives and experiences from you, as it can only make me better at my job!

Clinical scenario: 66 year-old Spanish-speaking male with a history of diabetes, COPD presents to ER with progressive dyspnea over 5 hours while at a car show. ECG on arrival shows “nonspecific” anterior TWI, initial troponin negative, received duonebs in ER with some improvement and was admitted with likely COPD exacerbation, pending rule out for ACS. He doesn’t know his medications and goes to a neighborhood free clinic for his healthcare. On further history, he reports a recent admission to another hospital with what he describes as a syncopal event, where he was admitted for 5 days and was discharged on “a whole bunch of medications” the names of which he doesn’t know.

I cannot tell you how many times I have admitted patients to the hospital who are not only unclear about their past medical history but also do not know which medications they are currently taking. As the hospitalist assuming care for this patient, I strive to provide not only the best inpatient medical care I am capable of, but upon discharge, I would like to provide them with a complete, updated list of their medical illnesses, summary of hospital course, and discharge medications. Many times we are able to deduce much of their pertinent medical history based solely on the medications they are currently taking. But what do you do when the patient does not know his/her medications?

I’m certain I speak for most hospitalists that such situations can be quite frustrating. For one, what if these medications directly impact inpatient management? While missing a couple doses of a vitamin may not be a big deal, missing a dose of plavix 1week after a coronary stent placement can be devastating. Often, the time it takes to clarify such aspects of the medical history not only puts the patient as risk by causing unfortunate delays in the delivery of medical care (increased morbidity/mortality), it can unnecessarily prolong the length of inpatient stay. In the past, when PCP’s would follow their own patients in the hospital, this was not really an issue as they would have access to their notes from previous visits. But in this day, where a growing percentage of care is being delivered by hospitalists who have never met the patient before, this is a problem.

Usually, my first steps are to find out which pharmacy the patient gets his/her medications from and to get the name of their primary care physician. If I am lucky, I can use these resources to obtain a list of current medications or, if I am really lucky, the past medical history. But, of course, it’s not always this straightforward. For instance, it is often very difficult to reach primary physicians over the weekend. And of course, there is that patient who doesn’t have an established primary care physician, who invariably has a long list of medical diagnoses and an even longer list of medications, who has been admitted to multiple hospitals, and who gets his/her medications from multiple pharmacies.

This is obviously not an easy problem to fix; it would require a joint effort by healthcare providers at all levels and, of course, the patient. The good news is that, in this era of advanced technology, we are not too far from establishing a universal medical record database. But what can we do until then to bridge this gap in healthcare delivery? A few things come to my mind that would really make our jobs as Hospitalists, who will be providing inpatient care for your patients, easier, safer, and more efficient. It should be expected that any health care provider, especially the PCP, provide the patient with an updated, consolidated list of Past Medical History and Medications at every visit. As physicians, we should be reviewing the PMH/Medications at every visit; it is the matter of one extra step to provide the patient with a copy of this information. Secondly, inform your patient that they should be bringing this list or all their medication bottles (not the pill box) if they ever come to the emergen. Although, this sounds intuitive, I can tell you that less than 10% of the patients actually do this. Finally, as hospitalists, it is our responsibility to accurately reconcile this list at the end of the hospital stay and, not only send it along with the discharge summary to his/her Primary Care Physician, but also provide a copy for the patient with instructions to carry this information with them at all times. This way, if the patient ends up getting admitted at another facility before their next PCP follow up… you get the point.

The patient in the above scenario who had recently been hospitalized for “syncope” was actually admitted with a cardiac arrest. He was found to have tight LAD lesion which was stented with a DES (drug-eluting stent). The “new” medications that he was discharged on were aspirin, plavix, statin, ACEi, and beta blocker. He was admitted to me on Friday evening and I was unable to reach the medical records department at the OSH. After speaking further with the patient and family, I was able to deduce that he had recently undergone a cardiac catherization that showed a blockage. Repeat EKG 2 hours after arrival to floor showed ST elevations in the anterior leads suggesting in-stent thrombosis and he was taken immediately to the cath lab.

With a little effort, I wonder if we can avoid these situations from happening.