Own the Patient (Clinical Case 126)

It is January – so in Australia that means it is the time of year when all of the junior doctors in the country rotate into new jobs, hospitals and towns.  Here in Broome we have taken on a brand new cohort of super-smart residents [and welcomed back some old faces].

Inspired by some discussions I have had with fellow educators online and in person I have decided to try something a little different this year.  We will still be rolling out the same “regular” medical education, sim training and bedside / floor teaching. However, I am promoting a new concept [not really new, just formalised].  I call it “Own the Patient”.

One of the things I love about my job is the way our place is structured.  As a generalist in the hospital I have the opportunity to treat a patient “from door to discharge”.  I can meet them in triage, admit them, take them to theatre for an anaesthetic, arrange their recovery and care for them on the ward afterwards.  Our trainees on the other hand are constrained by their roles – the ED RMO admits, the Surg RMO assists etc….

This is tradition – it is how we do business and it works. But….  there is a lost opportunity.  I believe that much of what I have learned over the years, especially many of the subtleties and nuances of medicine, have come from following my patients through their inpatient journey.

Closing the loop on your emergency care by following your patient through their care is a potent learning habit.  Most of us are good at following up our “interesting” or “difficult” cases.  Rarely though do we make the effort to check-in on the 76 y.o. chap with a mild exacerbation of his COPD.  Patients have so much to teach us – and yet we routinely decline the offer of free tuition.

So – I hear you thinking: “That’s all very nice, but how will we actually harness this educational trove?”  Let me explain:

Here is the current state-of-play in most places I have worked.  The ED docs admit the patients, and those with “interesting” diseases, symptoms etc are followed by stealth almost.  We check their bloods and images on the computers.  We might call up the inpatient team to see what happened to them or chase the surgical pathology.  Rarely do we actually go to the bedside and visit our patients. So here is the plan, the instructions to how one might “Own the Patient”.

• At some stage in each shift our ED residents will be encouraged to “visit” their patients on the wards.
• Ten or fifteen minutes during the inevitable lulls.
• I want them to specifically visit the “standard” patients, e.g.  the ‘mild COPD’ or the ‘RUQ pain for investigation.’
• When I say “visit”, that is exactly what I mean.  I want them to go to the bedside in the same way a concerned relative might do.
• They should not check on the progress with their inpatient colleagues first – I want them to go in and get an untarnished patient perspective.
• When they visit the patient whom they admitted I want them to ask 3 simple questions:
  1. How are the symptoms that lead to their ED presentation going?  Have they been relieved?
  2. Ask them to explain what has happened since admission – ask the patient to explain their understanding of what has happened to them OR what do they understand the treatment plan is going forward.
  3. Ask, “is there anything I can do for you?”
• After visiting they can then go and do all the usual doctorly things – look at the CT, chase the bloods or get the 30 second thumbnail from the inpatient team.
• As they walk back to ED I want them to meditate on what they could have done differently to make that patient’s experience easier, less painful or less confusing.

(Addit:  A few astute commenters have noted the potential for this “visit” to lead to conflict on the wards…  here is how I imagine it will play out.)

• Most of the patients will be pleasantly surprised that their ED doc took the time to come visit and be uncomplaining.
• The ED RMO will almost always notice a few things that they could improve upon for future patients – the 1%-ers, of “no clinical importance”.
• Sometimes the futility of admission will become apparent – could we have done the same or better as an outpatient?
• Sometimes there will be an opportunity to provide some simple education and decrypt some patient confusion (e.g.. why did that nurse need to give me the blood thinning injection – I thought  had a chest infection not a clot….”
• Occasionally the visit will reveal either serious missed information or potentially useful data – this should be formally noted and brought to the treating team’s attention – in the same way that the night ward cover MO would not “take over care” but ensure that appropriate immediate action was in place and communicate it to the admitting team.
• I really hope that this may actually breakdown some of the “Us vs. them” tribalism that take place in hospitals.

Hope that last step – the team feedback makes sense to you all.

THIS IS NOT ABOUT THE MEDICINE.

This exercise is hopefully going to allow the residents to get a fresh and realistic perspective on what patients go through after we take the decision to admit.  A chance to understand the peculiar rituals of wards, the confusing language, the disempowerment of being in “a bed” tied to drips and lines.  This is what I want them to learn.

Here is an anecdote to illustrate the point I am making.  This really happened just last week when I went to visit a lady on my own “Own the patient round”.

Helen is a 68 y.o. Aboriginal woman who lives in a community a few hours out of Broome.  She was raised in a mission, never drank alcohol in her life and is pretty shy.  English is her second / third language.  She has type 2 diabetes, chronic renal failure and COPD all of which are well managed by the local community clinic.  She gave up smoking last year after her sister had an nasty STEMI.

Helen developed a flu-like illness a few days prior and was being treated with salbutamol and a course of prednisolone at home for increasing wheeze and dyspnoea. She was transferred down by road [2 hours drive on a rough gravel track] as she was not improving and has a history of needing oxygen when she gets crook.

On arrival she was moderately dyspneic, sats 92% on nasal prong O2 and RR = 28/min.  She was still wheezy.  We did all the usual things.  She got some antibiotics and bloods done – which showed a deterioration in her renal function.  This was probably due to being a bit dry and her BSL was high (23 mmol/l, ~ 414 mg in the USA)  as a result of the infection and steroids.  In Broome we use a basal bolus insulin regime to control our inpatients’ hyperglycaemia – so she was started on SC insulin ‘as per protocol’.

The medical plan was to keep up the bronchodilators, keep the BSL around 10 if possible and give some IV hydration overnight to get the beans flowing.  Easy really.

So 16 hours later I popped up to see Helen. She was not looking too well.  She was tired, worried and keen to get out of hospital ASAP.  The breathing was a bit better with the oxygen and inhaled meds – but she was still chugging away.  She had not been up and walked or sat out of bed as she was too tired.

When I asked how she was going she told me that she was very thirsty, tired and that her left arm was “stiff”.  Odd.

When I pushed her to explain she told me that her arm was stiff as she had been holding it out straight all night.  The IV in her arm was “tricky” – if she bent her elbow the pump kept beeping and waking up the other 3 ladies in the room.  She had fallen asleep a few times but was woken once when the alarm “boinged” and once when the nurse came in to admonish one of her room-mates for trying to climb out of bed as she was a “Falls Risk”.  She didn’t sleep much after that… she was related to old lady in the next bed and was worried for her.

Helen had not passed much urine.  She felt thirsty but the water jug was on the same side as her drip arm and she was too shy (scared) to ask the nurse for help or to get out of bed and move it.  Because of the pump trouble she had only received about half a litre of the prescribed fluid via her veins.

I asked about the medical plan – and she was upset about the insulin.  She knew about the needles.  She had discussed them with her GP, but was reluctant to use long-term insulin.  Her sister had been on it – and put on weight.  Then she had the heart attack.  It was not a good medicine in Helen’s mind.

When I asked Helen if there was anything I could do for her.  She smiled. “Can you pass me that water please?”

I went back to the nurses station and read the notes.  The medicine was spot on.  Moderate COPD, maybe viral.  Hyperglycaemia and bump in renal function, poor urine output overnight.

The medication chart was interesting – where the insulin was prescribed the nurses had drawn an “R” for patient refused.  On the back was prescribed nocte temazepam for insomnia.  Two more litres of IV fluid had been ordered.  The nurses had noted the IV was “positional” but functioning OK for IV antibiotics.

Her CXR looked normal, but her creatinine has risen further.  Her BSLs remained in the 20s.

For me this was a fail.  It was not a medical error, or lack of knowledge.  This was a failing to do a few simple things well.  I call them “the 1%ers” – it’s an Aussie football term.  If we do the little things well, apply a fraction more effort then the big picture can work out much better.  This is not the stuff of heroics.

What would I do differently after visiting with Helen?

• I would have checked that the IV was working, that she could move her arm freely.
• I could have resited that drip to a better spot.
• I could have communicated the importance of oral hydration to the ward team more explicitly
• I should have spent time explaining why I wanted to use the short-term insulin
• I could have explored her fears around insulin and reassured her it was just for a few days.

These outcomes will never be counted in audits, but they matter.  The only way to learn the 1-percenters is to close the loop.  Go and talk to your patients.  Understand their experiences and then try to do better.  This stuff is largely tacit learning – it is unteachable.  One must consciously try to experience the “little” problems in order to prevent them from recurring.

So that is why I want to have a crack at “Own the Patient”.  We train very smart young doctors and yet we still have problems in healthcare.  Maybe this is one way we can guard against unnecessary suffering and make our patients experience  that little bit better?

Let me hear your thoughts.

Casey