After a recent hospital stay for a major surgery, I was made painfully aware of how hospital care has changed over the years.  Not only are patients having serious procedures done with very short recovery times in the hospital, there seems to be an expectation that families will provide the bedside care while the patient is in the hospital.

Where is your family?

As an example, when I called for a nurse to get a glass of water hours after coming out of anesthesia, the exasperated nurse asked where my family was. I told her that my husband was working and that my daughter was in school. She suggested that I call "a friend", or have my husband leave work to be by my side. She proceeded to tell me how many hours she had worked and how short staffed the floor was. She did get my water (my tray table was on the other side of the room), but I was left feeling guilty for having called her in the first place.

The following morning, my new nurse came into my room, put down the side rails of my bed and informed me that I needed to get up and walk. Fortunately, as a physical therapist, I knew how to splint my abdominal incision and roll to sitting. The nurse was long gone before my feet hit the floor. I muddled through unplugging my IV machine from the wall, loosening my catheter bag from the bed, and walking around the nurse's station by myself with all of the dangling tubes. Again, a nurse in the station asked, "where is your family?"

My question is when did the patient's family become responsible for patient care in the hospital? What happens if the patient doesn't have a family or is a single parent? When I worked in acute care, I was drilled on never exiting the patient's room before assuring that all needs were met, the patient was tucked in bed, the side rails were up, tv, phone and call bell controls were in the patient's hand, and the tray table was placed within reach. These basic courtesies must be a thing of the past. Most of the nurses I had for the four days I was in the hospital barely seemed to notice that there was a patient in the room. They ran in and out, switching IV bags, checking incisions and dispensing pills. Lights were switched on and off, no matter what time of day or night and I was appalled to hear staff calling to each other down the halls and at the nurse's station.

My intent here is not to air a complaint about a bad experience. I am in and out of hospitals every day and have noticed that this level of care is now the norm. I think that hospitals are now trying to lower expenses by hiring staff to cover the minimum and utilizing agency nursing to cover the gaps.  This way, hospitals are not committed to providing salary and benefits to large numbers of employees who may or may not be needed as a hospital census waxes and wanes. By utilizing agency nurses, hospitals can minimize overtime and overhead for their employees.

Continuity of Care

Of course, continuity of patient care goes to the wind. Most patient documentation is now via electronic records. How much training do the agency nurses get on hospital procedures and computer use? How much time are they afforded to peruse patient charts prior to the start of their shifts? In the past, nurses were required to overlap shifts, so they could "give report" to the incoming shift. This process was downshifted to a tape recording left behind for the incoming shift, and then was just dropped altogether. This means that nurses are coming in to a place they have never worked before, to patients they have never seen before, to technology they are untrained to use, with no supervision or guidance. Is there any wonder that medical errors are on the rise? I realize that there is a nursing shortage, but the shortage of common sense is even worse.

When patients enter the hospital, their care is assigned to a hospitalist physician. The advantage to having a hospitalist is that this MD is a full-time employee of the hospital. This hospitalist is fully aware of the hospital policies and procedures as well as the technology. This MD is available for emergencies when they arise, writing orders for changing patient needs and discharging/admitting patients. This keeps the "flow of patient care" smoother and more efficient which equates to cost effectiveness. I really have no problem with this.

Problems arise when there is a lack of communication between the hospitalist and the patient's primary care physician. Patients are now required to be admitted through the emergency room, since primary care doctors cannot arrange for direct hospital admissions anymore. Patients can only be directly admitted for pre-scheduled procedures. Spontaneous admissions are directed to the emergency room. Given the chaos and overcrowded emergency rooms these days, ER physicians gather what information they can from the patient themselves or the patient's families. There is rarely time to contact the physician - particularly if the patient is being seen after hours or on weekends. The patient is then asssigned to a hospitalist and admitted to a hospital room, if necessary. In many cases, the primary care physicians are never notified that their client is in the hospital. Necessary information on the client's medical history, treatment record, medication record, and history of allergies fail to pass from doctor to doctor, putting the client at risk for potential injury. When the client is discharged from the hospital, the primary care physician generally has to request the hospital records in order to know what tests were run, conditions were diagnosed and what treatments were rendered. Of course, if the physician is never told that the patient was in the hospital in the first place, the records never get transferred.

Patient Advocate

The bottom line is that patients need to have an advocate with them from the moment they enter the hospital until they are safely discharged at home. (Keep in mind the many elderly are discharged to rehab facilities, where the same lack of communication and errors are likely.) This advocate needs to be fully informed of the patient's medical history, medications, insurance and allergies. An advocate needs to be at the patient's bedside for the duration of stay, or at a minimum, until the patient can self-advocate. The advocate can be a family member, a trusted friend, or part of an "advocacy team" (a group of advocates who tag team to cover the clients stay.) For patients without family, hired advocacy teams are highly recommended. Advocates can facilitate communication between the medical entitites and the patient/ patient family. Advocates can communicate with social services to ensure that the discharge instructions are clearly understood. The advocate or team can assist with discharge planning; picking up drugs, groceries, meal preparation and assistance with mobility and safety of the patient throughout the patient's home. Home health services are commonly set up prior to discharge, but there is often a two to three day gap in getting these services started. The advocate or advocacy team can bridge this gap.

Because hospital stays are often not planned, it is difficult to set up advocate arrangements at the last minute.  Patients are advised to discuss potential advocacy plans with their loved ones proactively.  The discussion needs to include under what circumstances a professional advocate or team might be utilized, and the potential costs and how they will be paid.  If possible, advanced arrangements should be made with a home health or care management company.  Even though hiring help to provide an advocacy team can get expensive, having people who know what they are doing can get patients out of the hospital much faster with better outcomes.  Family members are able to work and keep the rest of the household running smoothly while the advocate or team monitors the patient status in the hospital.  Many times it is more than worth the cost to ensure that a guardian angel is watching over you.

Excerpt from "Someone To Watch Over Me" July 2008, Elder Advocates, Inc., Orlando, FL Newsletter