A Hall Bed and a 2 Day Coma

hospitalmedicine2014.org

by Jeffrey Frank, MD, MBA

Last month, my perfectly healthy 43 year old cousin John D. suffered an adverse hospital event which nearly killed him. Unfortunately his story is a common occurrence of which we witness on a regular basis, work hard to prevent, and thankful when it does not happen to our patients (or family).

John’s story starts with the death of his cancer ridden dog of 14 years. After several months of an intense grief reaction, he sought help, was placed on an antidepressant, and then started a rigorous workout regimen. John went to the ED c/o palpitations. He had the usual ED work-up and was going to be admitted for observation. He was started on IV fluids, and given two doses of IV lorazapam for anxiety.

The resident agreed to see him when he arrived on the telemetry unit, the usual hand-off for admissions, and John was placed in an ED hall bed. John wisely checked in with his physician father every two hours as he finally began to relax for the first time in weeks. He said he felt better and fell into a comforting, deep sleep…

This is where the system broke down.  John woke up two days later in the ICU, intubated and recovering from severe shock. In the ED he was noticed to be “blue and unresponsive” by a nurse walking by his hall bed, and was successfully resuscitated. However he suffered acute renal failure which required ten days of dialysis, shock liver, myocardial injury, a RUE thrombosis, and a helluva sore throat from the emergency intubation.

John nearly died due to the inherent and chronic problems with patient flow at most hospitals. The risk management team explained the event to him as an unfortunate circumstance because there were no available inpatient beds, and he may not have received the usual monitoring per hospital policy.

Because of cases like John’s, CMS and The Joint Commission now measure and query hospitals about their throughput processes and related boarding protocols. ED Turnaround Times (TATs) are one of the first identified measures of overall hospital efficiency because they are associated with inpatient quality outcomes. Lower ED TATs for admissions are correlated with lower mortality, higher HCAHPS, earlier antibiotic treatment, and other quality measures.

On Wednesday, March 26, 2:50 pm at Hospital Medicine 2014, I am moderating the presentation, Optimizing Patient Flow: The New Challenge for Hospitalists. David Yu, MD, MBA, SFHM, Director of the Adult Inpatient Medicine Service at Presbyterian Hospitals in Albuquerque, and Joseph Guarisco, MD, Chairman of Emergency Medicine at Ochsner in New Orleans will be presenting inpatient and emergency medicine views and efforts to tackle this difficult problem. We look forward to seeing you there.

If you have specific questions or concerns about hospital patient flow, please email me at [email protected] and we will try to respond at our presentation.

 

Jeffrey FrankJeffrey Frank, MD, MBA has been practicing medicine for 23 years, including 13 years as a hospitalist. Dr. Frank just started a new position as Program Director of Quality at CEP America-Hospitalist Division after 5 years as the Medical Director of Case Management at John Muir Health, a 500 bed 2 hospital community health system in Northern California. Throughout his career, he has worked to improve quality, workflow and utilization. He graduated from USC School of Medicine, completed his residency at Highland Hospital in Oakland, California, and obtained his MBA degree from the University of Tennessee. He maintains his certifications in Internal Medicine and Hospice and Palliative Care.

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