Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Becoming the Change: The Crucial Importance of Adaptability in Medicine

12/11/2013 12:20:07 AM | 2 comments

"Change is optional. So is survival."

— W. Edwards Deming

It's Saturday at 6 p.m., and the emergency department (ED) is running at full tilt. An elderly patient comes in complaining that he's felt weak and dizzy for the past month. It's clear that he needs a workup. During registration, he mentions that he lives alone, doesn't drive and has a hard time getting to the grocery store and doctor's office.

Now, my instinct as an emergency physician is to rule out any potentially catastrophic conditions, order the initial set of labs and admit him as quickly as possible. After all, that's my job, right?

There are definite upsides to this plan. He can have his tests done upstairs where he'll be more comfortable, watching HBO while he waits for the results. And he won't have to wonder where his next meal is coming from, at least for the moment.

But over the past few years, I'll admit that I've started to see things differently.

Healthcare is experiencing the most rapid change we've seen in recent history — perhaps in the last century. Due to changes in Medicare reimbursement, many acute care services will likely shift to the outpatient setting. This means we're going to need far fewer hospital beds in coming years, and what's more, hospitals will almost certainly close. Those that hope to survive must demonstrate new levels of quality and efficiency.

That's sobering news for physicians in hospital-based specialties. But in a way, we've done this to ourselves by concentrating too closely on our own little piece of the pie. For years, the notion of cross-departmental collaboration was nonexistent and system-wide integration was unattainable. As a result of this lack of communication, our system became more costly and inefficient year after year.

And who suffered most? Our patients and our country, of course. Medical bills are the most common cause of bankruptcy in the United States, and the skyrocketing cost of medical insurance is causing our country's manufacturers to lose their competitive edge with other countries — in part because our system did nothing to encourage physicians to work together.

We finally became so compartmentalized, the government stepped in to force us to collaborate. Those hospitals or physicians that could not foster this integration would be penalized.

To survive, physicians now need to stretch in new and uncomfortable directions. We may need to make decisions that seem counterintuitive because they serve towards improving the overall system, seemingly at our expense. But in the end, a flexible, collaborative approach is better for our patients, our hospitals and ourselves.

Getting back to my dizzy patient example: I would prefer to admit the patient. But as I mentioned, it's 6 p.m. on a Saturday, which likely means the CT scan won't be done until 10 a.m. the next day. And even then, there will be hours of waiting for the results.

On the other hand, if I keep the patient a bit longer and have the scan done in the ED, the case will be a high priority. Depending on the results, I might be able to avoid a short-stay admission, work with a case manager (assuming my hospital has one available on Saturday evening) to get him some in-home assistance and rapid follow-up with his primary physician and have him home tonight. And should we find an abnormality that would support an admission, our hospitalist colleagues will have the diagnostic information they need to provide quick, responsive care.

Let's say we do the CT scan and all of the labs are normal. As things stand, I'm still not comfortable sending the patient home. I'd love to admit him just to give him a safe haven for a few days. But today, the criteria for admission is changing, so I need to be more resourceful.

Coordinating a patient's care may not feel comfortable or convenient, especially on a busy Saturday night. But in the long run, I do benefit.

The patient is satisfied and has his needs met, which is why I went into medicine in the first place. And if my ED colleagues and I can demonstrate this level of efficiency and serve as examples to the rest of our hospital colleagues on a consistent basis, we're more likely to be employed a few years from now. (And the hospital itself is more likely to stay open.)

Sure, change is uncomfortable. We generally don't want to change if we don't have to. We can always choose to dig in like the Sears, Kodaks and Blockbusters of the world. But we know how their stories turned out.

Change is never easy, but a shift toward greater collaboration is the right thing for our patients. And in the long run, what's best for the patient is best for all of us.

Dr. Bass, what you say is so important. Collaboration and working together will be the only way to succeed. I am curious as to your thoughts on how we continue to have competing goals and incentives and how we deal with this. For example, as there is greater and greater scrutiny on ED physicians LOS for both discharged and admitted patients (i.e. "improve your metrics, or else!"), how do we reconcile that with the older and more complex pt mix (change in demographics of the nation and presumably more being done in clinics outside of hospital), increased intensity of services required in ED (dx, tx, case management, social services), the need to hospitalize fewer patients (i.e. evaluate, treat, arrange follow-up and outpt care, and send out sicker and more complex pts) and the scrutiny on hospitalists to improve their metrics (decrease decision to admit to order time, decrease hospitalized LOS)? Collaborate on developing metrics that better reflect overall system goals, such as combined ED and hospitalized LOS?
12/13/2013 7:33:28 PM

An absolute necessity, Adaptability is easy to some, very difficult for others. If you are a change Master, look around you to find a way to help those who are change Resisters. We cannot succeed as an individual nor an organization without embracing change.
12/13/2013 5:47:43 PM