It is happening.
And, you know me well enough to know that no way I'm gonna recommend a Snickers.
American Healthcare continues to go backward
- Thread starter steross
- Start date
And, you know me well enough to know that no way I'm gonna recommend a Snickers.
Full size Snickers with Pecans or one of those cute little mini Snickers that you hand out at Halloween?
Steross won’t let me have a Snickers…
Okay, so I got to Costco in Midland an hour early for my hearing aid appointment. I had a couple of things that happened in the clinic yesterday that had a commonality that is particularly bad in American healthcare so I am going to rant about it. I’ve said that there are some things that the VA is very good at. This we are no better than anyone else: transitions of care.
Transitions of care is when, in particular, a patient transitions from inpatient to outpatient. Decisions have to be made about therapy. Decisions are always made on discharge, but seeing to it that those decisions are carried out, and how they are translated and carried out in the outpatient environment is another story. You’ll see what I mean.
The first patient was in a VA facility down state last June. He was on fast acting and long acting insulin and two oral meds for diabetes. In June his diabetes was well controlled with an A1c in the 6s. When I talked with him yesterday his diabetes was out of control with an A1c of 9 drawn a week ago. He has a continuous glucose monitor (Libre) that also shows hypoglycemia throughout the day and night because he has been self-adjusting both of his insulins trying to get his blood sugar down. Reviewing his meds I find his last refill of Jardiance, a diabetes med, was May. When I ask why he states it was stopped when he was discharged from the facility down state. So I tell that I want to take time to look at the discharge summary and see why it was stopped. It wasn’t. He was supposed to be taking it. I’m sure a nurse went over his meds on discharge. It took all of two minutes. While he was anxious to leave. And didn’t listen.
The second patient had a trans arterial aortic valve replacement by a local cardiologist. A diabetes medication, Ozempic, was held prior to the surgery, which is standard procedure. They intend for him to restart it post-procedure, but did not tell him when to restart it post procedure. No it is 6 months later and his A1c is 7.9, which is not a train wreck. But we have to start over with the Ozempic dose to avoid GI side effects.
The last one… I wish this were the only time something like this has happened and I wish it were unique to the VA… another hospital did this recently… had a patient discharged from the Detroit VA to a shelter in Saginaw (and I’m getting alerted to this at 4pm on Friday afternoon, my tour ends at 4:30). He was given fast acting insulin in a vial with no syringes and doesn’t know how to use syringes and vials and can’t without syringes in the first place. He was given a sliding scale (where you take more insulin if your blood sugar is higher and less if your blood sugar is lower), but discharged without a glucometer or any method for checking his blood sugar. And he was given long acting insulin pens, but not then pen needles so there was still no way to inject himself. So I send prescriptions for everything he needs to the outpatient pharmacy window in Saginaw. I am in Oscoda. I call the outpatient pharmacy and talk with the pharmacist and explain the situation to him, because by now it’s almost 5pm and they close at 5:30, and my tour ended 30 minutes ago. He said they would try to call him, but if he couldn’t get there by 5:30 they would take everything to inpatient and if he went to urgent care he could still get it. I did everything I could. But, good lord, what were they thinking in Detroit? How was that supposed to work?
Good transitions of care in the first two cases could have prevented the problems. I guess I was the one doing transitions of care in the third case.
Transitions of care is when, in particular, a patient transitions from inpatient to outpatient. Decisions have to be made about therapy. Decisions are always made on discharge, but seeing to it that those decisions are carried out, and how they are translated and carried out in the outpatient environment is another story. You’ll see what I mean.
The first patient was in a VA facility down state last June. He was on fast acting and long acting insulin and two oral meds for diabetes. In June his diabetes was well controlled with an A1c in the 6s. When I talked with him yesterday his diabetes was out of control with an A1c of 9 drawn a week ago. He has a continuous glucose monitor (Libre) that also shows hypoglycemia throughout the day and night because he has been self-adjusting both of his insulins trying to get his blood sugar down. Reviewing his meds I find his last refill of Jardiance, a diabetes med, was May. When I ask why he states it was stopped when he was discharged from the facility down state. So I tell that I want to take time to look at the discharge summary and see why it was stopped. It wasn’t. He was supposed to be taking it. I’m sure a nurse went over his meds on discharge. It took all of two minutes. While he was anxious to leave. And didn’t listen.
The second patient had a trans arterial aortic valve replacement by a local cardiologist. A diabetes medication, Ozempic, was held prior to the surgery, which is standard procedure. They intend for him to restart it post-procedure, but did not tell him when to restart it post procedure. No it is 6 months later and his A1c is 7.9, which is not a train wreck. But we have to start over with the Ozempic dose to avoid GI side effects.
The last one… I wish this were the only time something like this has happened and I wish it were unique to the VA… another hospital did this recently… had a patient discharged from the Detroit VA to a shelter in Saginaw (and I’m getting alerted to this at 4pm on Friday afternoon, my tour ends at 4:30). He was given fast acting insulin in a vial with no syringes and doesn’t know how to use syringes and vials and can’t without syringes in the first place. He was given a sliding scale (where you take more insulin if your blood sugar is higher and less if your blood sugar is lower), but discharged without a glucometer or any method for checking his blood sugar. And he was given long acting insulin pens, but not then pen needles so there was still no way to inject himself. So I send prescriptions for everything he needs to the outpatient pharmacy window in Saginaw. I am in Oscoda. I call the outpatient pharmacy and talk with the pharmacist and explain the situation to him, because by now it’s almost 5pm and they close at 5:30, and my tour ended 30 minutes ago. He said they would try to call him, but if he couldn’t get there by 5:30 they would take everything to inpatient and if he went to urgent care he could still get it. I did everything I could. But, good lord, what were they thinking in Detroit? How was that supposed to work?
Good transitions of care in the first two cases could have prevented the problems. I guess I was the one doing transitions of care in the third case.
How about this one:
Patient gets recurrent ear infections and fluid buildup behind the ear, gets seen by teleER service for resp infection and ear pain, decreased hearing etc. States has had many times before. Gets meds, told to f/u with primary care if not better.
Getting worse. Sends message to primary care asking for consult to go back to the ENT that treated him before. PCM says need to see him in person first. Put through to scheduling-no appointments. Scheduling messages back to PCM. They don't respond for 2 days, so patient calls nurse triage, gets put through to our teleER service again.
2nd TeleEr doc, says, Well your doc wants to see you before the consult is placed. But pt is angry that there are no appointments. So, doc agrees to place the consult.
Next day, PCM nurse documents "Patient seen by TeleER and consult placed. No need for appointment."
Next day ENT cancels consult because no in person exam.
Patient gets recurrent ear infections and fluid buildup behind the ear, gets seen by teleER service for resp infection and ear pain, decreased hearing etc. States has had many times before. Gets meds, told to f/u with primary care if not better.
Getting worse. Sends message to primary care asking for consult to go back to the ENT that treated him before. PCM says need to see him in person first. Put through to scheduling-no appointments. Scheduling messages back to PCM. They don't respond for 2 days, so patient calls nurse triage, gets put through to our teleER service again.
2nd TeleEr doc, says, Well your doc wants to see you before the consult is placed. But pt is angry that there are no appointments. So, doc agrees to place the consult.
Next day, PCM nurse documents "Patient seen by TeleER and consult placed. No need for appointment."
Next day ENT cancels consult because no in person exam.
Last edited:
We really need an SMH emoji. Yes, this is exactly the kind of transitions of care garbage I’m talking about, except in this case the patient never actually transitioned, he got lost.
A huge fault in this system is this ability to unilaterally cancel consults without ever seeing the patient. See the Vet, and if the consult was actually faulty have a mechanism to correct the issue for the future. Instead, they cancel a bunch of consults assuming some are wrong and the vet gets the raw deal.
Similar threads
