Learning About Systems to Improve Health by Turning Problems Into Solutions

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The handoff of patients from the overnight team was more hectic than usual. Most of our emergency beds were filled with admitted patients awaiting a hospital bed, and the waiting room had many patients who had not yet been seen. Several had been waiting more than four hours. Gil, the resident working with me, dutifully took down detailed information on all the patients as I noted specific tasks that I needed to complete. (Descriptions of Gil and our patients have been altered to protect their identities.) At the end of the sign-out we discussed two “problem” patients that the departing team had alerted us about.
The first was Mr. Mares, an undocumented immigrant, who worked as a roofer and had recently developed chronic renal failure requiring ongoing dialysis. Mr. Mares was relatively young for renal failure, only 42 years old, and he smiled weakly as we walked by his cubicle and introduced ourselves as his new team of doctors. He wore a corduroy jacket with black stains from roofing tar and his lips revealed the pallor of anemia associated with renal failure. I noticed that he was breathing rapidly and mentioned this to Gil and the students and residents rounding with us. “Fluid overload,” the departing resident had said, “but his X-ray looks okay.” That resident had also explained that the overnight on-call renal fellow had agreed to evaluate whether hospital dialysis was needed right away. The problem was that because of the immigration status of the patient, Medicare would not cover the costs of dialysis as it did for most U.S. citizens, and Mr. Mares had no way to pay for the expensive procedure. This was a serious issue for undocumented immigrants with renal failure and had resulted in an awkward compromise in which the hospital agreed to dialyze patients like Mr. Mares only when they represented a true medical emergency. This approach resulted in frequent delays and return visits to the emergency department until the inevitable true emergency of a dangerously elevated potassium or pulmonary edema occurred. “Crazy system,” concluded the departing resident, and we all nodded in silent recognition of the difficult dilemma of providing appropriate care for Mr. Mares due to the health system constraints.
The other patient was an elderly gentleman named Mr. Jackson, who was waiting for a consult with the cardiology team to evaluate his new onset of chest pain. We were told that all the EKGs and lab tests were negative and that the previous team had anticipated discharge and an outpatient stress test, but since Mr. Jackson was 75 years old and had hypertension and diabetes, they wanted cardiology to evaluate the need for hospitalization. Mr. Jackson was afraid to go home in spite of his negative workup, and the team anticipated a struggle with cardiology over admission because the hospital was full. Decisions about admission for patients like Mr. Jackson had become increasingly difficult as they got handed off from one team to another with a consequent loss of information. I resolved to speak with Mr. Jackson as soon as I could so that I could verify the information and be ready for the cardiology team’s questions, but first I grabbed the chart of one of the patients who had been waiting for five hours to begin her workup.
When I returned to our work station 20 minutes later I overheard Gil arguing with the nephrology fellow. The nephrology fellow said, “We’ve determined that the patient is stable for discharge. He doesn’t need emergency dialysis today. His potassium is only 5.8 and there’s no pulmonary edema.
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