I’ve known Pat McCann (identifying information changed) for many years. He carries a diagnosis of COPD and has a preventative and a rescue inhaler, but he has never really had any serious flare-ups.
He fell and broke his hip. Then he went to skilled rehab, one of a half dozen near Cityside Hospital. His stay turned longer than expected because he fell, luckily didn’t break anything, but had to go back to the hospital because he hit his head and needed to be observed for a small subdural hematoma.
I saw him late Friday afternoon for a hospital followup visit. Medicare pays us handsomely for such transition of care visits (CPT 99495 or 99496) when a care coordinator reaches out by phone, does a medication reconciliation, makes sure what follow-up tests are needed, if the patients understand their instructions and so on.
In this case, we had reams of printouts from the two hospitalizations, but we only had a medication list from the rehab facility. Pat’s regular boarding home had all kinds of questions about all his nebulizers, his oxygen orders and so on. We never did get anything from the nursing home, so “Continue the nursing home orders until we see him”, was all we could tell them, as we had nothing to go on.
So, 4 p.m. Friday Pat shows up, in a wheelchair, tied to an oxygen tank set at 3 liters per minute. He is coughing. He tells me he is raising phlegm, green and brown. His lungs have crackles and wheezes on both sides. I get a normal blood count and a chest X-ray that shows double pneumonia.
I know what happened. I used to be medical director at a rehab facility.
Because he carried a diagnosis of COPD and was on a maintenance inhaler, and because he ended up coughing and desaturating, it is safe to assume a nurse acted on standing orders to administer oxygen to COPD patients to keep levels above 90 percent. It is also likely that the inhalers were switched to nebulizers because his symptoms weren’t controlled.
It is equally likely that no medical provider assessed him at that time, and only responded to incoming faxes from the rehab facility. There’s only so much time for sick visits when you round at the nursing home, which is not every day.
It is also certain that the rehab facility had no access to my records, and even if they did, would not have had the available time to go through them to see that he’d never had a serious COPD exacerbation before.
It is also a cold hard fact that it is easier and less expensive for the rehab facility to administer oxygen and nebulizers than to put him in a wheelchair van and send him, with staff, across town to the hospital for a chest X-ray to check for pneumonia.
I sent Pat home with prescriptions for prednisone and antibiotics and a few words of encouragement about hopefully getting him off the oxygen soon.
I think we could do better.
Hans Duvefelt, also known as “A Country Doctor,” is a family physician who blogs at A Country Doctor Writes:.
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