Is your patient having trouble breathing? I can ask respiratory to give him a nebulizer. I’m looking at his chest X-ray now — why don’t we bump up that Lasix, too? I wish the ER would have grabbed an ultrasound of that swollen leg. Does he need more oxygen?
If something is missing from this picture, it isn’t the clinical people who are at fault.
Clinicians solve problems with the tools they’re conditioned to use. And a roadblock to best care has been built into our thinking: we default towards passive, revenue-producing interventions instead of starting with cheaper, easier ones — even when a cheap and easy treatment may be more effective. How often does the decision sequence for managing acute dyspnea begin with mobilizing the patient out of bed?
Sometimes, but not often enough.
We make these choices in this way because the biomedical profit-center model asks us to: this is but one iteration of health care’s pervasive conflict. And in doing so, whether we realize it or not, we enable a harmful reversal of care principles.
This inversion is the same reason that we perform so many costly knee scopes and invasive lumbar fusions, despite evidence that those procedures are no more effective than cheaper and safer conservative treatment. It is the reason for our explosive health care costs and floridly mediocre patient outcomes.
But we look past mountains of literature that detail how older adults lose strength and endurance quickly while hospitalized, mostly because we don’t help them maintain any amount of activity, for a number of reasons. This isn’t a flashy topic. Accountability doesn’t exist because nobody will analyze this care failure retrospectively. No revenue will be lost.
In a system of logical principles which reward providers, hospital systems, and payers equally for delivering high-quality, cost-effective care, the cheapest and safest path to the best patient outcome becomes the path routinely chosen. But in an unraveling system of high-priced procedural care, hospitals need to perform as many big-dollar interventions as they can justify. Medicare and other insurers certainly pay a price for this mindset, but it is patients who are harmed most by these sometimes-hidden care failures.
Consider, for example, that same amount of patients are discharged to post-acute facilities for no reason beyond hospital-acquired deconditioning. Others are readmitted from home because the strength they lost over days in a hospital bed resulted inevitably in a fall after discharge. Could one of them be your grandparent or parent? To each of these patients, our system is guilty of committing preventable harm – if not in action, then through omission. We all see this, and still, the cycle continues.
Our bright and dedicated clinical people are entitled to the satisfaction of patient outcomes proportional to the time and energy they pour relentlessly into their care. For their patients to return worse-off or languish in bed because of a short-sighted administrative focus on cost savings is not the rewarding experience that doctors, nurses, or therapists deserve. And for what reason should they allow it? When patients are harmed by facilities’ failure to provide the resources that good care demands, I assert that providers, too, are harmed.
To perpetuate a system organized to fail at care by removing cost-effective solutions produces incredible emotional dissonance, of which ideas like burnout are just one fulminating symptom.
Hospital immobility is more than a glaring deficiency: it is an encapsulation of our system’s fundamental flaws. But it can become an opportunity for administrators to show commitment to outcomes that matter beyond balance sheets; to those that matter to patients.
Momentum is building towards conscientious, accountable care. Executives can continue to enable a damaged system until forced to change or can become part of a solution now by hearing demands for change, which can improve patient care at very small cost. Keeping patients mobile while hospitalized is an easy, cost-effective part of good care. If your clinical people are telling you that resource limitations are the barrier, listen to them.
John Corsino is a physical therapist who blogs at his self-titled site, Health Philosophy.
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