Careful What You Wish For (or, Creating a Monster)

About four years ago I had a meeting with a dear and trusted colleague and a bunch of Vancouver Coastal Health administrators. The chief executive officer and her group said “We have a culture of admission here”. Too many elderly people were being admitted to hospital through the big-city emergency room in Vancouver and they weren’t benefiting. And they were costing a lot of money.

Silence in the room.

I said to the assembled potentiates, “Put Jay (my trusted colleague) and me in that ER and we will turn that around for you in three months.”

“Who’s going to organize it?” they asked, and each of us pointed to the other. Jay it turned out was busy defending our home care of the elderly program and doing a lot of other things, and so making real of my boast fell to me.

The result was “EDiCare”, a unique program with a lot of funding and a lot of flaws. It arranged for me and as many doctors as I could gather together for weekday duty, plus a bunch of nurses spectacularly experienced and qualified at clinical care and dealing with our public health community system, to consult in a little office in a back hall of the huge ER. We started out feeling our way, and slowly convinced the emergency room doctors, nurses, and administrators we meant well, knew how to care for old people in the community, and were pretty good at basic critical care too.

Fast forward four years. About a year ago I left the EDiCare Medical Coordinator job and then quit working in the program altogether, moving outside Vancouver and slowly cutting my practice down as I got ready to retire.

Shortly after, one of my remaining patients in Vancouver got into trouble. She had been in the other big-city hospital with heart disease that nearly killed her about two months ago, and was discharged home still in a bit of heart failure but having survived her near-death experience. I look after a lot of medically sick frail elderly people at home and am pretty good at dealing with heart failure, but with this lady there were too many complicating factors, not enough laboratory support, and a risk that treating her heart failure too aggressively could make her worse. I referred her to a geriatric medicine specialist, and he recommended we admit her to hospital to get her treatment properly organized, and going against my instincts and everything I had been teaching and encouraging my team to do in the emergency room, we sent her in to be admitted.

There is a right time to do the wrong thing and I was pretty sure this was it.

But my team (no longer really mine) and even the hospitalist who would have admitted her thought she was “looking too good” to bring into the hospital. Over the years I had convinced these people to be skeptical of bringing frail elderly people into the hospital because of the risks of admission, and to at least try to get them out of trouble at home. But as I tried to explain I had already tried in this situation and it hadn’t worked out. She needed admission! But the team and the hospitalist sent her home.

My patient hung on in her little apartment still short of breath, still obviously in heart failure, still needing pretty well daily medication adjustment and monitoring with laboratory studies that take two weeks to obtain, a mentally intact person who wants to get better. Eventually we succeeded in getting her on enough medication to control the failure without drying her out. Happy ending but quite honestly much riskier for this dear lady then a week or two in the hospital.

Hospital was what she needed. But I couldn’t do it because of the culture of discharge we had created at the behest of our local administration, convinced in our hearts and minds that for frail elderly people community care is good and hospital care is bad.

And that’s true. Most of the time.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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