Rain on my parade

[nikolaite]

Since starting at the “House of God” I’ve seen some things.

I don’t know the whole backstory here, but we had an objectively unsafe discharge here from Neuro ICU. An incapacitated aphasic neuro patient was discharged 26 hrs after acute onset of cortical signs (basically MCA syndrome). 1123F documentation of surrogate decision maker. Again, no idea of the whole story (just records and snippets of talk) but the word coming down the pipeline is that all providers on the case have to “come together” since admin is sensitive to the latest report of pt dumping from Valley Hospital in NV. I was really getting the vibe of “let’s get our story straight” around the proverbial water cooler yesterday.

Word is that there’s going to be an internal review for SOC reporting and due to my background admin asked me informally to provide a written review in advance. I was supplied with four different edits of the “record” and spent the night reading through. So, even without the alterations and obliterations, it’s bad, folks.

Uh…so…now the last edit of the record shows that discharge provider, OT, SLP, and the day RN massaged a “pt left AMA” notation in the pt record. I talked to social work today, he let slip that he saw the pt and the pt was not ready for discharge and could not express anything. Overheard third hand PT said the pt was effed up, high fall risk, couldn’t talk, was apparently trying to be cooperative but couldn’t consistently follow commands, etc. I wheedled out of security a verbal that the pt did ambulate out of the room with the assistance of whoever was rooming in and the day nurse. I viewed footage over lunch and there were a number of anterior losses of balance and the pt had no shoes on his feet. Pt went by security checkpoint to get out of hospital basically using his wife? or gf? as an assistive device, teetering, and no shoes. Why didn’t security question it? Discharge orders. I’m so exhausted that the ridiculousness of this is causing inappropriate laughter.

What could be worse here? Stroke protocol was not completed. Discharge provider noted pt refusal to have an MRI even with surrogate-signed screening form and written consent on file. No AMA documents (signed or otherwise) or AMA education noted. No note of surrogate decision maker involvement in discharge or discharge planning. Discharge summary not provided to surrogate decision maker or pt, noted withheld by discharge provider. Oral meds with no instructions for safe administration ordered for strict NPO pt on discharge and scripts sent to pt pharmacy of record. This is a total WTF case.

Basically, if the pt family doesn’t sue over the likely and foreseeable residual deficits (or pt death?) I’ll be surprised. I’m guessing my report is going to end up with legal to consult on potential settlement size as well as scale how wide the internal SOC review has to go. Seriously…what the heck?

Updating CV…prepping to get away from this cluster. Just writing somewhere to commiserate and keep sane. I agreed to review with good intentions…giving the benefit of the doubt…but no way I’m closing ranks on this mess.

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[ProReduction]

After doing all my training at "Houses of God" / "World's Best Medical Centers", being an academic attending and division director at a regional powerhouse but not a WBMC, and having done TeleHealth for many years where "client" hospitals include some of the worst urban and rural medical centers in the South and Midwest, I've learned that the only thing that really distinguishes the WBMCs from rural "World's Worst Medical Centers" is how many U.S. New and World Report banners they hang in the main entrance and how patients feel about the hospital. Some of the scariest cases I've seen were at Top 5 USNWR medical centers.

 

[chessknt]

Since starting at the “House of God” I’ve seen some things.

I don’t know the whole backstory here, but we had an objectively unsafe discharge here from Neuro ICU. An incapacitated aphasic neuro patient was discharged 26 hrs after acute onset of cortical signs (basically MCA syndrome). 1123F documentation of surrogate decision maker. Again, no idea of the whole story (just records and snippets of talk) but the word coming down the pipeline is that all providers on the case have to “come together” since admin is sensitive to the latest report of pt dumping from Valley Hospital in NV. I was really getting the vibe of “let’s get our story straight” around the proverbial water cooler yesterday.

Word is that there’s going to be an internal review for SOC reporting and due to my background admin asked me informally to provide a written review in advance. I was supplied with four different edits of the “record” and spent the night reading through. So, even without the alterations and obliterations, it’s bad, folks.

Uh…so…now the last edit of the record shows that discharge provider, OT, SLP, and the day RN massaged a “pt left AMA” notation in the pt record. I talked to social work today, he let slip that he saw the pt and the pt was not ready for discharge and could not express anything. Overheard third hand PT said the pt was effed up, high fall risk, couldn’t talk, was apparently trying to be cooperative but couldn’t consistently follow commands, etc. I wheedled out of security a verbal that the pt did ambulate out of the room with the assistance of whoever was rooming in and the day nurse. I viewed footage over lunch and there were a number of anterior losses of balance and the pt had no shoes on his feet. Pt went by security checkpoint to get out of hospital basically using his wife? or gf? as an assistive device, teetering, and no shoes. Why didn’t security question it? Discharge orders. I’m so exhausted that the ridiculousness of this is causing inappropriate laughter.

What could be worse here? Stroke protocol was not completed. Discharge provider noted pt refusal to have an MRI even with surrogate-signed screening form and written consent on file. No AMA documents (signed or otherwise) or AMA education noted. No note of surrogate decision maker involvement in discharge or discharge planning. Discharge summary not provided to surrogate decision maker or pt, noted withheld by discharge provider. Oral meds with no instructions for safe administration ordered for strict NPO pt on discharge and scripts sent to pt pharmacy of record. This is a total WTF case.

Basically, if the pt family doesn’t sue over the likely and foreseeable residual deficits (or pt death?) I’ll be surprised. I’m guessing my report is going to end up with legal to consult on potential settlement size as well as scale how wide the internal SOC review has to go. Seriously…what the heck?

Updating CV…prepping to get away from this cluster. Just writing somewhere to commiserate and keep sane. I agreed to review with good intentions…giving the benefit of the doubt…but no way I’m closing ranks on this mess.

Eh if you aren't familiar with the case then why are you involved at all? Why would the wife agree to drag his incapacitated husk out of the hospital back to home? Why would a provider discharge someone like that home outside of an ama unless they were grossly incompetent. More to the story methinks.

 

[nikolaite]

Eh if you aren't familiar with the case then why are you involved at all? Why would the wife agree to drag his incapacitated husk out of the hospital back to home? Why would a provider discharge someone like that home outside of an ama unless they were grossly incompetent. More to the story methinks.

There is more to the story. The discharge provider is not employed by the hospital, but an independent staffing org. He and the admit provider (same staffing org) are chums. From the record it looks like he was trying to cover for the admit provider inexplicably canceling the pts MRI and IR consult (no documentation why she did this)…and the pt not getting a needed conventional angio or MT. I called the MRI dept and they have no idea why the MRI appt was cancelled within the same hour they received the screening form. Weird stuff.

According to snippets in early edits of nursing record wife asked for services and testing to continue, but the day nurse was instructed to DC patient and tell them to leave. They’re marked as unknown ethnic background in epic and the wife is obviously dressed ethnic in security footage (head scarf and some long garb), which admin is concerned may be construed as a contributing factor for the weird events. Admin is also concerned since pt is self-pay meaning possibly Medicaid eligible. Clinical services note show encouragement to sign up for financial aid and wife’s declination with offer to prepay…which is different.
The reason I’m involved is the same for any internal SOC review: quality of care and required reporting to the state. Any time a reportable incident occurs in hospital, the admin are required to have a disinterested internal review and report to the state if the result falls under a specific level of state defined standard of care violation. You can’t be involved with the case in any way to review the case. They’re skating the informal request for my report under that mantle.

Outreach nurse (does exit satisfaction calls) has documented from wife a poor review of the hospital experience. Call back documentation from nurse manager and risk manager show the wife believes she was told her husband was done with hospital treatment and needed to go home. Wife reported all her requests for interpretation services, advocacy, physician services and hospital services were denied. Wife reported she and her husband dc-ed nothing. She reportedly asked for encounter documentation to give new providers before they were told to leave the room, but she said it was refused. She said she asked for a wheelchair and was refused. She claimed someone at the hospital stole her husband’s boots. She took the pt to receive treatment at a private stroke center.

Verbal report has been called in to stroke center for continuity of care, but no encounter documentation has been provided pending review.

Definitely more to the story…and more keeps unfolding. I thought i was toughened up from the last three years of pandemic level stress, but, though this case piques my interest from an activist or advocate POV, it hurts my heart.

 

[TransformerInWestVirginia]

they discharged straight out of the ICU?

Red Flag #1

 

[chessknt]

There is more to the story. The discharge provider is not employed by the hospital, but an independent staffing org. He and the admit provider (same staffing org) are chums. From the record it looks like he was trying to cover for the admit provider inexplicably canceling the pts MRI and IR consult (no documentation why she did this)…and the pt not getting a needed conventional angio or MT. I called the MRI dept and they have no idea why the MRI appt was cancelled within the same hour they received the screening form. Weird stuff.

According to snippets in early edits of nursing record wife asked for services and testing to continue, but the day nurse was instructed to DC patient and tell them to leave. They’re marked as unknown ethnic background in epic and the wife is obviously dressed ethnic in security footage (head scarf and some long garb), which admin is concerned may be construed as a contributing factor for the weird events. Admin is also concerned since pt is self-pay meaning possibly Medicaid eligible. Clinical services note show encouragement to sign up for financial aid and wife’s declination with offer to prepay…which is different.
The reason I’m involved is the same for any internal SOC review: quality of care and required reporting to the state. Any time a reportable incident occurs in hospital, the admin are required to have a disinterested internal review and report to the state if the result falls under a specific level of state defined standard of care violation. You can’t be involved with the case in any way to review the case. They’re skating the informal request for my report under that mantle.

Outreach nurse (does exit satisfaction calls) has documented from wife a poor review of the hospital experience. Call back documentation from nurse manager and risk manager show the wife believes she was told her husband was done with hospital treatment and needed to go home. Wife reported all her requests for interpretation services, advocacy, physician services and hospital services were denied. Wife reported she and her husband dc-ed nothing. She reportedly asked for encounter documentation to give new providers before they were told to leave the room, but she said it was refused. She said she asked for a wheelchair and was refused. She claimed someone at the hospital stole her husband’s boots. She took the pt to receive treatment at a private stroke center.

Verbal report has been called in to stroke center for continuity of care, but no encounter documentation has been provided pending review.

Definitely more to the story…and more keeps unfolding. I thought i was toughened up from the last three years of pandemic level stress, but, though this case piques my interest from an activist or advocate POV, it hurts my heart.

Parts of that definitely sound bad but the litany of complaints from the wife (including stolen boots and being refused a wheelchair which I think is highly unlikely and asking a nurse to print medical records isnt appropriate either) also sounds like she might have been a factor in the discharge despite her claiming the opposite. I have absolutely had patients with a language barrier get angry and clearly not understand what was happening, claim they do understand, decline to ask questions etc just for the next day to be told that nobody spoke to them and ask the same questions over again etc etc. Even with a translator.

A private stroke center and self pay? Are they Saudi royalty?

I think focusing on neuro deficits, pt/ot eval, duration of deficits, and imaging obtained is where the objective meat of the case is to see where the standard of care was lost. Focusing on intangibles that you can't fully understand like ethnic background/language barriers and what was/wasn't communicated isn't where you can help as a doctor reviewing a case.

 

[DeadCactus]

Maybe just me, but this seems like a lot of detail to throw on the internet especially given the high medicolegal risk you're describing.

 

[turkeyjerky]

Sounds like the OP is hired by the hospital to throw docs under the bus. I don't think he's got any clinical background, fyi.

WTF is this story anyway? Crazy family signs out AMA b/c they think they're in a ghetto hospital and prefer to go to the fancy place down the street, not realizing that by being overly demanding they've torpedoed the patient's chances of a recovery. Despite being "ethnic" they're wealthy, astute and able to create a fuss for the hospital. Rather than man up and tell them to pound sand, the hospital hires OP to F over the docs.

Wonder if he was involved in ratf-king Husel.

 

[Splenda88]

they discharged straight out of the ICU?

Red Flag #1

Hospitalist here.

We sometimes discharge patients straight out of the ICU... DKA patients and when transfer has been delayed due to no available floor beds

 

[nikolaite]

Parts of that definitely sound bad but the litany of complaints from the wife (including stolen boots and being refused a wheelchair which I think is highly unlikely and asking a nurse to print medical records isnt appropriate either) also sounds like she might have been a factor in the discharge despite her claiming the opposite. I have absolutely had patients with a language barrier get angry and clearly not understand what was happening, claim they do understand, decline to ask questions etc just for the next day to be told that nobody spoke to them and ask the same questions over again etc etc. Even with a translator.

A private stroke center and self pay? Are they Saudi royalty?

I think focusing on neuro deficits, pt/ot eval, duration of deficits, and imaging obtained is where the objective meat of the case is to see where the standard of care was lost. Focusing on intangibles that you can't fully understand like ethnic background/language barriers and what was/wasn't communicated isn't where you can help as a doctor reviewing a case.

Not Saudi royalty…apparently they’re Hasidim.

The wife’s issue was discharge docs generated automatically by a few keystrokes in epic. There are no discharge docs for the patient. The summary is there, though.

Thanks for your input on focus. I was really torqued when I first came on.

 

[nikolaite]

Maybe just me, but this seems like a lot of detail to throw on the internet especially given the high medicolegal risk you're describing.

It is a lot of detail, though sanitized. Part of the reason it’s thrown out here is that it’s beneficial in the long run to get the hive all chiming in. Most people err thinking this detail has to be kept private for legal reasons. However, if I can drag up a multitude of interpretations from the same information I can show a reasonable uncertainty to the decision making process, etc. This breaks most patient medmal claims of cut and dried presentations that no one could possibly come to any other conclusion on …if I can get people with differing legit interpretations from the same info to come on record.

 

[nikolaite]

Sounds like the OP is hired by the hospital to throw docs under the bus. I don't think he's got any clinical background, fyi.

WTF is this story anyway? Crazy family signs out AMA b/c they think they're in a ghetto hospital and prefer to go to the fancy place down the street, not realizing that by being overly demanding they've torpedoed the patient's chances of a recovery. Despite being "ethnic" they're wealthy, astute and able to create a fuss for the hospital. Rather than man up and tell them to pound sand, the hospital hires OP to F over the docs.

Wonder if he was involved in ratf-king Husel.

The prejudice in your reply aside, no one was signed out AMA in this case. The discharge provider ordered discharge to home without services. Billing and coding filed AMA due to mentions from discharge provider, OT, SLP and day nurse in conformity with JC instruction.

The record supports the wife’s claims about withheld info and services in hospital. There is no objective record of wife or fam being “demanding,” not even a single instance of call button use. This case is adding up to a comedy of errors.

My job isn’t about f-ing anyone over. If you’ve ever worked with DHHS or internal hospital review, you’d know the result to patients is nearly always “we were unable to substantiate your allegations.” In the copious reviews I’ve processed this last three years, only one was acknowledged by DHHS as substantiated, and even so, the Attorney General declined to take any legal action. The benefit of the situation is always with the medical practitioners.

 

[turkeyjerky]

The prejudice in your reply aside, no one was signed out AMA in this case. The discharge provider ordered discharge to home without services. Billing and coding filed AMA due to mentions from discharge provider, OT, SLP and day nurse in conformity with JC instruction.

The record supports the wife’s claims about withheld info and services in hospital. There is no objective record of wife or fam being “demanding,” not even a single instance of call button use. This case is adding up to a comedy of errors.

My job isn’t about f-ing anyone over. If you’ve ever worked with DHHS or internal hospital review, you’d know the result to patients is nearly always “we were unable to substantiate your allegations.” In the copious reviews I’ve processed this last three years, only one was acknowledged by DHHS as substantiated, and even so, the Attorney General declined to take any legal action. The benefit of the situation is always with the medical practitioners.

Yeah, you're damn right I'm prejudiced against you rat****er

Stay in you're lane, don't they have online forums for clipboard nurses?

 

[nikolaite]

Yeah, you're damn right I'm prejudiced against you rat****er

Stay in you're lane, don't they have online forums for clipboard nurses?

I couldn’t care less about your prejudice toward me. I meant your obvious prejudice regarding the pt.

I guess this is how you demo your deep commitment to professional ethics.

I’m brought in to find any possible avenue to discredit the patient and get the doc out of the bad situation he’s put himself in. And I’m good at it.

I think any reasonable person could understand why I’d want to jump ship on this meshuggas.

 

[turkeyjerky]

I couldn’t care less about your prejudice toward me. I meant your obvious prejudice regarding the pt.

I guess this is how you demo your deep commitment to professional ethics.

I’m brought in to find any possible avenue to discredit the patient and get the doc out of the bad situation he’s put himself in. And I’m good at it.

I think any reasonable person could understand why I’d want to jump ship on this meshuggas.

Prejudiced against whom? Antagonist idiots who compromise their medical care? Sure, guilty! Meh, not the first time I've been called a self-hater.

Considering your history of inevitably taking the least hospitable view towards physicians and medical care on these boards, I highly doubt your self-characterization is accurate.

You shouldn't be on the ship, rat****er.

 

[lymphocyte]

Hospitalist here.

We sometimes discharge patients straight out of the ICU... DKA patients and when transfer has been delayed due to no available floor beds

This is topical. Just published. Featured in NEJM Journal Watch. Perfectly safe for select patients.

Lau VI et al. Safety outcomes of direct discharge home from ICUs: An updated systematic review and meta-analysis (Direct from ICU Sent Home study). Crit Care Med 2023 Jan; 51:127.

Safety Outcomes of Direct Discharge Home From ICUs: An... : Critical Care Medicine

tive Index to Nursing and Allied Health Literature from inception until March 28, 2022. Study Selection: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. Data Extraction: We screened and extracted studies independently and in duplicate. We...

doi.org

 

[SurfingDoctor]

This is topical. Just published. Featured in NEJM Journal Watch. Perfectly safe for select patients.

Lau VI et al. Safety outcomes of direct discharge home from ICUs: An updated systematic review and meta-analysis (Direct from ICU Sent Home study). Crit Care Med 2023 Jan; 51:127.

Safety Outcomes of Direct Discharge Home From ICUs: An... : Critical Care Medicine

tive Index to Nursing and Allied Health Literature from inception until March 28, 2022. Study Selection: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. Data Extraction: We screened and extracted studies independently and in duplicate. We...

doi.org

Frankly, we do it not infrequently in the pediatric ICU.

At least for pediatrics, most skilled home health nursing is just as adequate as floor nursing and with a smaller patient to nurse ratio. It’s actually getting to the point in some instances where the patients have to be quite well to go to the floor, at which point you question, do they need to go there at all.

 

[chessknt]

This is topical. Just published. Featured in NEJM Journal Watch. Perfectly safe for select patients.

Lau VI et al. Safety outcomes of direct discharge home from ICUs: An updated systematic review and meta-analysis (Direct from ICU Sent Home study). Crit Care Med 2023 Jan; 51:127.

Safety Outcomes of Direct Discharge Home From ICUs: An... : Critical Care Medicine

tive Index to Nursing and Allied Health Literature from inception until March 28, 2022. Study Selection: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. Data Extraction: We screened and extracted studies independently and in duplicate. We...

doi.org

I think there is a gulf of difference on discharging a recovered dka or intubated belligerent drunk and a massive mca stroke

 

[lymphocyte]

I think there is a gulf of difference on discharging a recovered dka or intubated belligerent drunk and a massive mca stroke

Yes, there is. I don't think I'm saying what you think I'm saying.