Standard of Care
Standard of Care
I have recently had a loved one in the hospital. I won’t say which loved one, and only note this is someone very close to me. I won’t say what hospital, or name the condition either. My indictment is of the system at large, so no one need be named, let alone blamed. In fact, there are many individuals in the mix for whom I have only deep gratitude.
My loved one is an “older” person, in her upper 70s. She is, however, or at least until now has been, quite healthy and vital and very active. Her series of nearly lethal, unfortunate events was set in motion by an elective orthopedic procedure in the service of that vitality and those activities. She still loves to bike, ski, and to a lesser extent (especially when hills are involved), hike.
Receiving intravenous fluid per protocol in a corner room far from the nurses’ station or anyone’s frequent attention, my loved one was put into fluid overload and pulmonary edema, a potentially lethal state and a serious trauma to all of the organ systems working to recover, along with others uninjured until now. She was discovered in this condition in the morning not by the medical staff, but by a family member. We had made the mistake the night prior, thinking she was fairly stable, of not having a family member stay overnight with her.
Subsequently, receiving a diuretic in the ICU to correct the fluid overload, our patient was put into a state of acute fluid depletion, dropping her blood pressure to a potentially lethal 40mm Hg. This was discovered by another family member, who spent that night in the hospital, and called me as soon as she saw the ominous trend.
Of course, a blood pressure that low triggers alarms in the ICU, and would have resulted in a response by the care team- at some point. But family, not the alarm, got their attention immediately. This is not because of lack of human decency, but because hospitals are routinely under-staffed, the staff on hand are overworked and overwhelmed, and all concerned have “alarm fatigue.” There are alarms sounding in the ICU at almost all times. Like the boy who cried wolf, they are prone to induce not the intended emergency response, but selective inattention.
A day or so later (they blur together under these conditions), there was another episode of dangerous and utterly unnecessary fluid overload. There was a potpourri of less acutely dangerous but nonetheless maddening lapses. Every avoidable trauma delayed the recovery of already injured organs, compounded the list of established problems, and invited consideration of more treatments- each with its own associated risks.
This same system – overwhelmed, understaffed, and itself a victim of misguided priorities– is an inadvertent threat to you and your loved ones needing in-patient care as well. I see five levels of progressively greater defense against its deficiencies.
First is familial vigilance. While it helps to have some medical expertise in the ranks, constant attention and persistent advocacy go a long way. Next is patient-centered care. This model, involving everything from staffing to architecture devised to accommodate the needs and comfort of patient and family, is unfortunately still more exception than rule, but that is slowly changing. My own hospital is an epicenter of this culture change, and I have seen up close- and from both sides of the bed– how powerfully, and favorably, it can alter the acute care experience. It should become the standard of care.
Third is state-of-the-art virtual care. Continuous, video access to teams of experts monitoring clinical data filtered by sophisticated algorithms so that what most warrants attention always gets it- can do even more than family at the bedside. In my loved one’s case, this system would likely have detected, and corrected, the falling blood pressure long before it became critical. Expect, welcome, and encourage the propagation of virtual care. Fourth is all of the above.
Fifth is all of the above in the context of a healthcare system actually about health, and care. A system that actively promotes health with lifestyle, and protects health with preventive medicine, is possible any time we choose. Such a system would result in many more healthy, and many fewer sick people. Resources freed up accordingly could allow for a much-enhanced level of care for those who do get sick.
Until we fortify our defenses, hospitals will kill our loved ones at times, despite hard work and good intentions, and conceal it even from themselves. It hides in plain sight as the standard of care; business as usual. It is the business of each of us to do all we can to defend our loved ones from that. It is the business of all of us to change it.