By Anjali Varma Desai, MD
Mr. X is an 83- year-old male with a history of dementia, hyperlipidemia, irritable bowel syndrome, benign prostatic hypertrophy, hypothyroidism and chronic kidney disease stage III, presenting with new-onset left hip pain for1 week. Hip x-rays showed changes consistent with osteoarthritis with no evidence of fracture or dislocation. All other laboratory data were unremarkable. The patient was admitted to Medicine for management of his hip pain. On the night following admission, he became delirious in the setting of receiving morphine and percocet for pain control; during his delirious episode, a behavioral code was called, the patient required IM Haldol and IM Ativan and transient 1-to-1 status. By the following afternoon, the patient’s delirium had resolved. He was given a new room with a bedside window to help regulate his orientation and sleep/wake cycle, his children brought pictures for him to put by his bed, and all opiate pain medications were discontinued. Per discussion with Pain Management, the patient was started on tramadol, diclofenac and an analgesic balm with greatly improved symptoms. He had no further delirious episodes for the duration of his hospital course. He was medically stable for discharge a few days later.
DAY 1: “Are you ready to go home today?” I asked Mr. X. He gave me his usual snaggle-toothed grin, which had become his customary daily greeting. He expressed his desire to return home to his children and grandchildren, eat “regular food and kit-kats” instead of “this hospital junk” and sleep in his own bed. I shook his hand, wished him well and headed back to the call room to prepare his discharge paperwork. About a minute after I had submitted all of the necessary forms, I received a phone call from our team’s social worker. “You’re not going to believe this,” she began, before telling me that we could not safely discharge Mr. X. It turned out that his family had thrown out much of the furniture in his house due to what they claimed was a bed-bug infestation that had occurred while Mr. X. was in the hospital. Among the discarded furniture was Mr. X’s bed frame and mattress. We could not discharge him safely until we knew that the family had procured a new bed for him.
“Waiting for a bed,” I thought to myself. I had heard that phrase many times before. The phrase was often used when patients remained in the ER even though they had technically been “admitted;” they were simply waiting for a bed before they could come upstairs to the Medicine floors. Similarly, patients that needed to be transferred from one type of service to another (e.g. MICU to Medicine floors, Medicine floors to CCU) were often waiting for a bed to become available before the transfer could be completed. One month into intern year, the phrase had already become a part of my occupational vocabulary. But this was an entirely different set of circumstances. We could not call Bed-Board for an update on the “bed situation.” We had no assurances as to when the bed would become available. Instead, we were at the mercy of Mr. X’s family, the only people capable of buying the bed that would eventually allow Mr. X. to go home.
DAYS 2-3: Our social worker attempted to contact the patient’s children as well as the APS case workers who were overseeing the bed acquisition mission. My supervising resident and I likewise attempted to contact the patient’s children, leaving voicemails until we were told by a way-too-cheerful-sounding automated speaker that “The mailbox is full and can no longer accept messages at this time. Please try again later. Goodbye!”
DAYS 4-6: A repeat of Days 2-3. The frustration of the medical team was rapidly building, not only because we felt sympathy for Mr. X and this predicament that was entirely out of his control but also because Mr. X was occupying a hospital bed that could certainly have gone to better use on our busy Medicine floor.
DAYS 7-14: More of the same. We did our best to address all of Mr. X’s requests and to keep him as comfortable as possible over those fourteen long days. This included arranging a trip to the hospital barber, having podiatry trim his overgrown toenails, and chatting with him about his life experiences and his grandchildren. He had no “medical” problems or requests per se; he simply felt lonely and wanted to go home. Every morning, he would gaze at me with the same forlorn look and ask, “Am I going home today?” One morning, his eyes studded with tears, he implored, “Please send me home. I’ll even sleep on the floor! I don’t mind.” But the bed acquisition mission wore on inexorably.
We schemed about ways to get in touch with the patient’s family, including sending a telegram and taking a field trip to the patient’s house (about an hour’s drive from the hospital). We ultimately pursued neither of these tactics. Our team struggled with our role in this situation. How much time, how many resources, and how much personal attention should we expend on a patient who was not “sick” or injured like the rest of our patients?
DAY 15: Finally, on the 15th day of battle, I received an elated phone call from our social worker, informing us that APS had secured the necessary funding to help the family purchase a bed and that the bed would be delivered the next day. We had overcome our first major hurdle. But we still needed to contact the patient’s family and make sure that someone would be at the house to receive our patient. This entailed another frustrating series of phone calls and failed attempts to get in touch with the patient’s family.
DAY 16: At about 4 PM on the anticipated date of discharge, APS called us to say that the family was ready and waiting for Mr. X. at his home. “Battle Waiting for a Bed” was over, but the war to manage patient turnover and our duty as healthcare providers is still ongoing. While this incident could be described as simply an unfortunate circumstance, in truth it was a perfect storm of various aspects of the system breaking down and not functioning efficiently. On the one hand, patients’ families should want to keep their loved ones in the hospital for as little time as possible, as this allows patients to return home and prevents further nosocomial infections and iatrogenic complications. On the other hand, families who are confronted with socioeconomic obstacles that make caring for patients more difficult may tend to consider the hospital a convenient limbo for family members to reside. At the same time, hospitals wish to maximize patient turnover and discharge those who no longer “need” to stay in the hospital, but our duty as health care providers does not permit us to discharge even a healthy patient into an unhealthy environment. The end result of all of these competing social forces was a patient desperately wanting to go home but being forced to stay in the hospital while numerous resources were expended to keep him there. Perhaps we would all have been better off calling 1-800-Mattress on that very first day?
But the resolution to this story reveals a glimpse of the light at the end of the tunnel. As I watched Mr. X leave the hospital, I knew that his successful discharge was the product of an intensely coordinated care effort that spanned not only different disciplines within the hospital, but also state-wide agencies. Teamwork had ultimately prevailed. Mr. X. was free to return home to his kit-kats, his grandchildren, and a brand-new bedbug-free bed.
Dr. Desai is a second year resident in internal medicine at NYU Langone Medical Center
Image courtesy of Wikimedia Commons