WHO is Dr Jason Lo? Dr Lo was listed as my physician on the whiteboard on the wall next to my hospital bed, but during the 21/2 days I was in the hospital, I never met him. While "all's well that ends well," there are aspects to my recent hospitalization regarding continuity of care that the health care system needs to address if my experience is at all representative.
Day 1: I arrived at the emergency department (ED) at 4:00 PM and was admitted to the hospital at 11:00 PM, relieved to be finally going to a room. The nurse said the physician listed on the whiteboard next to my bed would be in to see me in the morning. Nurses showed concern, were efficient, and shared important information. All seemed well despite the seriousness of what I was informed was a potentially life-threatening condition, a deep vein thrombosis and saddle pulmonary embolism.
Day 2: Breakfast seemed surprisingly unhealthy, soggy hash browns. I had been up since 6:00 AM, but Dr Lo had yet to appear. The nurses indicated I needed to talk to him to find out my treatment plan. My blood pressure was higher than I ever remembered: it was 120/80 at my physician's office before visiting the ED but now was 165/85 ("white coat" hypertension, according to physician friends). At 10:00 AM, I met Dr R. He had read my file, had a treatment plan for me, but said I must first see the oncologist. I was surprised at that. I had never been told I had cancer. Did he mean a hematologist? He did and apologized, thanking me for the correction. Dr R, however, continued to refer to my impending meeting with the "oncologist" after lunch. He was apologetic when over again I said "hematologist." Dr H., the hematologist, came in after dinner and outlined the treatment plan. He would put me on a new medication, Xarelto (rivaroxaban), although there could be some issue with insurance approval.
Day 3 begins early: A "masked-woman" turned on my room lights at 6:15 AM. "Wake up," she said, "I have orders to draw blood." She came around to the side of my bed and said: "William, how are you?" I told her "I'm not William." She looked at my wristband and exited the room without another word. At 7:15 AM, another woman entered my room and awakened me, yet again. She said: "Good morning ma'am, I'm here to take vitals." Upon seeing I was a man, she too left, saying "excuse me."
My nurse came in later, took my vital signs, was quite thorough in checking me out, and was nice and conversational. She told me my right leg was swollen compared with my left. This was no news, as the right leg swelling was present at admission. I asked, "How does the swelling compare to when I came in?" She checked the chart and responded, "Nothing recorded on that. What about your problems with "shortness of breath" and "pain" on the whiteboard?" I told her that I had no pain whatsoever on admission and that the shortness of breath occurred when running up 3 flights of stairs, something I had never experienced as an inveterate stair-climber. I told her this event was the reason I came to the ED and that I never experienced shortness of breath at rest. I surmised that perhaps the "shortness of breath" and "pain" were words placed on the whiteboard as symptom alerts for staff. But my nurse said that she had no understanding as to why these words were on the whiteboard. So I asked: "Who is Dr Lo? I have never met him," and she responded: "I guess you have another doctor. The in-house doctor is Dr R." My nurse returned with Lovenox (enoxaparin) instructions, as the Xarelto had not yet been approved by the insurance company.
Another woman came in with a form regarding Medicare discharge rights. I was happy to sign off on these rights; I just wanted to leave. Then another woman entered and introduced herself as my case manager. I was about to be discharged, yet this was our first meeting. Dr Lo was identified as my physician on her informational sheet along with Dr R.
I walked out of the hospital after 21/2 days of Lovenox injections and a transition to Xarelto. No wheelchair was available, so the nurse escorted me to the door. I walked 6 blocks uphill to my outpatient physician's office, worried that I would experience shortness of breath. I entered the office to make a follow-up appointment. Fortunately, he was there and I relayed my experience to him. He called the insurance company for approval of the prescription for Xarelto. He said I should have told him I had been hospitalized: I was amazed that the hospital had not notified him of my admission and the admitting diagnoses.
Three months posthospitalization, a nurse associated with my insurance company's nurse advocacy program called. She knew I was hospitalized and my diagnosis but was not aware of my treatment or medication. She said she "found me" and offered to be my advocate and case manager. Another case manager!
In sum, I had never met my assigned physician; my nurse did not know who my physician was; the information on my whiteboard was inaccurate and seemingly meaningless to the staff; the staff was not aware of my progress; and I was subject to frequent and disturbing intrusions from the staff who did not know who I was, placing me at risk for receiving inappropriate treatment. My referring physician was not notified of my admission, and a case manager arrived about 5 minutes prior to my discharge. There was no communication between my inpatient and referring physicians. The insurance company dragged out the approval of my medication; its nurse advocate took 3 months postdischarge to contact me and had no knowledge of what transpired in the hospital or of my present medication, a clear disconfirmation of her advocacy ability.
I cannot say enough for the competent and well-meaning people who provided direct care to me. Continuity of care, however, requires accurate sharing of information with all those involved in overseeing care, including the patient, so everyone understands the progression of the illness and is engaged with the treatment strategy. The system seems to fail in the sharing and conveyance of information and the lack of respect for the patient. I did well despite a lack of continuity of care. Will others be so lucky? I wonder and worry.
Dr Miriam Bender, PhD, RN, CNL, provides a response. Read her article, "Clinical Nurse Leader-Integrated Care Delivery: An Approach to Organizing Nursing Knowledge Into Practice Models That Promote Interprofessional, Team-Based Care," in this issue.