Critical Thinking

Quicker and Sicker

I recently accepted a position on adjunct faculty at Duquesne University teaching a Differential Diagnosis course.  Within the text I am utilizing for the course, I came across the phrase “Quicker and Sicker“, to describe the current landscape of US healthcare (its actually not a new concept and has been around for around 25 years).  In a nutshell, this term indicates patients are being discharged from our hospitals more rapidly, making them more unstable in their post-acute care environment.  This leads to the increased necessity for competence in medical screening by those who may interact with them after point of discharge.

While the concept is not new in the United States, I was struck to learn that the clinical culture is much different in China.

See my current class includes a group of students from Shanghai, who are completing a graduate degree in rehabilitation sciences. While discussing this topic, they were shocked to learn that “same-day” surgeries exist in the United States.   They stated in China, you will be hospitalized for 1-2 weeks following a total joint replacement, 2-3 days following a rotator cuff repair, etc.  During this time, your care is monitored closely by the physician and rehabilitation begins in the hospital.

So what is best approach to care?  From my understanding, this is quite a complex question that involves everything from culture to payment models and a load of variables in-between.

In all of this I’m wondering…Do you suspect the landscape is becoming “too quick” and discharging patients who are “too sick”?

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5 replies »

  1. I think maybe there’s a happy medium in there somewhere when comparing length of stays between US and China. Currently working in home health I do encounter people who I think were D/C’d too soon, they often have a lot of unanswered questions regarding their surgery, also I think some rehab in the hospital is beneficial short term to establish a routine before people return home and possibly fall into a comfort zone where mobility decreases. On the flip side, I think staying in a hospital too long could be detrimental to possible psychosocial aspects of recovery (people often start improving/feeling better just being in their usual environment). It’s also hard to rest in hospitals with nurses, various MDs, rehab professionals etc. coming into the room all hours of the day/night where recovery could be impacted.

  2. “Do you suspect the landscape is becoming “too quick” and discharging patients who are “too sick”?

    I recently spent time in 2 separate meeting this week discussing nursing turnover/retention in the home care setting. The conversation quickly moved from an ‘us’ problem to a ‘home care’ problem. Most participants in the meeting had experiences that would indicate that home care nurses are nomadic people and ‘come and go’ regardless of the agency. Some proposed solutions included reducing documentation burdens, improving technologies used and financial incentives for productivity. I thought that each of these strategies would fall short.

    One party noticed that PT/rehab turnover was far less compared to the nursing staff and they wondered aloud why that might be. My response was that PTs are trained to be critically thinking and autonomous clinicians. We go to school with these objectives in mind. We are trained to be direct-access clinicians, and while the focus of the outpatient may be different for the outpatient PT, they are prepared for a variety of patients requiring varying levels of care.

    Nurses are trained differently, to work in offices/hospitals under direct supervision of – and with instructions from – PAs, NPs, MDs, or DOs. Nurses are trained to assess and follow specific pathways – they are technicians. Experience engenders them with increased skill-levels in their areas of expertise, but that expertise is usually narrow and not a global as is required in home care.

    Yet, throughout the country, a greater reliance is being placed on nurses in the community to provide care for progressively more involved/complicated patients. In turn, nurses are being stretched thin. They are under significant stress as they are perpetually required to work as hard, with more acute and challenging patients, as they would in the hospital with greater responsibilities, less support and limited input and responsiveness from primary-care NPs and MDs who are being over-worked in their own offices. This is a recipe for disaster. In my estimation, the communities are woefully prepared for the influx of acute patients that are to be receiving care outside of the hospital setting.

    This, in my (anecdotal) experience, is why the health care system is ill-prepared to get sicker patients out of the hospital quicker. With bundled payments on the horizon, patients are going to be moved out of the hospitals sooner and are incentivized to avoid short-term rehab for cost savings. The problem, in my estimation, is that the care for these patients is being handed over to staff in the community who are going to be inadequate (in many respects) when trying to handle the demands of the patient in the home. In the hospital, an MD has academic and practical experience in thinking on their feet and assessing the patient with a systems approach in a way that most providers of home care do not. Such an appraisal is not available in the home care setting – there is a widening gap between the care the patient needs and the care that the community is capable of providing.

  3. Definitely an interesting thing to think about. I had no idea places like China would be appalled by “same-day” surgeries – makes me want to look into what other countries’ times are for certain surgeries. I wouldn’t be surprised if we’re letting people out too quickly for most of the world’s tastes.

  4. Clinical pathways and standards in practice and educational systems in Asia are quite different from the United States. Many educational systems in Asia still rely heavily on “book” knowledge (which may also be outdated) alone and not enough on critical thinking skills and forward-thinking methods. This makes it difficult for the entry level practitioner (sometimes, even a seasoned practitioner) to have a progressive mind-set or have the ability to challenge their current (clinical) practices. Although some institutions in Asia may be striving for evidence-based practice, there is really no indication that the landscape will change soon there soon. In addition, much of the payment system in the hospitals and other medical services are out of pocket. The length of stay may also be driven by how much a practitioner and institution can gain financially.

    For us here, the landscape may be changing too quickly and for the wrong reasons; Are we discharging our patients too soon because of superior medical advances or because insurance is dictating our timeline? Can we continue to provide quality patient care, if our hands are tied by external factors such as insurance limitations?

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