Newsflash: Acute Care system fails an older patient, reflections from a relative

Ron Murphy is a software designer, he blogs at ronmurp.netthumbnail

An older patient presenting acutely to A&E in an unwell and frail state can erroneously be assumed to be at their baseline pre-morbid state, with some additional new complaint like a “UTI” as an over-riding diagnosis. My active and mobile mother was reduced over a period of three months to a delirious crumpled wreck who didn’t know what day it was because of a persisting UTI that had not been dealt with. Her past medical history was complicated: stroke, heart attack, pacemaker, diverticulitis, arthritis, diabetes not well controlled, kidney function not right … you get the picture. But still, before the UTI she was sharp and active.

What follows is a brief account (you don’t want the detailed version) of what happened in A&E on three failed visits.

1st A&E attendance – Finally seen after a wait of a couple of hours. Labelled as a possible  “fit” for outpatient management. My mother who was a diabetic was than left slumped in chair for another two hours, with no drink or food offered; she was too unwell to get up and  get her own. UTI? Need the toilet often? Good luck with that.

When I arrived she was confused, and in tears, “They just left me here.” And so it seemed. I found a nurse, but a change of shift meant she knew little other than the patient had been discharged. Better to get her home than hang around for an hour for more information that wouldn’t change anything.

2nd A&E attendance – She waited for an hour or so, sat in a wheelchair, in a corridor, in pain. We’re seen at last, and a chance to lie down is a relief for her. I give the history and concerns about a persistent UTI. After blood tests the conclusion is that it’s a UTI (no kidding). More antibiotics and we’re off home to await an outpatient appointment. I’m assured this is all that’s needed.

3rd A&E attendance- The GP, running out of options, writes a detailed referral letter requesting a thorough investigation in hospital. The letter is intended for the medical team, to bypass  A&E. No chance. She waits for a couple of hours, slumped in another wheelchair. Asking nurses about progress gets the response that someone will be with you shortly. Shortly doesn’t come anytime soon .

Why did the GP letter leave the patient in the A&E waiting queue when it was supposed to get us onto an assessment ward? Why do nurses walk past someone in distress and clearly unwell? Too common in A&E to draw attention? How many times can I interrupt staff to attract attention without stopping them doing their job, without being evicted for being a nuisance?

At last, we’re in an A&E cubicle and the patient can actually lie down to relieve the abdominal pain from the UTI. The assigned nurse recognises the sorry state of patient, spots dehydration and wires up a drip. Why did this nurse perceive with one look problems overlooked by others?

A doctor arrives, and I relay the story again. There’s prodding and poking of an exhausted patient. I ask about admission to a bed. Oh, sorry, this is an A&E doctor who has no say in the matter. A member of the medical team will be along, ‘shortly’!

Eventually one arrives. Long story given, again. So, five hours after arrival we’re off to the assessment unit. All the right noises are made – yes the patient does need attention, but don’t worry, we’re arranging an  ultrasound, procuring bloods for this and that, improving the kidney function so she can undergo a CT scan, “should be in for a few days”. Great, that should allow them to identify the problem.

Next day I call. She has been moved to another ward: “Looking well, ready for discharge. Pick her up at 4pm.” What about the few days scanning and testing? The nurse doesn’t know anything other than “it’s a UTI that can be treated in outpatient”. The patient, dismayed, just wants to go home. Not the time to wait to speak to the doctor.

Within 24 hours she is looking worse than ever. Second day, she collapses in the bathroom at night and comes to the next  morning. Next day, a visitor finds her collapsed again and the GP is called.

Finally she is admitted, treated  four weeks, and diagnosed with an atonic bladder retaining about 800ml of urine. The UTI was causing problems with diabetes control, resulting in high blood sugars – great culture environment in the bladder. All of this was missed on previous admissions.

Three months suffering; one month of treatment. Opportunities missed. Mistakes were made.

Did I tell you about the outpatient experience? Or how about the discharge fiasco? Or the lack of appreciation of geriatric limitations? Stories for another time perhaps.

Ron writes in response to Sean Ninan’s recent blog Streamlining Admissions, telling the other side of the admissions story.

7 thoughts on “Newsflash: Acute Care system fails an older patient, reflections from a relative

  1. There are many great patient experiences and that is wonderful, but your account is sadly very typical of a large number of patient journeys which are very far from perfect. I could relate my late father’s apallingly negligent treatment, but his ‘experience’ is only one of dozens upon dozens of similar cases I’m aware of.

    EVERYONE who endures poor care needs to speak out about it.

  2. Sadly familiar tale. I experienced similar issues when accompanying my Grandmother to A+E on several similar trips, she had dementia which considerably complicated matters and I was just thankful that I could be there as her advocate. Our record was 13 hours from the time she was seen at the local community hospital and referred to the District General hospital for assessment to her actually being admitted to a bed on the ward. Things need to change.

  3. Sadly these experiences will be familiar to many health care professionals involved with managing older patients in acute settings. What is clear from this description and those I hear from patients and carers on a regular basis is that our emergency care system is not designed to meet the complex needs of older patients. All too often, hospital admission is labelled as a ‘failure’ of community care, and the pressure is considerable to transfer a patient out of the ‘acute’ hospital environment as soon as a diagnosis has been made and a treatment plan has been initiated. Urinary tract infection is a common problem in older female patients, and is listed as an ‘ambulatory sensitive’ condition – one which should be managed without overnight stay in a large proportion of patients. However as this case illustrates it can mask a multitude of more complex problems which may take time to unmask.

    As ever, communication is key and needs to be a two-way dialogue; failure to explain the nature of a problem or a treatment plan at the time of discharge may lead to Readmission to hospital; however failure to listen to the perspectives of those involved in the patient’s community care can be equally damaging. The involvement of multiple teams and frequent patient moves creates challenges within hospital in ensuring that the necessary information is passed on; this case illustrates how easy it is for planned actions not to be carried through, or for the reasons behind changes in the care plan not to be adequately communicated.

    However we do it, we need to do this better: emergency departments and acute medical units are busy places, but being busy must never be an excuse for poor care or poor communication. We need to redesign our systems to optimise continuity and improve communication, to reduce duplication and reduce delays. Many have already started to do this, and these are central themes of the RCP’s forthcoming ‘Future Hospital Commission’; but there remains much work to be done if we are going to improve the experience of patients and their carers in the acute care setting.

  4. Dear Ron
    On the face of it this sounds like a care system delivering well short of the standard we could all expect. I have to say “on the face of it” because when i have investigated all manor of complaints and legal claims, it is always important to explore the story from all sides. However, if events are as you say, then in my view the system has let your mum down. What I would love to know (and i realise you mightn’t be able to answer this) is why on earth if the GP had made a point of referring her to the on call medical team or medical assessment unit, she ended up (twice) being processed through A&E as if there had been no referral
    David Oliver

  5. I see this happen all too often. At least they identified the UTI. I can’t tell you how many times I’ve been called for a psych consult on an inpatient who has 10 different specialists seeing him/her, but nobody ever checked for a UTI as the cause of altered mental status. If Medicare would make ruling out a UTI a condition for payment, watch how fast clinical practice would change!

  6. Pingback: Unco-ordinated care: we need named responsible clinicians in hospital too! | British Geriatrics Society

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s