Off the Charts

It’s a common scenario: a 90-year-old resident of a U.S. nursing home — call her Ms. B. — has moderately advanced Alzheimer’s disease, congestive heart failure with severe left-ventricular dysfunction, and chronic pain from degenerative joint disease. She develops a nonproductive cough and a fever of 100.4°F. The night nurse calls an on-call physician who is unfamiliar with Ms. B. Told that she has a cough and fever, the physician says to send her to the emergency room, where she’s found to have normal vital signs except for the low-grade fever, a normal basic-chemistry panel and white-cell count, but a possible infiltrate on chest x-ray. She is admitted to the hospital and treated with intravenous fluids and antibiotics. During her second night in the hospital, Ms. B. becomes confused and agitated, climbs out of bed, and falls, fracturing her hip. One week after admission, she is discharged back to the nursing home with coverage under the Medicare Part A benefit. The episode results in about $10,000 in Medicare expenditures, as well as discomfort and disability for Ms. B.

There is an alternative scenario, however . . .

That’s from an article in NEJM called “Reducing Unnecessary Hospitalizations of Nursing Home Residents.” In any health care system of as much complexity as ours, there’s bound to be a huge amount of waste. The article gives a good example of how the skills of NPs might be put to excellent use both saving a lot of money for Medicare and making the lives of nursing home residents a whole lot nicer. It may be cheaper, but it’s not “rationing”—it’s rational.

Now a matter of language rather than money: the Viewpoint essay by Kathleen Thies in the October issue of AJN is about the use of military language to refer to nursing staff. Here’s how it begins, and you can click the link to read the whole article, including the author’s suggestion for an alternative terminology. We’d love to know whether the author’s perspective resonates with you:

How often have you heard the term frontline staff used to refer to direct care nurses and others working at a patient’s bedside? It conjures images of the great world wars, of soldiers marching across battlefields to fight the enemy. The infantry are invariably young, dispensable, interchangeable. Commands are issued by generals and passed down through the ranks. No questions are asked.

Blog roll update: We’ve added some interesting new blogs to our blogroll (they’re not new blogs, actually, just new to our blogroll). A few of them are by MDs, such as The Carlat Psychiatry Blog and Movin’ Meat, and a couple of are by nurses, such as madness: tales of an emergency room nurse, which has a good short post about why it doesn’t always help to be a nurse when your family member is in the hospital (there have been a few posts on this topic lately in different venues, I think?). Also added: The Nursing Ethics Blog, which is run by two people, a nursing professor/ethicist and a philosopher. It should be interesting to explore.

As the editor of the Reflections column (and this blog), I read hundreds of submissions each year about dying patients, with a subgenre of submissions devoted to dying infants or miscarriages. Read the rest of this entry ?