Beyond the Dashboard
As a hospitalist, I am accustomed to dashboards measuring my performance by length of stay, number of hours in observation, and catheter-acquired infections. When these metrics are unfavorable, the dashboards are followed by a call from a case manager, “Can Mr. Jones be upgraded to inpatient status?” Then comes a doc query asking me to clarify if Mr. Peterson’s catheter was infected on admission. I’ve come to view these administrative interruptions as part of the job. I frequently grumble about their negative impact on patient care. Still, I didn’t fully appreciate how serious those consequences could be until these bureaucratic speed bumps led to the death of my uncle.
The first call I received about my uncle’s hospitalization was straightforward. “Your uncle had a fall,” my mom relayed to me, “he broke his kneecap.”
My uncle had a progressive neuromuscular disease, and over the years, his mobility had significantly deteriorated. A misstep at home had led his leg to buckle, and the force of landing on the knee had resulted in a non-operative patellar fracture.
A day or two later came an update, “He’s going to need to go to rehab. They’re waiting on the insurance company to decide which one,” my mom reported.
Reading between the lines, I understood my uncle’s medical team was waiting on insurance authorization for acute inpatient rehab. I immediately knew he would not be a candidate. Though the slowly progressive nature of his disease had allowed time to retrofit his home to be handicapped accessible and arrange in-home caregivers, it would never allow him to tolerate the intensity of therapy required to be approved for inpatient rehab. I thought we were wasting time waiting on an authorization that would undoubtedly be denied.
I’m all too familiar with the prior authorization process and the number of excess hospital days it leads to. One absurd example that comes to mind is a prior authorization that took 13 days spanning the Memorial Day holiday weekend. In the end, my patient spent twice as many days waiting on authorization for rehab as he spent medically necessary days in the hospital. Thankfully, no harm came to him.
My uncle was not so lucky. While awaiting the prior authorization, he contracted COVID-19. This was 2023; hospital-wide masking mandates had long been lifted, and there was no routine testing of admitted patients. There is no way of knowing if an asymptomatic staff member, a visitor, or a fellow patient had been the source of infection.
The same neuromuscular disease that had led to his initial fall made it hard for my uncle’s respiratory muscles to keep up with the increased work of breathing COVID-19 brought. As he continued to worsen and progressed to respiratory failure, it became clear he would never make it to rehab.
Our family was fortunate that his mind remained clear, and he was able to voice his wishes until the end. When faced with needing mechanical ventilation, my uncle chose comfort measures instead.
A patella fracture. Days waiting for insurance authorization. COVID-19 acquired in the hospital. Death from respiratory failure. A new patient-centered perspective on the meaning behind those dashboards.
2024 National Hospitalist Day Submission
Dr. Caputo-Seidler (@jennifermcaputo) is a hospitalist in Tampa, Fla. Her interests include medical education, narrative medicine, and civic engagement. Her writings have appeared on KevinMD, STATNews, and SheMD.