The Hospital: A Very Expensive Pathway of Least Resistance for Broken Systems

Recently, we discharged an, intellectually disabled patient after a stay of 257 days in the hospital. 

The patient, who was over 50, originally presented to the Emergency Department with her group home caregiver. In the several months prior she had been in and out of the hospital and psychiatric facilities with behavior related issues such as throwing herself on the floor. The reason for her admission to the hospital was that she was acutely unable to walk. She was sent to our Integrative Care Unit with a diagnosis of an infection. 

Her infection was treated, and she returned to her previous state of health after a few days of care- the work of our Integrative Care Unit was done. 

And then the waste began since she no longer needed to be in the expensive setting of the acute care hospital. GBMC has no inpatient psychiatric unit to provide treatment to a patient like this. For the next step in discharge, the question then became whether she would go to subacute rehab, long term care, or back to her group home. She is financially supported by the State, through the Maryland Developmental Disabilities Administration, since she is not capable of supporting herself.  

During her hospitalization the patient would frequently act out, screaming, cursing, and exhibiting other attention seeking behaviors. Due to her high acuity behavioral needs, she was initially recommended to go to a neuropsychiatric disorder unit, but a bed was not available. Then the care team learned that she had exhausted her lifetime Medicare days but that her Medicaid benefit had not yet kicked in. By the time she became Medicaid eligible roughly two months later, the team learned that she could not go to the neuropsychiatric unit and she would have to be admitted to a state operated facility. 

We know that the longer someone remains in the acute care hospital, the more at risk they are for hospital acquired conditions. This patient developed a hospital acquired condition and was transferred to another unit where she stayed for 36 days. She was then transferred back to the Integrative Care Unit.

During this time, planning for her discharge continued. Her family was hoping for a group home placement closer to where they lived. Over the next few months, the patient was declined by several facilities as they were not able to accommodate her needs. 

During her sixth month of hospitalization a facility reviewed her case and subsequently approved her for admission. However, the facility had not yet been approved by the Developmental Disabilities Administration, so the team continued to wait. It was only recently that the team learned that the facility had been approved and they were finally able to plan for her discharge. 

The Integrative Care Unit Team was incredibly resilient in caring for her. They took turns reading books to her. The patient loved our volunteer guitarist Chris Maggitti and would sing along when he played for her. Nurse Manager Carolyn Keller took her to our beauty salon in the West Pavilion twice for a haircut during her stay, which was challenging due to her behavior. Lisa Palmer, our hairstylist, was patient and compassionate. Dr. Rebecca Moore from psychiatry managed the patient’s medications which at times needed to be adjusted daily to control her behavior. Dr. Moore had a wonderful relationship with this patient. Dr. Rachna Raisinghani, the unit’s Medical Director, spent much time assisting to find a placement for the patient.  Sarah Sackett from social work worked tirelessly, day in and day out to advocate for her and to coordinate the safest and most appropriate placement. Our Hospitalist Team also deserves recognition for being there to support the patient through her entire stay and for attending to any issues that arose. The entire Integrative Care Team went above and beyond to provide kind and compassionate care to a patient who was incredibly trying to care for, as GBMC does not have the resources to provide inpatient psychiatric treatment or residential psychiatric care. 

The case underlines the need for redesign of the behavioral health system and for the simplification of our health insurance system. The acute care hospital is often used as the pathway of least resistance to care for behavioral patients and the public should demand that leaders step up to find a better way. 

Please join me in thanking everyone that cared for this patient. They were determined to make things as good as they could even though the patient was not in the right setting. We are indebted to all of them. 

Back to Life

On Tuesday afternoon, I had the privilege of being part of a special event with a grateful family whoselife-altering experiences played out right here at GBMC.   

Back in early July, Kathy Patten was slated to play golf with family and friends when she got the call that her daughter, Stacey Fifer, was going into labor at our hospital. Due to the easing of COVID regulations for a patient’s family and friends at that time, Kathy decided to join Stacey and her son-in-law, Richard Fifer, in our pre-birthing room.

After arriving to attend the birth of her grandchild at GBMC, Kathy started to not feel well. Stacey became worried about her mother, and she called her nurse Kiana Dowdy, RN, to have her mom checked out. Kiana evaluated Kathy, put her on a cardiac monitor, and called for the Rapid Response Team. The team decided to take Kathy to the Emergency Department for further evaluation.  As they were leaving Labor and Delivery, Kathy went into cardiac arrest. They began CPR and called for the Code Team.  Drs. David Vitberg and Ari Zaiman ran to Labor and Delivery with the rest of the Code Team. They were joined by Dr. Dov Frankel from the Emergency Department and they managed the Code. The Labor and Delivery charge nurse Michelle Lukehart, RN, along with Rebecca Rubin, NP, took on critical roles during the code and also in assuring that all of the patients in the Unit got excellent care. Melanie Dowell, the Parent Education and Doula Program Manager, stayed with Stacey to assure that she was OK. Meghan Shackelford, NP, the Director of Advanced Practitioners, assisted the code team in L&D and also followed the team to assist in ongoing stabilization in the ED. After 48 minutes of cardiopulmonary resuscitation (CPR), and just before the Team was going to end the Code, Kathy’s heart began to beat again, and she awoke. After further outstanding stabilization, by Dr Frankel and our ED team, Kathy was then transferred to the University of Maryland St Joseph Medical Center and there she received wonderful cardiac interventional care and was set on a pathway for cardiac rehabilitation. 

Despite her intense worry about her mother’s condition, Stacey’s baby was on its way into the world, and she continued with the delivery. Hoping to have a natural childbirth, the baby became stuck in the birth canal requiring an unexpected caesarian delivery and a neonatal resuscitation. After a relatively brief stay in GBMC’s Neonatal Intensive Care Unit (NICU), Alora is a happy, healthy baby girl. 

Kathy, who essentially came back to life following this astounding near-death experience, is now fully functioning and enjoying her life as a mom, grandmother and grateful former GBMC patient.  

At this week’s event, Kathy, Stacey, and other Patten and Fifer family members expressed their gratitude to the GBMC team that brought Kathy back to life and who served Stacey and Alora so well. Drs. Vitberg and Frankel reflected on the outstanding work of all involved, starting with our Labor and Delivery staff and including all those who assisted. Dr. Vitberg commented that our staff has been under so much stress since the beginning of the pandemic and following the cyber-attack and that this life-saving event was so helpful to replenish the energy and spirit of all the GBMC staff involved. 

This story further highlighted to me that the hard work of clinicians who care and are experts in their field is necessary for outstanding performance. Well-designed systems are also necessary, as is training as a team for infrequent and life-threatening situations like the one the team encountered with Kathy that day in July in Labor and Delivery. Dr. Vitberg and his team train regularly in our simulation center and GBMC recently earned the official designation as a Resuscitation Quality Improvement (RQI) Lighthouse Organization for our adoption and consistent use of an innovative CPR training program. GBMC is the first hospital in Maryland to receive this designation and to use the RQI system to train nurses and other clinical providers in CPR. This recurrent training and testing of CPR competency played a role in keeping Kathy’s brain oxygenated when her heart was not pumping for 48 minutes!

I am in awe of the entire team that was involved in saving Kathy and in serving Stacey and Alora as well. Great work and Thank You!

Thank-You EVS Team
This week, we are celebrating Environmental Services (EVS) and Housekeeping Week. After more than a year on the front lines of the COVID-19 pandemic, EVS and housekeeping professionals have served as a source of reassurance for patients unable to see loved ones, while maintaining rooms to the highest standards of cleanliness.  Our dedicated EVS and Housekeeping staff work day and night to keep our facilities clean and to prevent infections. They replace linens, remove regular and medical waste, and take care of unscheduled or emergency housekeeping services such as spills or event set-up. Please join me in thanking all our colleagues in EVS for their great work especially during these challenging times!

Neonatal Nurses Day
Last Wednesday (9/15) was Neonatal Nurses Day. We are very fortunate to have such a high-level NICU to care for those babies who are born too small, too sick or too soon. Please join me in thanking this exemplary group of nurses for all they do.

Yom Kippur
Yom Kippur, also known as the Day of Atonement, was this week and is the holiest day of the year for those of the Jewish faith. Yom Kippur has a unique place in the Jewish calendar. Following Rosh Hashanah – the Jewish New Year – Yom Kippur marks the end of the 10 days of repentance, which is a time to reflect on wrongdoings and pledge to do better as the New Year begins.

What about the Flu?

The 2021 influenza (flu) season is right around the corner. To predict how much influenza, we will see in the northern hemisphere, we look to the experience in the southern hemisphere. The good news is rates of the flu have been very low in the southern hemisphere just like last year. The biggest single reason for this is drop in cases is people are travelling less. They have also been wearing masks and practicing social distancing. So, there is a good chance that we will again see fewer than the average number of cases than we usually see in a year. 

However, experts worry that our antibody levels against influenza A in particular, may be low since we have not had much exposure to the virus over the past year or two. They are concerned, therefore, that we may have rapid spread of the flu virus once it becomes more widespread in the community. 

We can’t really know for sure what the flu season will be like, but we do know what we can do to limit the spread of the virus and keep ourselves healthy. Step 1 is to get vaccinated as soon as the influenza vaccine becomes available. Then, it will help to wear a mask, wash our hands often, and maintain social distancing if we do have outbreaks. Sound familiar?

Soon we will be announcing our 2021 employee influenza vaccination plan. I want to thank Sophia Powell, MSN, FNP-C, Occupational Health Director for the GBMC HealthCare system, for her hard work on the plan.  Next month we will be offering our employees their flu shots at several clinics to be held in our Civiletti Conference Center. Stay tuned for the specific clinic dates and times in the coming weeks.  

Happy New Year

Earlier this week was the beginning of Rosh Hashanah, the Jewish New Year. It is a holiday at the “head of the year” that comes at the close of the harvest, when the Jewish community of faith focuses on repentance.  L’Shana Tovah! Happy New Year 5782!

Remembering 9-11

As a nation, this coming Saturday we will recognize the 20th anniversary of the tragic events of September 11, 2001.  Like all Americans I was stunned by the events of that day and the great loss of life. I was somewhat buoyed by the phenomenal stories of those who gave of themselves for others in the days and months after 9/11.

As we look back at the terrible tragedy that occurred and the brave first responders who showed tremendous heroism in the hours and days thereafter, let us join together and work for peace and justice in the hope that events like these never happen again. Thank you! 

A Big Day

Today is a day of celebration for GBMC and our community. After years of planning and changes to our master facility plan, with the realization that some of our inpatient beds were no longer meeting our needs, we finally broke ground on The Promise Project. You can watch the video from the ceremony here.

This construction project is necessary to move us towards our vision of being the community- based system of care that can deliver to every patient, every time, the care we would want for our own loved ones. The project exemplifies our commitment to the people we serve. 

The Promise Project will bring two historic advancements to GBMC—the replacement addition for inpatient beds, a new parking structure and the new home of the Sandra and Malcolm Berman Cancer Institute at GBMC.  These facilities will help GBMC continue to lead the way into the future of patient care in the Greater Baltimore community.

When GBMC opened in 1965, our medical center was marveled at by the community – private patient rooms were unheard of at the time.  Yet, 55 years later, these same patient rooms have lost their wow-factor. Out of a growing need for more spacious rooms on our medicine units that can accommodate team-based care, advanced technology, and visits from loved ones, we began planning for a hospital addition, and the Promise Project  began. 

Throughout the past decades, we have built a true system of care form birth to death, and our healthcare system is thriving. But now is the time for our campus facilities to be modernized. Because of the support of our community and elected officials, we can continue to improve our hospital and increase the services we offer. Now is truly the time for The Promise Project.

The road to today’s celebration, however, has been filled with a few challenges.  Much work and planning had to take place before the shovels hit the dirt.  First, a certificate of need application was created and approved, funding had to be secured, plans had to be developed, and numerous permits had to be filed. Of course, our team had to do this during the pandemic.

There are many people that have made today’s historic event possible.  I want to thank our chair, Frederick M. Hudson, and the Board of Directors who represent all the owners of GBMC, the diverse community cared for by our System.  I would also like to extend my gratitude to Dr. John Saunders, and all of those who have worked on fundraising, as well as longtime supporters Sandra and Malcolm Berman and the Volunteer Auxiliary for their leadership throughout this transformational campaign.  Let me also thank Stacey McGreevy, Vice President of Support Services, and Russ Sadler, Director of Facility Planning, Design, and Construction, for their oversight of the planning and actual construction, and Laurie Beyer and our finance team for their work in accessing the needed capital. I’d also like to congratulate our Vice President of Philanthropy and Marketing, Jenny Coldiron and her entire team for the overwhelming accomplishment of raising over 38 million dollars – 76 percent of our fundraising goal for the project. These funds are crucial in bringing the Promise Project to fruition.

Extending Gratitude Beyond Our Small Piece of the World
While GBMC is celebrating its past, present, and future, we cannot forget the servicemen and women who have made the ultimate sacrifice for our Country and our freedom. Our prayers go out to the families and loved ones of our fallen service members in Afghanistan. Our thoughts and prayers also go out to those who are struggling in the aftermath of Hurricane Ida. In times like these, we are all thankful for the support that surrounds us every day.

One Less Factor in Vaccine Hesitancy

Earlier this week, I was delighted to hear the Food and Drug Administration (FDA) granted full approval to Pfizer's COVID-19 vaccine for use in people ages 16 and older. 

It is clear the Pfizer vaccine—along with the Moderna vaccine—is safe, highly effective, and the strongest weapon we have to combat this virus. The FDA had already studied the early data before giving emergency use authorization, and has now gone through its full, rigorous process to grant full approval. The Pfizer vaccine is probably the best studied vaccine in the history of FDA approvals in that hundreds of millions of doses have been given around the world with very few significant side effects. 

This latest surge in COVID-19 patients we are experiencing in emergency rooms, outpatient clinics and hospitals across the nation is primarily due to unvaccinated people. This is very concerning since we are still not sure what the fall will bring with back-to-school activities and the potential spread of COVID-19 among our children. In a recent poll, 30 percent of unvaccinated people said they were holding off on getting the vaccine until the FDA had granted full approval, so we are hopeful this FDA approval will encourage those on the fence to get vaccinated to protect themselves and others.

With the Delta variant surging, there has never been a better time to get vaccinated. GBMC is requiring all GBMC HealthCare employees, contractors, independent medical staff members, volunteers, and learners without a medical or religious exemption to be vaccinated, and we have had to speed up this deadline after the Governor’s mandate that all hospital and nursing home employees be vaccinated by September 1. The GBMC HealthCare community is required to be fully vaccinated, or submit an exemption request, by October 1, 2021.

Congratulations!!
I want to congratulate our Primary Stroke Center which, under the leadership of Ellen Deibert MD, FAHA, Medical Director of our Stroke Center and our Chief of the Division of Neurology, and Aaliyah Franks, RN, recently achieved the 2021 American Heart Association’s (AHA) Get With The Guidelines® (GWTG)-Stroke: Gold Plus with Target: Stroke Elite Honor Roll and Target: Type 2 Diabetes Honor Roll. 

These awards recognize hospitals that meet specific quality measures for the diagnosis and treatment of stroke patients. Despite challenges in the last 18 months presented by the pandemic and a cyberattack, the Primary Stroke Center has been able to maintain extraordinary award levels with the American Heart Association for stroke and diabetic stroke patients.

The awards are a testament to our Stroke Center’s strong commitment to reliably provide care according to nationally recognized guidelines built on the latest scientific evidence.

I want to thank all our clinicians for their hard work and dedication in achieving this level of performance. Great work and congratulations!

More Changes on Our Campus

This week I want to provide you with another update about campus changes as we begin construction on The Promise Project. 

In June, we began with the creation of a temporary main entrance (until the new addition is complete) and we then continued with the closing of the Rose parking lot to address the need for a staging area for construction. 

On Monday, August 23, the main entrance of our hospital will close, and we will begin using the temporary main entrance in the Sherwood loop.  Since the three-story addition will be built in front of our current main entrance, we need to close it now. As we cordon off space in front of the main entrance, we will lose some handicapped parking spots. We have taken a number of steps to limit inconvenience to our staff and patients.

• We have added another valet parking location (we added a valet attendant by the Daffodil garage last month) at the Sherwood loop. We have also added additional handicap spaces in the Sherwood Loop area and in our Lily Parking Garage. There are also additional wheelchairs and dedicated transporters to serve our patients and visitors with mobility issues. We recommend that our patients utilize the Tulip and Lily garages since they have abundant parking spaces. As I have pointed out in the past, the Lily Garage is closer to the main entrance than the Rose lot and is connected to the hospital to protect employees, patients, and visitors from the elements.
• We have set aside many parking spots for our patients. Most of our staff have refrained from parking in those spots and historically we have not enforced our no-staff parking rule in patient spots. Sadly, some of our people have been parking in patient-only spots so now we have begun to enforce the rule.
• In order to make it easier for folks to get around the campus, we added a new shuttle bus this past Monday. Current drop-off and pick-up locations include: the William E. Kahlert Physicians Pavilion North, Farmhouse Hill, Physicians Pavilion West Main Entrance, and the Sherwood loop.  Stops are every 15 minutes from 6:30 a.m. to 7:00 p.m. on weekdays.

The first two levels at our Daffodil Garage will remain closed until October 31. The garage is open for our patients, but we are asking staff to park in the Tulip garage. Thank you to all for your patience as we continue the repairs. 

Lastly, our new Ambulatory Imaging Center will open in mid-September in Physicians Pavilion East at the former location of the Kroh Center for Digestive Disorders.

The official groundbreaking for the Promise Project will occur on Thursday, Sept. 2. We will continue to update you on necessary changes to the campus as the construction progresses. 

Thank you!

Outstanding Redesign Work in the Emergency Department

In the early 20th century, as medical care was progressing, and therapies became available that actually improved patient outcomes (like antibiotics and sophisticated surgical procedures), the Emergency Room became the place to go for serious injuries or acute medical problems. Later in the century, as medical care became more complex, and there was more specialization in medicine, the Emergency Department (ED) became a sort of “catch all” for anything that couldn’t be handled anywhere else in the system. If the doctor’s office was closed or the doctor was already too busy, patients were sent to the ED for real needs that were not truly emergencies. In 1965, with the advent of Medicaid and payments below what private practicing doctors would accept to cover the costs of running their practices, ED’s became the place where poor people went for care, not because they wanted to be there for non-emergencies, but because many doctor’s offices would not accept Medicaid. And finally, the aging of the population is another reason  Emergency Departments here, and around the country,  continue to be in high demand.

For the last few decades, ED’s have been under siege. The professionals working there are incredibly dedicated and well-trained. They work extremely  hard, but the system is not designed for efficient flow. 

The GBMC ED is operating under the same stressful situation as other ED’s. We, however,  have an advantage over most ED’s --  outstanding leadership. Dr. Jeff Sternlicht, Medical Director, and Mark Fisher, RN, Nurse Manager, have fully embraced our vision and have become quite proficient at redesign. With the help of our performance improvement advisors, they have redesigned much of the care of ED patients who don’t need to be admitted to the hospital.

There are three areas to focus on to improve patient flow in the ED:

1. Input: You can work to make sure that only patients with emergencies come to the ED. (This is the work of primary care, specialty physician offices, and other community providers.)

2. Throughput: You can work to reduce waste in the processes from check-in to discharge home. (Clearly the work of the ED team.)

3. Output: You can move patients to an inpatient bed as quickly as possible once you know they need to be admitted. (This is the work of the inpatient teams led by our hospitalists or inpatient specialists.)

Jeff and Mark have been happy to work with our patient-centered medical homes on reducing non-emergent visits and to work with our Department of Medicine in particular, to move admitted patients to the floor faster.  They have not wasted any time  getting in action to redesign the work of assessing and treating those who they think can be sent home – the throughput work. 

So, what have they done so far? 

Redesign of Triage:  They added a medical provider in triage to connect the patient to a provider sooner. This is allowing the Emergency Department to start care on entry, during busier times of the day. 

Implementing a Protocol Bay: This allows labs and IVs to be started right after triage. This gets blood sent to the lab sooner and test results back quicker for patients even before they get to a treatment space.

Implementing a Rapid Assessment Zone: This allows patients with lower acuity needs to have their care started in the waiting room even before they get to a formal treatment bed.

Yesterday on our Lean Management System rounds, Katie Koestler, RN4, presented the ED’s results so far. I am so proud of Jeff, Mark, and their team. They are doing phenomenal redesign work and moving us faster toward our vision. They are clearly improving the care experience and reducing wasted time in the ED. Please thank the members of the ED team when you see them!