Treating “Since You Are Here” Syndrome

In a recent article in the prestigious New England Journal of Medicine, a rheumatologist at a teaching hospital lamented about “hospital problems,” a recent phenomenon wherein patients are not allowed to stay in the hospital when they no longer have medical necessity for hospital care, even though the physician may want to keep the patient longer to wait for test results or get them prepped for a test.

He proceeds to blame this loss of physician autonomy on the development of hospitalists as a specialty, the increasing employment of physicians by health systems, and “business majors.” His patient, who required a kidney biopsy but no longer required hospital care, was not allowed to stay the three days necessary to allow aspirin to clear, in order to safely proceed with the procedure.

What this physician may not realize is that in many if not most hospitals, patients requiring hospital care are being held in hallway beds in the emergency department for hours or days due to lack of inpatient beds – and patients requiring non-emergent surgery are having their procedures postponed due to lack of inpatient beds for their post-operative care. This lack of inpatient bed capacity is multifactorial, with limited capacity in post-acute care settings and patients’ lack of ability to afford such care when needed, resulting in patients occupying acute-care beds when that care level is not necessary.

In addition, hospitals are often constrained in their ability to adequately staff ancillary departments such as physical therapy, extending patients’ hospital stays while they are awaiting necessary assessments.

And while it would be convenient for the patient to remain in the hospital awaiting the biopsy, hospital confinement imposes risks to patients, including exposure to nosocomial infections, medication errors, effects of sleep deprivation, and other healthcare-acquired conditions. The financial aspects can also not be ignored. Most hospital admissions are paid as a single payment covering all care provided during the stay. A discussion of the profitability of nonprofit hospitals and their executive salaries is beyond the scope of this article, but adding three days of convenient hospital care, including the required nursing care and daily physician visits, without any additional reimbursement is not a sustainable model to expand services to all in need.

This physician does express hope that “value-based payment models may break down the barriers between inpatient and outpatient medicine.” The term “value” itself has components of quality, safety, and experience divided by cost. Using principles of “since you are here” methodology not only adds to the cost; it also compromises quality and safety, and thus decreases the value of care markedly. These would not be “value-added” services for the patient or the hospital. They would do more harm than good by creating increased competition for already scarce resources. This happens all too frequently, not only with ordering services and consultations that could be deferred to the non-hospital setting.  

There is no equity in using highly paid clinical staff to provide hospital care to a stable patient awaiting a procedure that can be safely done after discharge, while a patient with sepsis needs to be transferred to another facility because the ICU is filled – partially with patients awaiting transfer to a medical bed, but there are no medical beds available. Medicine in the U.S. is evolving to be specialized, and that’s why many specialists such as rheumatology or dermatology rarely admit patients and are less aware of the issues unique to the hospital environment. A consult to a rheumatologist for this patient in many hospitals would probably get a response that “I will see this patient in the clinic.” Using precious hospital beds to carry out outpatient work would be antithetical to the very idea of the right patient receiving the right service in the right setting.  What we are missing is seamless communication, shared ownership, and missed opportunities to remove psychosocial barriers for patients to meet goals for their healthcare.

We offer a simpler solution here. Develop a relationship with the hospital’s care management staff. They can provide that bridge between settings, helping to arrange outpatient follow-up and testing, communicating with the patient so they do not miss their appointment, and ensuring that the results of testing are conveyed to the patient and the physician so they can get the best of care in the most appropriate setting.