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

28 June 2013

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.


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