Curbside Consult with Dr. Jayne 2/28/22

I spent the week wading into the world of post-operative care at home, as I stayed with a friend who is recovering from surgery. I know plenty of people in healthcare who are enthusiastic about discharging patients quickly and getting them home to recover. It certainly cuts down on the risk of hospital-acquired infections and can help patients psychologically as they return to a familiar environment. However, it can be challenging for people who don’t have family or other support, and I think we sometimes overlook those factors when we’re considering hospital at home and other initiatives.

My friend is a physician who had the misfortune to severely injure her knee on an escalator at a London tube station several months ago. She initially had difficulty being scheduled for an orthopedic evaluation due to the rise of COVID cases last autumn, and once she jumped through all the hoops and was able to get an MRI and a definitive diagnosis, her health system had stopped performing any elective surgeries. Her planned recovery was complicated by the fact that she needed to be non-weight-bearing for six full weeks, compounded by the fact that she is single and has no family in the town where she practices. She also lives in a two-story home, so had to think about that in her recovery plans as she worked to figure out what her strategy might be. Even though she is a physician, she hadn’t had surgery before and wasn’t sure what to expect regarding post-op pain or other potential complications.

Her large, multi-state health system has a hospital near her parents, so she was able to have her local physician arrange for an orthopedic surgeon in the other city to review her studies. Following a telehealth visit, he agreed to perform the surgery once scheduling opened up again. In the mean time, due to the physicality of her job (she is also a surgeon), she was unable to do her usual work duties, which was stressful. Once the hospital started scheduling elective procedures, she was finally able to get on the schedule due to a cancellation. The operating surgeon’s office arranged to have a variety of medical equipment delivered to her parents’ house, including a wheelchair, walker, ice circulating machine, continuous passive motion machine, and more. By the day prior to surgery, only half of it had arrived, which created stress for everyone. On the day of the procedure, her parents had to decide who would stay home and wait for the rest of the equipment and who would accompany her, which added to the stress.

Fortunately, the procedure went well, and by the time she arrived back at home, nearly all the equipment had arrived. For someone non-medical who isn’t used to making follow-up calls, having to track down the rest of the supplies would likely have been more stressful than it was for her. She wasn’t having to use a lot of opioid pain medications, so she could advocate for herself on the phone, but not everyone is in that situation postoperatively. At least the magic ice machine had arrived, so she was able to rest without worrying about changing out ice packs. The next day, when she got ready to use the passive motion machine, she noticed a discrepancy between the instructions she had been given before the procedure and those in her discharge instructions, which led to a call to the surgeon’s office and difficulty getting a straight answer. She also began doing injections of blood thinners due to her forecast immobility. As a physician, not a big deal, but probably more challenging for other patients.

Prior to the procedure, my friend had suspected that two weeks with her parents would be more than enough family bonding, so she arranged for friends to help during the next few weeks after she returned to her own home. She had set up an inflatable guest bed in her first floor living room, and fortunately her home has a full bathroom on the first floor. Unfortunately while she was away, the bed had sprung a leak, leading to an emergent online order and a Target run by her next caretaker. After getting that situated, she had to figure out logistics for navigating the house in a wheelchair when the house hadn’t been adapted for it. Doorways were too narrow, the laundry room was impassible, and there were a couple of other challenges they had to work through. She would have liked to use the walker more, but was having some wrist pain after a slip while transferring, prolonging the use of the wheelchair. Fortunately, her friend was able to stay for several days until I arrived for the handoff.

By the time I came on the scene, they had figured out quite a few ways to further adapt things, including just storing dishes on the countertop versus using cabinets and rearranging the refrigerator to make things more accessible. As a physician with a good income, ordering takeout or grocery delivery wasn’t an issue, but we discussed how a lot of our patients don’t have that option. Not everyone can put their frequent flyer miles to use and fly someone across the country to stay with them or have the relative luxury of paying a neighborhood kid to manage trash and recycle cans. Not to mention, what if she had been the primary caregiver for children or another adult? Without this level of support, patients might elect not to have a procedure, especially if they don’t have paid sick time to cover the entirety of their recovery.

Because of the nature of the procedure and her pre-existing good health, my friend wasn’t eligible for any kind of home health or other services. Due to the pandemic, her physical therapy was delivered via video visit, removing another possibility for personal contact. Although I did enjoy following along with the video PT and seeing what another EHR’s technology looked like, it made me think quite a bit about what this experience looks like for other patients who might not be as tech savvy or medically aware. She was also fortunate to not have any postoperative complications, so it was relatively smooth sailing while I was there. She’s not scheduled for an in-person physician visit for another two and a half weeks and I was surprised that the orthopedic surgeon’s team hadn’t followed up with her to see how she was doing.

I handed off over the weekend to one of her physician colleagues, who came to stay for a couple of nights while her own family was out of town. Those days will get my friend to the end of the four-week milestone and she’s feeling more confident about being alone, although still worried about what would happen if she fell and no one else was around. Hopefully the rest of the six weeks will be uneventful, but we both know that’s when the real work starts, as she has to start using her leg again and figuring out how to get the strength back to spend long hours in the operating room. While I was there, she got to experience a taste of what being a CMIO looks like and admits she doesn’t envy the eight hours of calls and meetings each day. I’m glad I was able to help, but it did give me quite a bit to think about as I help my clients with their telehealth and in-home care strategies.

Have you experienced hospital at home, or a prolonged recovery? What did you think, and how did your caregivers fare? Leave a comment or email me.

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