04 September 2013
Another Reason to Be Careful of Hospitalists
On August 22, I blogged about hospitalists and what this can mean for you. Now another case of why hospitalists may not be the best. This hurts as it affects those of us with diabetes and those with hypertension. Hospitalists see it as their duty to fine tune our management of both. No matter the reason for being hospitalized, I would encourage all people with diabetes and/or hypertension to be careful what they allow the hospitalists to do to you.
The author of this blog relays information from the University of California, San Francisco about elderly patients admitted for an acute problem of pneumonia. They also have hypertension, diabetes, and other conditions that are unrelated to the reason for admission.
The well intentioned hospitalist may see the hospitalization as an opportunity to “tune up” the patient by intensifying the treatment of these conditions. The blog author continues, “This usually does more harm than good. Unless these conditions are out of control, or their treatment is part of the treatment of the acute illness, the patient will be better served by a less is more approach, leaving management to the outpatient doctor.”
An acute illness often causes problems in management of hypertension and diabetes while in the hospital. This is problem one, as control generally returns to normal after the acute illness resolves. But, when a hospitalist intensifies treatment in the hospital, the patient will then go home dangerously over treated.
Problem number two is that is impossible to determine the ideal regimen for blood pressure and glucose management in the hospital. It is just stupid (my words) to titrate medications for these conditions in the hospital. The acute illness may increase hypertension and make glucose management almost impossible until it is resolved. Then the patient is discharged and told this is what he/she must take and because the home regimen, diet, exercise, and other activities, is totally different than the hospital, this can cause all sorts of problems for the patient.
The hospitalist may have made the numbers look great while the patient was in the hospital, but clearly the numbers will be very different when the patient is at home. Hospitalists should think twice before trying to change established outpatient regimens for hypertension and diabetes in the hospital. Changes should only be made in consultation with the patient's normal doctor.
A local person with type 1 had his pump totally messed up by a hospitalist and needed to use multiple daily injections until he could get home and get help from the pump manufacturer. Then he needed to call his endocrinologist to get the settings corrected to what they had been before the hospitalist took charge. Since he knew he would be going back into the hospital two months from now, he has sent a registered letter to the hospital requesting that the hospitalist not be allowed near his room. In addition, the letter stated that under no circumstances was the hospitalist even to touch his insulin pump under threat of a lawsuit.
Since the hospital has refused, he and his doctor are investigating another hospital for the operation and they will go through the same procedure to limit what the hospitalist can do. Because of the location of the operation on his body, his wife will accompany him and take charge of his pump until after the operation is completed. Then he or his wife will reattach the pump to another area and start it. She will also have control of his testing supplies. His endocrinologist will see to it that he can use his own insulin.
Since hospitals are nefarious in allowing blood glucose reading to be maintained at 180 mg/dl to 200 mg/dl, his endocrinologist wants to help him heal faster and maintain his own glucose levels. His endocrinologist says that he should be able to manage having the hospital allow this especially since he has hospital privileges at the new hospital. He will also have a CGM for his use while hospitalized.