Jay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative (CC-QIRC). This post is first of a three-part series.
Everywhere you turn these days, there’s an airline, grocery store or coffee shop pushing a “frequent flyer” or “rewards” program. You know the gist – the more money you give these businesses, the more discounts they give back to you and the more money you “save.” In theory, these programs are win-win: customers like frequenting the same business; businesses love holding onto satisfied customers.
But when I was a medical student, and overheard a nurse call my patient a “frequent flyer,” I wondered, “Who gets the ‘reward’ in that frequent flyer deal?” I hoped this child, a 4-year-old boy with cerebral palsy, was benefiting from being admitted over and over again.
I asked around: “Hey, why is this kid admitted so frequently?” The nursing staff was miffed. “It’s just ‘him.’ That’s just the way it is.”
I asked my attending physician, who was ultimately in charge of the patient while in the hospital. “I don’t know. I only work in the hospital a few weeks a year. I’ve never admitted this patient before. I don’t help care for this child in the community.”
The boy’s parents told me, “When we’re here in the hospital, he does just fine. But when we go home, he always gets sick again.”
That seemed odd. What was triggering this child (who I’ll call Jim) to become repeatedly sick at home? His hospital health records showed four hospitalizations within the last year – all for vomiting. He had a feeding tube in his stomach to receive nutrition. Why would his vomiting always get better when he was admitted and get worse at home?
“Every time we leave the hospital, we’re told to go see his regular doctor when he vomits,” Jim’s parents elaborated. “So we do that, and every time, that doctor tells us to go to the emergency room. So we do that, and every time the emergency room doctors tell us that we need to come into the hospital.”
So why was this kid vomiting? The nurses, doctor team and I checked everything under the sun, including the positioning of his feeding tube, his stomach and intestinal anatomy, the rate at which food exited his stomach, his stomach acidity and the number of times food was refluxing into his esophagus. Everything checked out okay. We were deflated. Something was wrong, but we couldn’t figure out what.
Jim was now better, had no vomiting and was ready to leave the hospital. As we prepared the family for discharge, we asked a final, desperate question: “Is there anything that seems unusual about his feeding habits when you’re at home?”
At this, his mother told us that the pump for his feeding tube at home was different than the one we used in the hospital. She showed us the home feeding pump, and we decided to let Jim use it once before going home – to make sure there wasn’t a problem with it. As Jim was getting formula into his stomach through the pump, he nearly vomited.
We turned off the pump and realized that it was set to deliver formula into Jim’s stomach four times faster than the hospital’s pump. The food was filling his stomach too quickly, causing him to vomit.
We were simultaneously joyful and disheartened at this finding. Happy that we’d found a simple reason why Jim was vomiting at home, one we could alleviate by slowing down his home pump. Sad that this overlooked problem had led to a child being hospitalized four times this year.
Emerging evidence suggests that small groups of adult patients who are frequently readmitted to the hospital not only experience major life disruption, but are responsible for a large proportion of health care costs. My colleagues and I began asking if the same is true in pediatrics. Who are these “frequent flyers?” What is their impact on the health care system? Our findings, published recently in JAMA, will be the focus of my next post.