Avoid chaotic care

When Jim Costigan, 69, of Edison, N.J., was hospitalized in December 2008, two doctors ordered separate tests, each of which required fasting, he said. But they didn't coordinate their schedules. "I don't mind fasting for a procedure," Costigan said. "But when I wind up not eating for 72 hours, that's when it gets out of hand."

Disjointed care is seen as a problem by both patients and nurses, our surveys showed. Thirteen percent of patients and family members who monitored care told us they had problems with care coordination. Thirty-eight percent of the nurses, who have a more complete picture of what's going on in hospitals, said they saw problems in the coordination of care, such as unnecessary or duplicate tests or treatments.

Disjointed care usually stems from having multiple doctors involved in your case, which can lead to confusion and miscommunication—such as when the two doctors inadvertently condemned Costigan to three straight days of hunger pangs. A March 2007 study in the New England Journal of Medicine estimated that the typical fee-for-service Medicare beneficiary sees seven doctors each year—two primary-care physicians and five specialists—from four practices.

Uncoordinated care can also be dangerous when it puts patients at increased risk of infections and medical errors that can occur when different doctors independently prescribe drugs or order tests.

Whether your hospital stay is planned or unplanned, do your best to take along a knowledgeable family member or friend to run interference for you when you are too sick or too sedated to advocate for yourself. This person can monitor your care, ask about treatment options, and speak up for you if you can't. Most nurses in our survey also said it would help if patients or their relatives or friends kept a written log of tests, treatments, drugs, changes in condition, the names of hospital caregivers, and notes of doctors' visits.

If your admitting doctor or hospitalist isn't doing a good enough job of coordinating your care, you have some options. Fifty-two percent of nurses in our survey agreed that patients should work closely with a patient advocate, social worker, or case manager to coordinate care.

But patients usually have to ask for such help, and only 9 percent of patients and 17 percent of their relatives (12 percent overall) in our survey did so. They might not have known they can summon those allies simply by using their bedside phone (see Whom to call).

Use the call button for urgent requests, such as alerting a nurse if the patient's condition deteriorates suddenly or pain is inadequately controlled. But be aware that 34 percent of nurses in our survey said they had to take longer than 5 minutes to respond at least once in their most recent work week because of inadequate time or not enough staff or other resources.

That's not surprising, considering that American Hospital Association statistics show a shortage of registered nurses, nursing assistants, licensed practical nurses, and pharmacists. "If you don't have enough RNs on the unit, we're not going to be able to pay as much attention" or be as responsive to call buttons and requests to treat pain, says Cheryl Peterson of the American Nurses Association.

So when calling for a nurse it's important for patients and family members to articulate what's wrong. Specify whether you're short of breath, in pain, or just want more ice water, so whoever answers the request knows whether to send a nurse, an aide, or an orderly.

And if there's something you need or think you might need, let the nurses know about it an hour before they change shifts, says Laura Pike, a registered nurse in San Diego. "Sometimes patients can feel almost abandoned during change of shift," she says.

And be nice. In our survey, just 33 percent of nurses strongly agreed that patients respect nurses' contribution to their care; 78 percent said patients and relatives might find that being respectful to hospital staff would "help very much" in getting better hospital care.

"In a hospital, you definitely catch more flies with honey than you do with vinegar," says Howard Abramovitz, 51, of Brooklyn, whose mother was recently hospitalized. "You assert your rights when you have to, but if you don't need to, make nice with everybody because hopefully they'll make nice with you, too."

Summing up

• Have a friend or relative with you as much as possible during your stay.
• Keep a bedside log of tests, treatments, and consultations.
• Identify a single individual to coordinate your care, whether a physician, hospital social worker, case manager, or patient advocate.
• When using the call button, be specific about your needs.
• Be respectful to the staff, but don't hesitate to ask to speak to a nursing supervisor if you feel your needs aren't being met.

Steps to getting better care