Hospital Care

Many people with HIV infection are admitted to a hospital at some time during the course of the infection. But since 1996, when HAART was introduced, people’s need for hospital care has changed greatly.

Nevertheless, hospitals remain an important part of HIV care. Pa­tients may or may not have a choice of what hospitals they are admit­ted to. As discussed in a later section, the choice is largely dictated by the type of insurance they have and the hospitals for which their physi­cians have admitting privileges.

People are often frightened about going to a hospital—to be sure, hospitals are confusing places. This section discusses hospitals, and their people and practices, in an attempt to lessen the fear and confusion.

Teaching and Community Hospitals

Hospitals differ in the services provided and the style of care. One of the biggest differences is between teaching hospitals and community hospi­tals. Teaching hospitals are generally larger hospitals that provide on- the-job training for medical residents and often for medical students as well. Teaching hospitals are often affiliated with medical schools, the physicians are often on the medical school faculty, and physicians may be responsible both for patient care and for research programs.

The advantage of teaching hospitals is that their resources for test­ing and treatment are both extensive and up-to-date. This is important in a field that changes as rapidly as research in the treatment of HIV in­fection. Teaching hospitals are also more likely to have comprehensive programs for the care of people with HIV infection. This access to com­prehensive services is very important to some people with HIV infection and less important to others.

Community hospitals tend to be smaller hospitals with fewer re­sources and whose staff physicians often have less experience with HIV infection. Nevertheless, many community hospitals have devoted physi­cians who provide excellent care in an environment less overwhelming than that of a large teaching hospital.

Experience counts, however. Surveys of hospitals caring for people with HIV show that survival is better and the length of stay is shorter in hospitals that treat many people with HIV, compared to hospitals that treat few people with HIV infection. Still, there is no doubt that many of the common complications of HIV infection can be easily managed in a community hospital.

Choosing a Hospital or Care System

For many people with HIV infection, choice of a hospital or care system is limited. Participants in managed care organizations or HMOs are re­quired to use specific hospitals. People from small cities or from rural areas often have only one hospital near enough to choose. In medical emergencies, a public ambulance is required to take the patient to the nearest hospital, leaving the family and the patient little say in the mat­ter, unless they hire a private ambulance.

In most instances, the physician responsible for the care of the person with HIV infection will make a recommendation depending on which hospital has the resources necessary for that person, and in which hospital the physician has admitting privileges (meaning the physician is allowed to admit and treat patients).

A large teaching hospital might best be chosen by a person who has unusual complications that require specialized services.

Hospital People and Practices

Both teaching and community hospitals present the patient with a be­wildering array of people with different titles offering different services. Hospitals also follow certain practices that may likewise be confusing. To help eliminate some of this confusion, the following are the people and practices a person in a hospital can expect to see.

Physician-of-Record

Your physician-of-record is the physician medically and legally res­ponsible for your care—that is, for all medical recommendations, in­cluding decisions about diagnostic tests and about your treatment. Your physician-of-record is most often your primary care physician, but sometimes it is the physician assigned from the hospital staff. Even though you might see nurses and residents more often, the physician-of- record has ultimate responsibility for your medical care. Every person in a hospital has a physician-of-record.

Primary Care Physician

A primary care physician is a general practitioner, a family physician, or an internist. That is, primary care physicians are usually generalists who deal with a lot of different medical problems—high blood pressure, di­abetes, wax in the ear, and sinusitis. Primary care physicians are the backbone of managed care organizations or HMOs, and subscribers are invariably assigned to one. Whether in private practice or employed by a managed care organization, primary care physicians may or may not be HIV-savvy.

Residents, Fellows, and Interns

Residents and fellows are physicians who have recently graduated from medical school but who are not yet practicing medicine on their own. Residents are still in residency, that is, they are still in training to obtain their credentials in a specialty, usually in family practice or internal med­icine.

If you are in a teaching hospital, the physicians you are likely to see most often are residents in internal medicine or family practice, and fellows in infectious diseases or some other subspecialty. Their auton­omy in making decisions about your medical care varies, depending on their training, the rules of the hospital, and the idiosyncrasies of the physician-of-record.

Specialists

In addition to the physician-of-record, the residents, and the fellows, the other physicians you will see in a hospital are the specialist physicians. Because AIDS affects so many different parts of the body, and because it takes so many forms in so many different people, no single physician can treat all aspects of the disease. Specialists (technically, these are subspecialists) that are most likely to be consulted in HIV infection are neurologists, ophthalmologists, gastroenterologists, obstetricians, der­matologists, psychiatrists, and pulmonary specialists. Each has a spe­cific area of expertise that may be sought by the physician-of-record. In most instances these specialists make recommendations or provide spe­cial procedures. The person ultimately responsible for carrying out their recommendations and approving their procedures is the physician-of- record.

Physician's Assistants and Nurse Practitioners

Physician’s assistants and nurse practitioners are midlevel practitioners, meaning that their responsibilities lie somewhere between those of a nurse and those of a physician. Midlevel practitioners assess medical problems, order tests, and recommend treatments. They work with vary­ing degrees of independence, depending on state laws, the medical prob­lems they care for, and their relationship with the other health care pro­viders.

Midlevel practitioners often have specialized training in one area of medical care, including care of people with HIV infection. They are es­pecially valuable in highly specialized areas of medical care because they have often acquired, through training and experience, an expertise not usually found among physicians who care for people with many differ­ent diseases. Many comprehensive care programs for people with HIV infection rely heavily on midlevel practitioners.

Physician’s assistants have two years of specialized training, must pass a board exam every six years, are required to have at least one hun­dred hours of postgraduate education every two years, and are licensed. Physician’s assistants must practice under the supervision of a physician. They may prescribe drugs in some states but not in others.

Nurse practitioners are registered nurses who have nine additional months of advanced training or have received a master’s degree in nurs­ing. Nurse practitioners do much of what physician’s assistants do, but they are not required to serve under the direct supervision of a licensed physician.

Nurses

Registered nurses make certain kinds of medical assessments, including assessments of patients’ medical conditions, their ability to provide self­care, their psychiatric needs, and their nutrition. Registered nurses also provide psychological support, are responsible for certain types of treat­ments, and administer medications. Nurses can also be valuable sources of information about your care: ask them questions.

All hospitals are required to have a registered nurse on each unit of the hospital twenty-four hours a day. Each patient in the hospital is as­signed a nurse for every eight-hour shift.

Nursing support technicians, licensed practical nurses (LPNs), and nursing aides are paramedical personnel who are less extensively trained than registered nurses and do many of the jobs that were previously done by nurses: these include taking pulses and temperatures, measuring blood pressure, handing out medications, bathing the patient, changing beds, handling bedpans, and dressing wounds.

Gatekeeper

“Gatekeeper” is a new term in health care. Gatekeepers are a common feature of managed care organizations or HMOs. They make decisions about access to such specialized and often expensive services as specialty consultations, lab or radiology tests, and, most importantly, hospital­ization. Hospital care is by far the most expensive part of health care, so care in alternative settings is a major objective. Gatekeepers are often primary care physicians, but might also be other health care profession­als like physician’s assistants or nurses.

Social Workers

A social worker is a college graduate either with a degree in social work or with two years of postgraduate training and a Master’s of Social Work. Most states require these credentials for a license to practice so­cial work. The actual graduate training is primarily devoted to counsel­ing. In a hospital, a social worker’s primary role is to help people plan what to do when they leave the hospital. These plans, called discharge plans, include making decisions and arrangements for nursing home placement, home care, or outpatient care.

Good social workers also get involved with much more. They ar­range for such special services as rehabilitation from injection drug use, treatment of alcoholism, psychiatric care, physical rehabilitation, and contact with community organizations. The job of the social worker usually ends when the person is discharged from the hospital.

Social workers can be found not only in hospitals but also in clin­ics, in private practice, in community organizations devoted to HIV in­fection, and working as case managers assigned to an individual person. All U.S. hospitals that receive federal funds must have social workers; this means essentially that all hospitals have social workers, since Medicare and Medicaid fund so much of this country’s health care in hospitals.

Information about social workers or case managers may be obtained through the hospital social worker, by referral from physicians, through contact with the local health department, or through the yellow pages of the telephone directory (listed under social workers, therapists, or counseling).

Patient Representatives

Many hospitals have a public relations office with patient representa­tives who serve as links between the hospital and the patients. Patient representatives have varied jobs: for example, they answer questions about bills, provide translators for persons who speak foreign languages, and provide clothing for those in need. Patient representatives also serve as a complaint department. People with complaints document their con­cerns in writing, and the patient representative tries to deal with these concerns to the satisfaction of all parties.

Rounds

Rounds is a well-established ritual in medicine in which physicians, nurses, and often other members of the care team go “around” to see the patients every day. At the beginning of the twentieth century, rounds were very formal: a professor at a teaching hospital led a pa­rade of residents, medical students, and nurses through the wards of the hospital, reviewing each patient, writing down the findings, dis­cussing the patient’s condition, and making plans. At present, rounds are much more informal. In teaching hospitals, the rounding team usu­ally consists of residents, medical students, and nurses, with or with­out the physician-of-record. In community hospitals, rounds are sim­pler and usually involve the physician-of-record and sometimes a nurse. Rounds are traditionally held every morning, although many private physicians find it more convenient to round in the afternoon when test results are in hand and consultants are more likely to be available. Most agencies that fund medical care require that the physi­cian see every patient under his or her care nearly every day of hospi­talization.

For the person in the hospital, rounds are an opportunity to ask brief questions about progress and plans. Long discussions with more detailed questions are probably best asked in the more private company of the resident or the physician-of-record.

Universal Precautions

Universal precautions are a set of rules to protect health care workers from certain infectious diseases. Included among those diseases are HIV infection, hepatitis, and any other infectious disease transmitted through body fluids (blood, saliva, urine). All hospitals in the United States are required to practice universal precautions.

Though the rules of universal precaution apply to all body fluids, the major concern is for blood and bloody fluids. The rules require a bar­rier between the health care worker and the fluid. The barrier rule means that gloves are to be worn when dressing wounds and the like.

It should be emphasized that universal precautions are universal. They apply to all people participating in the care of any patient in the hospital. There are no precautions that are special to people with HIV infection. Exceptions are the complications of HIV infection—like sal­monellosis, tuberculosis, and shingles—that pose a threat to health care workers. But these infections require the same precautions regardless of HIV status.

The Hospital Bill

The anticipated charge for the average private or semiprivate room in a private hospital is $500 to $1,000 a day (in 2005 dollars), but it can be over $2,100 in such large metropolitan areas as New York City. Inten­sive care units are usually $2,000 to $2,500 a day. Additional charges include medications, laboratory tests, physicians’ fees, and specialized procedures like bronchoscopy or operations. The hospital bill is likely to be long and full of medical jargon with lists of numerical codes for every pill, syringe, gauze pad, and procedure. Physicians’ fees are billed separately from the hospital bill, except for Medicaid patients. Insurance companies determine the customary and reasonable charges for both the hospital and the physician and, on that basis, make their payments. Questions about the hospital charges should be directed to the hospital billing office or to the patient representative. Questions about a physi­cian’s charges should be directed to the physician. If finances are going to be a problem, the person should inquire about charges for various tests and their alternatives before the tests are done.