For the most part, long hospital stays are a thing of the past. Factors such as pressure from insurers to keep costs down, advances in care that speed recovery, more procedures and tests done on an outpatient basis, and the serious concern a longer stay could increase patient risk — for instance through exposure to treatment resistant hospital-acquired infections — have shortened stays to just a few days on average.
Most patients are ready to go when they leave. While clinicians emphasize that recovery continues after they are discharged, most are able to go home (or, in some cases, to a nursing home for intensive rehab). However, the decision regarding when to discharge a patient can be complex — due in part to the ongoing nature of a person’s recovery. In a significant proportion of cases, experts say patients are discharged before they’re clinically stable.
As research has found, abnormalities in a patients’ vital signs — temperature, heart rate, respiratory rate, blood pressure and oxygen levels — when a patient leaves the hospital can spell trouble. “For our study, we looked for … vital sign instabilities that were likely to be acutely abnormal — meaning abnormal in the short-term due to a new illness,” explains Dr. Oanh Nguyen, an assistant professor of internal medicine and clinical sciences at UT Southwestern Medical Center in Dallas.
“We found that about 1 in 5 people were discharged with one or more vital sign instabilities. We found that people had higher odds of being readmitted or of death within 30 days that correlated with the number of instabilities,” she reports, referring to research she led published last year in the Journal of General Internal Medicine. “The more instabilities people had when they were discharged, the more likely they were to have some bad outcome after they were discharged home, whether that was … needing to come back or, unfortunately, dying.”
[See: 9 Extra Safety Assignments for Hospital Patients.]
Warning Signs You May Be Leaving the Hospital Too Soon
“If a patient is not medically stable, they should not be discharged,” says AnnMarie Quintaglie McIlwain, CEO of Patient Advocators in Summit, New Jersey. But that’s exactly what happens all too often, patient advocates say.
Health providers should heed unstable vital signs. But to be proactive, patients can ask if their vital signs are normal, says Grace Cordovano, a patient advocate and founder of Enlightening Results in West Caldwell, New Jersey, who specializes in working with cancer patients.
Pay attention as well to any undiagnosed symptoms, says Linda Beck, the principal at Square One Elder and Health Advocacy in San Luis Obispo, California. Does a patient have a fever, or is the person vomiting or coming in and out of consciousness?
Before discharge, Cordovano also suggests considering:
— “Can I get in and out of bed safely and independently?”
— “Am I able to get to the bathroom?”
— “Am I having problems urinating or with bowel movements?”
— “Will I be able to self-administer my medications?”
— “Am I able to eat and drink and keep food [and] water down?”
— “Do I have any new symptoms or uncontrolled pain?”
— “Is there anything I am afraid of with respect to my health upon leaving the hospital?”
She adds that patients need to have a thorough understanding of next steps upon leaving the hospital. “Clear communication from their care teams is critical. Don’t accept discharge papers until they have been thoroughly explained and all questions and concerns have been answered,” Cordovano emphasizes. “Make sure you know who to call if you have a question within the first six to 12 hours post-discharge.”
Those who live by themselves or don’t have a lot of family support should consider if they’re unable to perform activities of daily living, such as bathing, dressing, toileting or getting around without assistance, or are considered a fall risk, said Erin Singleton, chief of mission delivery at the Patient Advocate Foundation, and Beth Moore, the nonprofit’s executive vice president of corporate communications, in a joint email responding to questions. Those who require further assistance may need to continue 24-hour care, such as at a nursing and rehab center, before going home.
[See: 9 Strategies for Reducing Emergency Room Medication Errors.]
What to Do If You Feel You’re Being Discharged Dangerously Early
First, start thinking about discharge at the beginning — not the end — of your hospital stay, patient advocates say. Of course this may be easier said than done for a patient who arrives in the whirlwind of a medical emergency. That’s all the more reason to enlist the help of a family member or caregiver or patient advocate to monitor care and advocate on the patient’s behalf throughout a hospital stay.
Don’t assume that just because you’re in the hospital you’ve been admitted. In some cases, patients are kept “under observation” at the hospital, while clinicians determine if they should be admitted. This limbo can affect insurance reimbursement, particularly for Medicare patients who need to undergo intensive rehab care at a nursing home after their hospital stay. So, experts advise, ask if and when you’ve been admitted.
“Talk to your providers about realistic expectations. Family members may think someone is going to be fully cured when they come home, while the medical team’s expectation is that the patient will merely be stable in the setting, wherever this may be” — whether that might be in acute rehab, a skilled nursing facility or home, Singleton and Moore say. “The medical team expectation may be that there would be ongoing physical, occupational or speech therapy after discharge to meet the treatment goals.”
Trust your gut as well. “If someone is unsure whether they should be going home, most likely they shouldn’t,” says Belena Butler, a patient advocate and owner of Caring Support & Solutions based in Alpharetta, Georgia. Most people don’t want to spend more time in the hospital than they have to, though in some cases anxiety can play a role in a patient’s hesitation to leave the hospital.
To ease concerns, Butler suggests taking a few steps before discharge. That includes asking what kind of resources will be available if problems arise, determining who to call if you have questions or issues do arise and ensuring any follow up appointments are set before leaving. And access community services as needed to ease the transition home. “Home health nurses can be arranged to come and check in to assess your status,” she says. “If they find something wrong they can call the doctor for you as well.” Butler adds, “If a discharge is complex, one of the best approaches is to have a care meeting while in the hospital,” noting that a social worker or private health care advocate can help set this. “This allows everyone to know what is going on, what is expected and their role in the discharge process. A care meeting is great time to address concerns or questions, versus when they are asking you to sign the discharge papers.”
Above all, if you feel for any reason you or a loved one is being discharged too early from the hospital, don’t hesitate to speak up, even if it’s difficult to do, experts say. Share reasons why you or your loved one needs to stay in the hospital or why you feel a discharge would be unsafe. “I recommend providing this information in writing — text or email — so there is no question about whether the hospital got the information,” Beck says. “The patient or caregiver should inform the medical team and the social worker that they disagree with the discharge plan,” Quintaglie McIlwain adds. If the person is on Medicare, they can request what’s called a fast appeal. That will buy them 24 hours to contest it, she says, although they may be responsible for co-insurance while the appeal is being adjudicated. “Non-Medicare patients can contact their insurer and ask them to intervene. They can also ask their primary care doctor to call on their behalf.”
[See: U.S. News Best Hospitals Rankings.]
Just as there’s a financial incentive to keep hospital stays short to hold down health care costs, hospitals can also be penalized by Medicare, if it’s determined that they have too many unnecessary readmissions. Though critics say hospitals can be penalized unfairly under this system, experts also point out that it’s led many institutions to more carefully monitor the discharge process in an effort to reduce the likelihood a patient will need to come back to the hospital.
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What to Do If You Feel the Hospital Is Discharging You Too Soon originally appeared on usnews.com
