Very few people want to return to the hospital once they’ve gone home to recover. Moreover, hospitals have certain incentives not to readmit recently discharged patients. During the pandemic, limiting hospital admissions of any sort unless absolutely necessary has been another consideration.
Yet, readmission may be unavoidable for a patient’s health and safety. If you suspect something is wrong, don’t wait until it gets worse to speak up. These are reasons you should seek evaluation for possible hospital readmission.
Signs You Might Need Readmission
Whether it’s a primary care physician, the surgeon who did your operation, emergency department staff members or a patient navigator assigned to your case, talk with a health care provider about these potential red flags for possible readmission:
— Condition changes for the worse.
— Emergency/deterioration signs.
— Postoperative concerns.
— Unrelated medical problem arises.
— Prescribed treatment fails.
— COVID-19: flare-ups or new symptoms.
— Medication mishaps.
Condition Changes for the Worse
Not surprisingly, some people come back to the hospital and are readmitted for the same reason they became inpatients in the first place. “When someone is told that they need to be readmitted, people frequently assume they weren’t really ready to go home when they were discharged,” says Dr. Eric Alper, senior vice president, chief quality officer and chief clinical informatics officer at UMass Memorial Health in Worcester, Massachusetts. “That’s probably true in some cases, but in many cases, the patient was ready for discharge at that point.” However, he adds, “things can get worse again if you came to the hospital with pneumonia, or heart failure or another kind of infection.”
Typically, “when you switch people over to oral treatments from intravenous, then usually they’re ready at that point,” adds Alper, who also practices clinically as a hospitalist at UMass. “But sometimes when you put them on the oral medications or a new therapy, symptoms can come back or get worse. And it’s just hard to know in advance when that’s going to happen.”
Difficulty breathing, spiking fever, extreme nausea or vomiting, confusion or disorientation, worsening fatigue or weakness, or severe pain that can’t be relieved — reasons you came to the hospital before — need to be readdressed should they reoccur.
Depending on the reason for your recent admission, you should be told what to look out for when you get home, says Dr. Catherine MacLean, chief value medical officer at the Hospital for Special Surgery in New York City.
“Anybody who’s having chest pains — please go to the emergency room,” MacLean says. “Don’t stop anywhere. Or if someone’s having a high fever, they need to go to the hospital.”
Family members should be on the lookout for signs of deteriorating health in recently discharged patients, says Helen Haskell, president of Mothers Against Medical Error, a South Carolina-based group dedicated to improving patient safety. These signs could signal conditions such as sepsis, a systemic blood infection that can be life-threatening, for instance, or a dangerous blood clot.
Obvious or more subtle signs that a patient’s health is deteriorating include:
— Breathing changes such as loud breathing or snoring, shortness of breath or inability to talk in sentences.
— Pain that’s new, sudden, worsening or persistent, or severe leg or belly pain.
— Body temperature changes such as high fever, subnormal temperature, shaking or chills.
— Mental status changes including inability to stay awake or loss of consciousness.
— Blood flow changes including extreme limb or facial swelling, and skin that’s blotchy, sweating or clammy.
— Urination changes such as low amounts of urine, very infrequent urination or highly concentrated urine.
“What patients need to do when they’re discharged is get a number they can call that works 24/7,” Haskell says. “That’s the first thing so you have someone to call. And ask them what to look for — what would give occasion for a call.”
Typically, you should know and what is and isn’t normal during recovery at home. However, as a patient it can be hard to tell.
For instance, “they had a knee surgery and their leg is warm and they’re concerned: Is that an infection?” MacLean says. “Pretty much everyone who has these surgeries is going to have a warm leg, but some people who have knee surgery have an infection.”
Sorting that out is a job for health professionals, who can then determine whether readmission is indicated. “Patients should have a pretty low threshold for reaching out to their doctor, or the nurse or the care team to ask if they’re doing things right or if a certain sign or symptom is something they should be concerned about,” MacLean says.
You could receive reassurance that the situation is normal, recommendations for how to take care of it at home or if needed, instructions to go to the emergency room. Common postoperative reasons to be readmitted to the hospital are:
— Postoperative infection.Fever, worsening pain, shortness of breath, drainage like pus from your surgical site and ongoing lack of energy can signal a postoperative infection that may require medical treatment like IV antibiotics.
— Bleeding. Bleeding at the surgical site that starts up after you go home needs to be immediately evaluated. That might not necessarily lead to a return to the hospital or readmission, however. “In some cases, particularly now with telehealth, we’re able to do a quick look at a wound and evaluation,” Alper notes.
— Blood clot signs. “One thing we worry about a lot with surgeries is if people develop a blood clot in their legs,” Alper says. “Significant swelling or pain in one of their legs would also be things to come back for.” Skin redness or warmth are also potential blood clot symptoms.
— Uncommon post-op complications. Before you’re discharged, your patient care team will alert you to specific potential problems. For example, cataract surgery is a common and usually safe procedure. However, seeing flashes of light or new floating spots could signal retinal detachment — a vision-threatening emergency.
New Medical Problem Arises
It’s possible that an entirely unrelated health problem occurs soon after you were discharged. “Sometimes people get readmitted for other reasons altogether,” Alper says. “They came in with pneumonia, then they go home, fall down and hurt themselves. Or they develop a heart problem that was not something they had when they first came into the hospital.”
The common thread is that you need what only hospitals offer. “The reason to admit patients back to the hospital is pretty much identical to the reasons they’re getting admitted to the hospital in the first place,” Alper says. “If they need to be at a hospital level of care with that continuous monitoring and observation, if they need intravenous therapies, advanced evaluations, diagnostic testing — then the hospital is the place for that.”
Outpatient Regimen Fails
Patients may leave the hospital with a discharge plan that can include prescriptions for new medications for a heart condition, outpatient treatments like physical therapy and diet and hydration recommendations. Unfortunately, patients don’t always respond as well as hoped.
“Sometimes, if treatment fails that is directed after a patient is discharged, then they may need to be readmitted,” Alper says. “It’s the same concepts. If they’re short of breath, they’re having chest pain, they can’t keep food down, they’re dehydrated: All those could be reasons to admit the patient back to the hospital.”
Throughout the pandemic, COVID-19 has been a top reason for patients to be readmitted. Alper describes a common scenario: “Someone comes into the emergency department or the hospital for a short period of time with COVID,” he says. “Maybe they’re treated with IV remdesivir or steroids in the hospital and that completes — and then the patient ends up with shortness of breath or pneumonia after they go home. Increase in shortness of breath would probably be the most common cause for patients coming back to the hospital.”
However, patients with COVID-19 can develop different complications, as well. “It can cause problems with the heart, it can cause confusion, it can cause a change in mental status (known as) delirium,” he says. “That might cause the patient to require additional observation. Severe weakness, being unable to eat or drink — those would all be reasons to come back to the hospital.”
When a patient makes transitions from health care settings — like leaving the hospital to go to a rehab facility or home — changes in medication regimens can cause confusion. Sometimes, it may be unclear whether you should continue taking routine medications you need for a chronic condition like high blood pressure. Alternately, medications newly prescribed during your hospital stay may interact with or duplicate drugs you already take. Scenarios like these can lead to trouble.
Confusion with medication is a common reason that people end up getting readmitted, MacLean says. “Patients go in the hospital with one set of medications, they go out with another set and maybe the patient is taking twice as much of the medicine, or something didn’t get restarted that should have been,” she says.
Clear communication during the original hospital stay can prevent such mishaps. “When a patient is discharged from the hospital they need to have a good understanding of what the follow-up care plan is, what medications they’re supposed to be taking or not taking, very clearly laid out,” MacLean emphasizes.
If You’re Reluctant to Return to the Hospital
As a patient who just got home, you may be reluctant to be readmitted. And it’s possible you may not need to go back into the hospital after all, after further discussion and evaluation. In her role, Haskell says, “the patients I hear from often have had bad experiences in the hospital and they don’t want to go back. So they’ll put up with a lot of risk before they’ll go back. And that can be a mistake, because some things can be life-threatening.”
Whether it’s a mysterious symptom that doesn’t make sense or a bad case of COVID-19, people may need to go to the hospital even if they don’t want to, Haskell says. The bottom line is: “There’s risk in hospitals, but hospitals are what we have.”
Bridges From Hospital to Home Care
Hospitals are under pressure to reduce readmissions. They face financial penalties for higher-than-average readmission rates within 30 days for Medicare patients who have certain chronic conditions. One challenge is how to reduce early readmissions without compromising patients’ health and safety.
Continuity of care means patients truly aren’t left home alone after they’re discharged. Medical centers are acting to provide in-between options to bridge the gap between inpatient care and at-home recovery.
“Many hospitals have post-acute systems of care in place,” MacLean says, including her facility. “And prospectively, with any patients who are at higher risk of readmission, we actually reach out to them to make sure they’re doing OK, and we have nurse practitioners and nurses who do some of that outreach.”
Telehealth is another way to extend care beyond the hospital. For instance, HSS@Home is a telehealth-rehab program for patients with hip and knee replacements, run by physical therapists. Nurse practitioners, who are also involved, can help with medication questions or other concerns. With the tele-PT program, MacLean says, “the thing that’s so wonderful is we remain connected to our patients.”
Many hospitals, including UMass, have been implementing hospital-at-home programs, Alper says. “This is really great for the kinds of patients who would rather be at home where, in our case, we have nurses coming into the home twice a day,” he says. “The patient can be on intravenous antibiotics. We do continuous monitoring of patients’ vital signs. We have telehealth visits with the patients, as well.”
Results are encouraging. “We’re finding that patients have excellent outcomes in this way,” Alper says. “Among other things, readmission rates go down pretty significantly. It’s been a win-win-win — because some patients love it, the costs are lower and the outcomes are generally outstanding.”
Still, there will be times when returning to a hospital unit is the only choice. “It’s an imperfect science,” Alper says. “As physicians, we always try to do right by patients, to get them discharged at the right time. But we don’t have crystal balls. We don’t know who is going to need to come back to the hospital and who is going to do just fine at home. We don’t like to readmit patients — but when they need to be readmitted it’s absolutely the right thing to do and we’ll do it.”
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