June and July are busy months for our medical center’s credentialing department. Every year, we have more than a hundred new residents, fellows, and attending physicians who apply for privileges....
Alright, from the title of this post, I’m sure you are trying to guess what it is. Open heart surgery? A craniotomy? Separation of conjoined twins? Wrong. The most dangerous procedure in medicine is the hospital discharge.
From the time a patient is admitted to the hospital, the medical resident or the hospitalist has one mission – to get that patient discharged, preferably alive. That’s because the discharge is the ultimate goal of a patient’s hospitalization.
We are singularly focused on discharge. As soon as a patient hits the nursing unit, we are pressing the admitting physician to enter a projected discharge date so that the hospital’s case management machinery can start working to get that patient out of the hospital. We analyze hospital length of stay for each physician, rewarding those who keep their length of stay index below one and chastising those with a length of stay index greater than 1. We put enormous resources into getting discharges out of their hospital room by noon so that we can make room for the next patient.
So why aren’t we patting each other on the back for every hospital discharge, after all, the fact that the patient is being discharged means that they are getting better so we were successful, right?
The problem is that there is so much that can go wrong when we discharge a patient. Here are just a few of them:
- Medication reconciliation. Everybody talks about it but nobody does it very well. In order to keep our hospital costs down, we have a relatively limited number of medications in our hospital pharmacy formularies, limited to those drugs in each category that we are able to get the best pricing on. The problem is that these are not the drugs that the patient will be taking at home which are dictated by their insurance company’s formulary. And so the drug that the patient got better taking in the hospital is often different than the drug that the patient will pick up at the drug store. Even more of a problem, the patients frequently assume that they are supposed to take both the drug that is on their hospital discharge instructions and the drug that their primary care physician had prescribed for them prior to their hospitalization. I can’t even count the number of times that one of my patients who had been taking Advair for years comes into the office after a hospitalization taking both Advair and Symbicort because Advair wasn’t on the hospital formulary and the hospitalist put them on the equivalent Symbicort when they were in the hospital.
- Medication access. This has gotten a little better as patients have had better access to health insurance under the Affordable Care Act. But it is still common for a drug to be prescribed at discharge from the hospital that the patient can’t afford once they go to pick it up at their local pharmacy. So what do they do when faced with a bill for a $300 antibiotic? They don’t buy it. And then they get sick again.
- Nursing & doctor care. When they are in the hospital, patients are getting vital signs every 6 hours and seeing the hospitalist once or twice a day. As soon as they leave, that changes to seeing their primary care physician 3 weeks from now. We monitor patients up the wahzoo in the hospital and then release them into the wild the minute that they walk out the door.
- Oxygen. This one is a pet peeve of mine, as a pulmonologist. We check the patient’s oxygen saturation by oximetry every day or multiple times a day in the hospital – almost always when they are resting quietly in bed. But they are not resting quietly at home, they are walking around, climbing stairs, carrying groceries, etc. And their oxygen saturation is a lot different when they are doing those activities. I’m always dismayed when a patient shows up in the office for their hospital follow up and the nurse checks their oxygen saturation right after they walk 50 feet from the waiting area to the exam room and the saturation is 76%. When you go back to the hospital record, it was always in the 90’s because it was always measured after the patient had been lying in bed for an hour.
- Medical follow-up. If a patient gets discharged on a Saturday morning, the case managers (if they are even in on Saturdays) can’t schedule a follow-up office visit with the patient’s primary care physician. So instead, the discharge instructions will typically say something like: “Please call your primary care physician’s office on Monday to make an appointment to be seen within 3 days.” Here’s what usually happens: the patient forgets to call, the physician is out of town for 2 weeks, the physician doesn’t have any available appointments until December, or the patient doesn’t even have a primary care physician.
- Communication with the outpatient physician. So lets be optimistic and the patient does call and get an appointment to see his primary care physician the next Tuesday. He shows up and his doctor asks him why he is there. The hospital policy is that a discharge summary has to be dictated within 5 days of discharge and the hospitalist hasn’t gotten around to dictating it yet. The patient says he was in the hospital because of high blood pressure. The primary care physician checks his blood pressure and it is normal so he sends the patient out. Two weeks later, when the discharge summary finally arrives in the mail, it says that the patient was admitted with hypertension and chest pain and was found to have an ejection fraction of 15%, an aortic dissection, and syphilis and that he should see his PCP for treatment.
- Diet. No human being ever gets put on a regular diet in the hospital. It is usually some combination of low salt, carbohydrate limited, caffeine-free, diabetic no added sugar, 15 gram protein diet. Its no wonder they all hate our hospital food, its nothing like what they eat at home. And so the patient with heart failure goes home and what’s the first thing he does? Open up his pantry and pull out a jumbo bag of Doritos and then wash it down with a liter of original Coke. When you ask him about it the next day when he’s back in the emergency department, he’ll tell you quite honestly that the discharge instructions didn’t say anything about avoiding Doritos.
- Pending tests. As soon as a patient is out of sight, they are out of mind. And so the chest CT scan result that was pending at the time of diagnosis comes back showing a “large lung mass that should be considered lung cancer until proven otherwise”. But the patient is gone so nobody sees the report. Or maybe the final culture from the bronchoscopy that the pulmonologist did comes back with Cryptococcus. But the report goes to the hospitalist who doesn’t know what Cryptococcus is and assumes it must be a part of normal flora.
There are a thousand things that can go wrong when a patient gets discharged. And that’s why the discharge is the most dangerous procedure in medicine.
October 31, 2016