COMMENTARY

When Can They Go Home? The Pressure to Discharge Patients

Melissa Walton-Shirley, MD

Disclosures

May 04, 2016

The minute a provider accepts a patient for admission, the sand starts pouring through the hourglass. Consults are dealt faster than cards in a floating casino. Clipboard carriers—nurses who now touch paper and screens instead of patients—begin foraging for an early discharge. Nervous bean counters tally the minute-by-minute profit/loss margin. Patients and family members are prompted to worry immediately about losing their life's savings if their fickle insurance company denies coverage. A costly 30-day readmission awaits facilities that push patients out too quickly. Providers lose cash and sometimes incentives if they are unable to chart a course for a solid month of smooth sailing. The storms of noncompliance, aging physiology, and a lack of resources for home monitoring lurk on the horizon. Before a patient can be tucked into bed upstairs, the tug of war between length of stay and quality of stay begins.

The dynamics and culture of hospital conversations have changed. In the good old days, doctors stopped in the hallway to discuss an interesting case or to request a curbside opinion. Those salient medical discussions along with sharing the discovery of the latest fascinoma have been relegated to the pages of medical history. Our daily script is easy now. Nearly all medical conversations begin and end with one question, "Can they go home?" The perfect Stepford physician will always answer, "Yes, of course." The hourglass sand keeps pouring and the conveyor belt from the ER to the ward continues to crank as long as everyone is in agreement. Answers like, "I'm a little concerned about their risk-factor profile" or "I'd feel better if they stayed one more night" abruptly grind the moneymaking machine to a halt. Smiles suddenly contort into something resembling Edvard Munch's The Scream. One can bet the collective anguish will always eventually find its way to the CFO's office.

I was chastised once for my reluctance to bless the discharge of a patient whose body-mass index was 47 and whose father had died of an MI at an age 7 years younger than my patient. This patient smoked one pack per day, was insulin requiring, and complained of neck discomfort hours after his supraventricular tachycardia had been one-two punched with a diltiazem bolus. A normal ECG and a negative troponin series did not allay concerns regarding his risk-factor profile and his symptoms. After IV beta-blockers, the rest pain was relieved. The following morning, I was on my way to have another "You need a cath" discussion when I got the call. You guessed it. "They don't meet criteria to stay" was the pronouncement, followed by the inevitable question, "Can they go home"?

My mental replies were "I don't care" and "No," but decidedly more politely I offered some suggestions to help the hospital personnel know when it's time to go home from a cardiologist's perspective.

They (the chest-pain patient) can go home IF:

  1. They have two negative troponins 6 to 8 hours apart and no ongoing symptoms.

  2. They have walked in the hallway without recurrent symptoms.

  3. Their ECG the following morning is unchanged.

  4. Symptoms have remitted and they have undergone a normal stress exam with negative biomarkers (in some instances as an outpatient).

  5. They have undergone a cath for leaking troponins, ECG changes, or ongoing symptoms.

  6. Their procedure reports from an outlying facility have arrived and have been reviewed.

  7. Their telemetry has been reviewed and found to be benign (no one seems to look at telemetry anymore).

  8. They have had appropriate nutrition counseling with Mediterranean-diet information, goal BMI explained, and, for CHF patients, if their sodium restriction, fluid restriction, and the importance of daily weights where appropriate have been explained. (Mediterranean diet adherence=50% reduction in death—try finding a pill that will do that with an NNT of 1).

  9. They have prn nitro available for an established diagnosis of CAD and if its use has been explained. (I promise that in some instance this will help your 30-day readmit rates if we put the nitro safety belt on the patient at discharge.)

  10. An echocardiogram has been ordered and read if one hasn't been performed in the past 12 months for LV function and valvular status.

  11. A clear-cut list of their medications has been explained and an accurate reconciliation of home meds has been made available to the patient and/or family members.

  12. Good follow-up has been offered.

These are the unchanging requirements for a safe or optimal discharge for a cardiac patient.

I don't really give a flying flip if the average length of stay is 25 days for any patient who isn't ready for discharge. As physicians, we swore an oath to patients, not facilities. On the other hand, I'm not an obstructionist. I'm game to get a stable well-recovered patient home as soon as it's appropriate. Quite frankly, a hospital can be a dangerous place for a patient who no longer needs it, but it's also dangerous to push patients out before they are ready.

If the patient isn't truly ready for discharge, hospitals and hospital personnel won't like me very much. It's not a popularity contest, so it doesn't matter. When I raised my hand and swore an oath in 1986 I vowed to side with quality of stay over length of stay. There was no clause in my oath that made exception for changes in the US economy. I believe that's how most US cardiologists and physicians still roll. I'm proud to be one of those. I vow to always be one of those, so when I'm asked when a patient can go home, my attitude will always be, "When they are good and ready."

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