Thursday, 3 April 2008

The Patient Discharge Plan

Dear Bloggers

Patient home discharges are as important as admitting the patient and getting the diagnosis and treatment correct.

As a medical student I was never taught how to assess a patient to plan for a discharge home. I assumed that it would be up to the decision from the senior doctor to decide whether the discharge home was appropriate. As I did my house officer years (residency) in the UK, through the many, many and sometimes tiring ward rounds, I was able to understand how the Consultants decided on how best to plan for a home discharge.

Young patients could usually be discharged on the day the Consultant gave them permission to leave hospital whereas with the elderly patients with mobility and social problems, I learned that a multi-disciplinary team was necessary to provide a safe transfer out of hospital to avoid re-admission because of failure to provide adequate supportive care. For example, elderly patients sometimes need a home visit with an Occupational Therapist to decide whether in fact the accommodation is safe or whether modifications need to be made to make the place more safe. Moreover, some patients who have no home support e.g. no family, need social worker advice to plan for home helpers or new accommodation.

Patients who have become weak after illness need rehabilitation to improve their activities. Sometimes, nutritionalists need to assess the patient to ascertain if calorific intake is sufficient.

All of these other modalities need to be considered in the elderly patients or those patients with special needs.

Hence, when the patient is admitted, it is worth considering when you are thinking of discharge home and what special services the patient is going to require. Hence, a plan can be organised early to engage such services so that the time can be used optimally. It is no good to just sort out the patient's pneumonia and at the end of it say that the patient can go home if they live in bad accommodation, have no support and can't walk properly.

However, patients who have no pre-morbid or social problems can usually be safely discharged as soon as possible.

I have heard of somewhat unusual examples as reasons for keeping patients in hospital and they include
  • waiting for the the CRP or ESR to become normal
  • waiting for liver function to completely normalise
  • waiting for dose of prednisolone to become less than 30mg/day
I previously based my discharge of patients particularly on how they felt and how they looked by physical examination with of course taking into account investigative data. A patient with a recent pneumonia who has entered the recovery phase and is feeling well should not be kept in hospital just for the sake of watching the CRP. That is not a cost-effective reason and blocks an acute bed costing the patient and medical services more money with no particular evidence basis for keeping such patients in hospital.
The CRP in such patient is of course going to be raised, but it is the patient's clinical condition that is most important.

A patient with a raised ESR for polymyalgia make take several weeks or even months to decreased to an acceptably 'normal' level on steroids. Most PMR patient feel well within 48-72 hours of starting steroids and by keeping 'well' patients in hospital again serves no purpose.

Doses of steroids e.g. prednisolone >30mg/day is not a good reason for keeping patients in hospital. Yes, steroids are associated with many adverse side effects. However, if patients are well on their treatment and they have a good social structure and can attend regular outpatient appointments for assessment, then there is absolutely no reason to keep patients in hospital even on high dose therapy.

Patients mostly want to get back to some sort of normal home life, and the longer they remain in hospital the more institutionalised they will become. Moreover, the more they are kept in hospital, the more expensive it will be for them.

In addition, the more patients that you acquire on your medical service without discharging them, despite the fact that they are well, it will lead to the system becoming clogged up with well patients!

Well patients should not be kept in the hospital a second longer than is necessary.

Please consider....