Over the years, I have heard families bemoan that their relative who was just readmitted to the hospital was sent home too early just a few days ago. Are they right?
First, let me say that in some instances they may be correct. It is certainly possible that the hospital, under increased pressure to kick folks out, may have pulled the discharge trigger too soon. The hospital is not always right even if their discharge checklist seemed to be in order. Of course, patients are not adequately represented by a checklist any more than physicians’ quality can be fairly measured in the checkoff, cookbook method that the government and insurance companies are now championing.
The hospital discharge checklist may indicate that a patient with pneumonia can be safely discharged home as she has no fever or need for supplemental oxygen. However, this patient may be 89 years old, riddled with arthritis and needs to attend to a spouse suffering from Alzheimer’s disease. Is she really ready for home life?
Hospitals these days are more careful than ever about premature discharge, not so much from newfound compassion, but because they will suffer a financial penalty if a patient is readmitted within 30 days under certain circumstances. For example, if a patient with congestive heart failure is sent home, but then returns two weeks later with worsening heart failure, then the hospital will lose money. This has created a robust outpatient follow-up industry with visiting nurses, physicians and social workers to try to keep folks from coming back to the hospital, at least within 30 days. (Joke alert: The terminal phrase of the last sentence was in jest.) I applaud this system that serves everyone’s interests.
In the hospital, care coordinators cruise through the corridors leafing through charts to initiate discharge planning. These are nurses who have left the wards for a cleaner administrative function. Although I did disparage the hospital discharge checklist mentality above, and rightly so, I have found these care coordinators to be compassionate and understanding with regard to individual patient circumstances. They know when to bend some rules, perhaps because they were once hands on nurses themselves.
Sometimes, a patient needs to be readmitted to the hospital, and it’s simply no one’s fault. It is a difficult concept for many Americans to grasp that an adverse event could occur without an individual or an institution to blame. Remember, we live in a society where folks sued Burger King alleging the company was responsible for their kids’ obesity. I counsel families that when we are sending their relative home, particularly when they suffer from chronic diseases or other incurable conditions, that we do so based on what I and the others on the team know at the time. We are not clairvoyant. If we had this power and knew that the patient would become more ill three days hence, we wouldn’t sent him home. It may not be quite fair, but would be quite understandable, to wonder if a patient who is readmitted should never have been discharged home in the first place. There are some patients who are so fragile, that they can tilt backwards anytime and for very small reasons.
What we know for sure is that life and illness are unpredictable.
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.
