The Patient Has Left the Building

The Hospitalist. 2008 August;2008(08):

August 1, 2008|The Hospitalist

The hospitalist service at the University of Wisconsin Hospital and Clinics in the Department of Medicine recently admitted a patient with altered sensorium, which the team determined most likely was narcotic-related. Going the extra distance, they did a spinal tap to rule out meningitis.

Within a day of changing the medication, the patient got better and was ready for discharge. However, says Julia S. Wright, MD, director of the Madison-based service, an important test remained from the spinal tap. “We thought that those results would not change the medical management of the case, but we knew if it were positive, it would be a big deal,” she recalls.

Not all medical-legal experts would agree the responsibility for patient care ends when patients leave the hospital. Often there are extenuating circumstances that may warrant the hospitalist’s continued communication and contact with patients and/or their providers and caregivers. Although there are no universally accepted standards of care that define these post-discharge issues, several hospitalists recently discussed their institutions’ and groups’ guiding principles for managing the nuances of post-discharge protocol.

Who’s Responsible?

Hospitalist Jeffrey Greenwald, MD, associate professor of medicine at Boston University School of Medicine, is a member of SHM’s Hospital Quality and Patient Safety Committee and also has been investigating pre- and post-discharge interventions through a grant-funded project from the Agency for Healthcare Research and Quality (AHRQ) called “Project RED” (the Re-Engineered Discharge, online at www.ahrq.gov/qual/pips).

One reason the post-discharge period is a “gray zone” of responsibility for care, he believes, is that the hospital system was designed to have a finite endpoint—the discharge. “This ‘out of sight, out of mind’ mentality has existed forever in the inpatient service, but it has become more highlighted in the post-hospitalist era,” he notes.

That mentality can sometimes take over in the hospitalists’ minds. “I think a lot of hospitalists are burying their heads [in the sand] about how these patients are being sent home and the chances for miscommunication and a ‘bounce-back,’ ” notes David Yu, MD, FACP, ABIM, medical director of hospitalist services, Decatur Memorial Hospital, Decatur, Ill., and clinical assistant professor of family and community medicine, Southern Illinois University School of Medicine. “This is going to be more of an issue as hospitalists become increasingly busy. The temptation is to squeeze time on discharges, because it takes an effort to reconcile medications and tie up loose ends at time of discharge. It is not acceptable to write, ‘resume current medications and follow up with PCP’ and think the job is done. It is magical thinking that discharge medications and follow-up instructions will be figured out somehow by the patient and discharging nurse.”

Potential Problem Scenarios

During discharge transitions, many factors outside the hospitalist’s control can lead to gaps in care. According to Dr. Grace, having a well-streamlined post-discharge period can be most problematic with:

Younger patients (“I feel fine; I don’t need to keep that appointment”);
Elderly patients living alone (especially those with mild, early dementia, and lack of family support systems); and
Indigent patients (for whom paying for outpatient care is often a barrier).

In addition, patients may not have a primary care physician to whom care can be transferred. If this is the case at Decatur Memorial Hospital, says Dr. Yu, “we either call one of our PCPs who is accepting new patients, or we’ll assign them to a local clinic and communicate that in our discharge. We always try to document some mechanism of follow up, because if you don’t tie up these loose ends, you’ll no longer be a hospitalist service, you’ll be a primary care physician.”

Dr. Grace shares this philosophical approach. “During orientation, I try to ingrain the concept in our new hospitalists that you have a continuing responsibility for patient care until the patients have re-established contact with their PCP after discharge,” he stresses.

His group employs a practice coordinator to supply extra continuity after discharge. The coordinator recently noticed a chest X-ray came back after a patient had been discharged. The X-ray originally had been ordered by the emergency department (ED) unbeknownst to the hospitalist. The patient was transferred upstairs before the ED physician saw the film and discharged prior to the report reaching the chart, where the hospitalist would have seen it. The coordinator flagged the X-ray; the hospitalists reviewed it, noticed a worrisome mass, and secured an appointment with a pulmonologist for the patient. “Had there been a bad outcome and the case ended up in court,” says Dr. Grace, “the jury would likely conclude that we were at fault. Without effective processes in place, an important test result may get filed away in the chart, never reaching the physician, and never to be seen again.”—GH