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Hospital at Full Census; Surgery Patients Discharged Too Early?

Posted May 16 2012 12:00am

We need beds. Discharge every patient you can. Most hospital-based physician will be familiar with this refrain. The problem is that it can lead to premature discharges of some patients, particularly post-op ones who may require closer monitoring and sophisticated nursing care. Revenue-driven surgery and poor planning result in some surgical patients being discharged too early concludes a pair of logistical studies conducted by researchers at the University of Maryland (see: Revenue-driven surgery drives patients home too early ). Below is an excerpt from the article:

The studies show a correlation between readmission rates and how full the hospital was at the time of discharge, suggesting that patients went home before they were healthy enough. The researchers recommend better planning and other logistical solutions to avoid these problems ....“Discharge decisions are made with bed-capacity constraints in mind,” [said one of the study authors]. “Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment,”[he added]. [The studies] found that patients discharged when the hospital was busiest were 50 percent more likely to return for treatment within three days....Surgeons and hospitals are incentive-driven to perform as many surgical procedures as feasible....“The hospital has to maintain revenue levels to meet its financial obligations. Surgeons are working to save lives and earn a livelihood. It’s what they do....“If the hospital says ‘sorry there are no beds available,’ there’s a lot of tension and pressure from both sides to keep things moving.” These problems are much more likely at large hospitals, which tend to provide more advanced, specialized surgeries not accessible at smaller, community institutions,the researchers say. Patients often have to travel a great distance for the procedures, so hospital delays become expensive for both them and the care providers. The study findings cover surgical discharge data from fiscal year 2007 covering more than 7,800 surgery patients who collectively spent 35,500 nights at the facility....Also, he suggests that hospitals increase the flexibility of where patients go post-surgery. Allowing them to be moved to units with empty beds, for example, could also lessen premature discharges.

All of this makes great sense to me. Now comes the interesting part. How are patients and their relatives supposed to convince a surgeon not to discharge a patient prematurely in the face of pressure from "upstairs". The latter often comes from hospital physician executives. The best argument, echoing the discussion in the excerpt above, is that the patient is not ready to go home and stands a good chance of being readmitted. This is an argument that will resonate with a surgeon if it is likely. A good surgeon, in fact, will have an understanding of which patients will do best at home and which should remain in the hospital for a longer stay. A patient's family should stand their ground and appeal a perceived premature discharge if the facts are on their side. Here's an excerpt from an article relating to premature hospital discharge (see:  New Medicare Rules Protect Against Premature Hospital Discharge ):

As a result of litigation initiated in 2003, hospitalized Medicare patients will now be better protected against being forced out of a hospital before they can be safely cared for at home or in a nursing home. The new regulations require that patients be given notice of their discharge rights on admission (although it can occur up to two days later) and again at least four hours before discharge. If patients or their families believe the discharge will be premature and not in a patient's best interest, they are entitled to an expedited review of the discharge decision. If they request an expedited review, the patient can remain in the hospital without charge at least until noon of the day following an independent agency's review. The independent review agency is called a Quality Improvement Organization (QIO) , and the patient must get in touch with its staff by phone or in writing before the close of business on the day the hospital plans to send the patient home. The QIO demands that the hospital give the patient a detailed, written explanation of her medical condition and the basis for the proposed discharge. 

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