Discharge criteria

• To discharge a patient, we must:
  • Achieve the treatment goals.
  • Arrange for a safe discharge.
• Both elements must be present before placing the discharge order!

Treatment goals

• Set the treatment goals for each patient on admission.
• Communicate these goals to your patients! Ideally at the end of our encounter, after you explain the diagnosis and the treatment plan.
• In general, the goal of any admission is to stabilize the primary acute problem to a point where the treatment can be finished as an outpatient (We don’t keep them until the full resolution of the problem).
• The treatment goals mean the following:
  • A significant improvement in the presenting signs and symptoms (Daily ask your patients how they feel on that specific day relative to the admission day).
  • A significant improvement in abnormal diagnostic data (Consistent improvement toward normal).
  • The patient is tolerating diet or has a secure source of nutrition.
  • Stable vital signs ( Not necessarily completely normal vital signs).

   

Example:

You are admitting a patient with acute gallstone pancreatitis with abnormal LFTs, what would be the treatment goals of this patient?

Treatment goals:

• A significant improvement in the presenting signs and symptoms: Significant improvement or resolution of abdominal pain and associated nausea/vomiting.
• A significant improvement in abnormal diagnostic data: Consistent improvement of LFTs toward normal.
• The patient tolerates diet or has a secure source of nutrition: The patient tolerates a regular diet without pain or vomiting.
• Stable vital signs ( Not necessarily completely normal vital signs): No tachycardia, hypoxia, tachypnea, or fever, mildly to moderately elevated BP may be okay for outpatient follow-up

This can be communicated to the patient like this:

“You may be asking how long you will be staying in the hospital. This depends on how quickly you respond to the treatment plan, we will get you home once your pain has resolved, you can eat, your LFTs are improving, and the general surgery team evaluated you for gallbladder removal as it’s the source of your problem, if they decide to remove your gallbladder this admission, then will have to wait until they clear you from their standpoint as wee. I suspect this may take 4 to 5 days, but could be sooner or later, it all depends on your response to the treatment plan”.

Notice that we don’t give any absolute answers to the length of stay or disposition!

Safe discharge

• Elements of safe discharge
  • The patient has a safe place to be discharged to.
  • The patient can perform essential tasks (transferring from one place to another, cleaning, preparing food,..etc.)  or have someone to help with that or be discharged to a place that can help with that.
  • The patient has access to follow-up care, needed medical equipment, and medications.
• The plan for safe discharge starts simultaneously with achieving treatment goals and includes:
  • Early ambulation.
  • Ordering physical therapy, occupational, and speech therapy whenever indicated. This is particularly important in elderly patients.
  • Discontinue equipment as early as possible including weaning of oxygen, discontinuing Foley’s catheter, and any other equipment whenever feasible.
  • Transition into oral medications as early as possible.
  • Advance diet to the patient’s home type of diet as early as possible.
  • Arrange for needed outpatient equipment early such as home O2, outpatient PT,…etc.
• Keep your case manager or discharge planner in the loop. All hospitals now have daily rounds between providers and discharge planets to remove any discharge obstacles.

Disposition

• Hospital patients get discharged to one of the following places:
  • Home independently.
  • Home with home physical therapy.
  • Skilled nursing facility (i.e.: nursing home or subacute rehab).
  • Acute rehabilitation facility.
  • Patients with suicidal attempts or ideation are discharged to a Psychiatric facility
  • Inmates are discharged back to prison.
  • Some patients will be transferred to another hospital for more advanced services.

   

• Physical therapy assessment will guide us on whether the patient should be discharged home, home with home health, skilled nursing facility, or acute rehab facility.
• Home is the best place for the patient to be discharged to whenever possible.
• Homeless patients may be offered to be discharged to homeless shelters.

   

The discharge day

• Explain to the patient discharge instructions/follow-ups/medication/major side effects to watch for new medications, and ask them if they have any questions.
• Reconcile the patient’s medications.
• Ensure prescriptions are sent to the pharmacy.
• To ensure patients have access to medications, particularly essential medications like dual antiplatelets after stent placement or oral anticoagulants for a patient with DVT, we must ensure the patients access these medications with no financial or logistic obstacles.
• Don’t discharge patients until you are 100% sure they can afford their must-take medications.
• Place the discharge order as soon as the discharge decision is made. The time of discharge is a closely metric that is monitored by the hospital administration. Hospitals are pretty obsessed with two things:
  • The length of stay of patients, the shorter it is, the more money they make.
  • Time Discharges on the day of discharge, the earlier we have more room for the new patients to keep the ED flow.

Discharge obstacles.

• Failure to anticipate any discharge needs before the discharge day is the main reason to, unnecessarily,  delay patients’ discharges!
• Discharge needs are something like:
  • Arranging outpatient IV therapy, TPN, outpatient medical equipment, and outpatient services.
  • Submitting early for insurance approval.
  • Working on prescription approval for expensive medications.
• Case managers/discharge planners should be involved on day 1 for the discharge plan. Most hospitals now have daily team meetings to facilitate and streamline the discharge process.
• Trying to fix all medical problems the patient has is another reason for discharge delay! Please focus on the primary problem and any problems that can’t be deferred to outpatient follow-up.

“A patient admitted with an acute exacerbation of COPD and has chronic back pain. Try to stabilize his COPD exacerbation and don’t try to solve his chronic back pain, leave that to outpatient follow-up, just resume his home medications for his back pain”

Discharge note/summary

• The discharge note is a summary of the patient’s hospital stay, a good summary is the one that passes the what I call first glance test!

   

  “The first-glance test: The most important pieces of info are mentioned first in the discharge note ( The reason for admission, discharge diagnosis, and important procedures and diagnostic data)”

   

• The following framework will ensure your discharge note passes the first-glance test:
  • Date of admission.
  • Date of discharge.
  • Reason for admission.
  • Discharge diagnosis: The final diagnosis or the most likely one.
  • Consultations: type of the consultation and name of the consultants.
  • Procedures: Type, date, and performer.
  • Relevant diagnostic data: Relevant to the final diagnosis.
  • Hospital course: a brief description of the events during the hospital stay.
  • Physical exam on the day of discharge.
  • Discharge medications.
  • Follow-up plans.
  • Disposition: where the patient was discharged to.
  • Discharge diet.
  • Discharge activity.
  • Discharge conditions.
  • Acknowledge that you explained to the patient the discharge diagnosis, follow-up plan, and new medications education, and answered all questions.
  • Discharge time: this will affect the billing code and how much payment is to be reimbursed.