Hospital Discharge Planning - Is the Hospital Sending You Home Too Soon?

In 1990, Desert Storm was initiated by President George H.W. Bush, along with coalition partners to reverse Saddam Hussein’s aggression with respect to Kuwait.  As American and allied forces moved into Iraq, many hawks wanted these forces to advance to Baghdad, and drive out Saddam Hussein.  As we all know, President Bush pulled us out as he did not feel this objective was part of the mission.  He knew when to get out.

Now, physicians are not military strategists, but there are parallels between military strategy and patient care, particularly when a patient is hospitalized.  Consider the following schema.  

The Conflict:  A patient arrives in the emergency room with a cough and a fever. 

The Mission: Disease eradication

The Tactics:  Hospitalization

Exit Strategy:  Getting the patient out.

Physicians, just like the generals in the Situation Room in the White House, need a sound battle plan.  The plan must be flexible enough to adapt to changing contingencies and unforeseen events.  I have found that explaining the Exit Strategy to patients and their families can be a challenging undertaking, in contrast to explaining the tactical decision to hospitalize someone.  For example, if a physician recommends hospitalization because this option is felt to be safer and appropriate, then patients and families readily accept this.  (Ordinary folks would not be expected to consider the risks of hospitalization with regard to infections, errors, sleep deprivation and excessive medical testing, but let’s leave this aside for now.)

In my experience, patients and their families need and deserve a detailed explanation from the doctor when hospital discharge is advised.  Here are some points that I cover during my Exit Strategy discussion.

Choose a Physician Who Can Predict the Future

Discharge home does not mean that the individual is 100% cured.  It means that the medical team believes that the recovery can safely continue at home or at an interim facility.  Hospitals are now equipped with teams of home care medical professionals, social workers and therapists to continue care and treatment after discharge.  In the olden days, patients would be fully recovered during their hospital stay, and might even linger a day or two longer because they could.

Every extra hospital day, as I noted above, carries direct health risks to the patient.  Feel free to Google, C diff, and you will readily understand my point.  Most families are not fully aware of the risks of hospital life.

Despite our extensive medical training, physicians were not taught the art of clairvoyance.   This is a serious oversight by medical educators as this skill would have enabled us to be much better physicians.  Hopefully, as medical education reform continues, students will be taught this practice so they will know exactly when to prescribe, when to operate, when to observe and when to refer to a colleague.  I take special effort at discharge to explain to patients and families that we are not fortune tellers. We know only what we know, not what will be.  If we knew, for example, that Granny would take a turn for the worse 3 days after we sent her home, then we would not have discharged her.  While physicians can certainly discharge a patient too soon, the fact that a patient’s condition worsens after discharge does not automatically mean the decision to discharge was wrong or premature.  I think it’s important that patients and their families buy in to the rationale and timing of hospital discharge.  If they haven't, and Granny's condition goes south in a few days, then the physician may face an irate family or be relieved of command.

The best generals and the best physicians are those that know when their mission has been accomplished and how to extract their people out safely.