Discharging by Wheelchair

choughlesRN · Dec 18, 2017

Our hospital has volunteers who can assist patients down to the front door, however hospital policy requires that they use a wheelchair. If a patient wants to walk, though, I'll walk downstairs with them. My only requirement personally is that he or she has a staff member or volunteer with them. I also try to chart pretty thoroughly on my patients' ambulatory capability: they walked 300 ft twice during the morning. This way, it's pretty clear what they are capable of doing.

nursej22, MSN, RN · Dec 18, 2017

People used to tell me all the time that it was "policy" that all patients must go via wheelchair, but there was no such policy. i worked on a cardiac floor that admitted and discharged rule out Mis in less than 24 hours. I always gave them the choice, and most chose to walk out, and I think many drove themselves home. No narcs on board, usually suffering from GERD. This was a smallish hospital though. Our elevator led straight to the lobby and the pick-up, drop-off area.

Of course, post-op were different, even though most ambulated 100 ft four times a day, they got a wheelchair, which was also useful to transport their belongings.

Kooky Korky, BSN, RN · Dec 18, 2017

I think it is an ingrained habit of sorts. in my local hospital, due to earthquake damage repair there is currently only one entrance and exit, and if someone is discharging from the medical wards it can be a hell of a long walk for a newly discharged patient.
I think though it requires some critical thinking, for example, my mum is terminal and I suspect in the last stages of life. She was in hospital recently for urosepsis, and while she is able to walk short distances around the ward she would have most likely collapsed had she walked all the way from the ward to the exit. . A young healthy or even an older healthy patient may perfer to walk out, some like to walk but have a wheelchair to carry their suitcase
I think the crux iMO is dont just do something without thinking, we need to be asking ourselves 'if this patient is mobile, why do they need a wheelchair" or do they just need a chair for their stuff

Good points but people also need to keep their jobs. Hence they need to follow the rules until those rules are formally changed.

Use the wheelchair. For the patient.

I am sorry about your Mom.

Trauma Columnist · Dec 18, 2017

I'll give you one scenario:

AAOx3 normally completely independent with all ADLs, drives, works, etc. However, just had major abdominal surgery, discharged the next day home. The distance from the hospital room to the pick-up point is multiple city blocks in length. So, for pt comfort and safety, wheelchair is used.

At home, this pt doesn't have to walk multiple city blocks in her house, so is safe to ambulate there.

KatieMI, BSN, MSN, RN · Dec 18, 2017

I'll give you one scenario:
AAOx3 normally completely independent with all ADLs, drives, works, etc. However, just had major abdominal surgery, discharged the next day home. The distance from the hospital room to the pick-up point is multiple city blocks in length. So, for pt comfort and safety, wheelchair is used.
At home, this pt doesn't have to walk multiple city blocks in her house, so is safe to ambulate there.

But:

- for some reason, patient was only ambulated to the restroom and back to bed during his entire hospital stay. His RNs routinely had 6 to 8 patients per shift, and CENAs had 10 to 12, so nobody had time to talk him into walking more or document it.

- as the patient was in hospital for only 4 days and he was completely independent before, he only had brief encounter with Case Management. CM asked, and was told, truthfully, that the patient lives with his wife in 1- level private house, no stairs, easy-in bath, bath stool, etc., etc. The patient was not asked, and so CM never got to know, that there was 200 yards walk from his garage and post box to the house's door, and that the walk was in fact, narrow thread made "rustic" by natural stone paving. CM wrote "no needs identified" note.

- POD#6 (48 h after he was discharged) patient walked out that 200 yards walk to get post and fell, hitting his head. He lost consciousness and was out there in sub-freezing temp for quite some time. ICU, LTACH, chronic vent, GCS 7, all the shabang.

- family sued, exactly the way Muno described it. They felt that lack of assessment of what patient could and couldn't do and therefore lack of recommendations constituted neglect, and that he was only carefully walked within his room before discharge and sent to d/c area in wheelchair showed that there were indeed concerns about his ability to walk independently but "nobody told us that, so we had no idea". Besides this, the discharge summary had note "activity ad lib, do not drive, do not raise/carry over X pounds" but nothing about "do not walk over X distance".

The case was presented as part of "Legal implications for Advanced Nursing Practice" workshop which I attended while in school. It was apparently settled out of court. I imagine that it was more than minor irritation for everyone involved.

Susie2310 · Dec 18, 2017

But:
- for some reason, patient was only ambulated to the restroom and back to bed during his entire hospital stay. His RNs routinely had 6 to 8 patients per shift, and CENAs had 10 to 12, so nobody had time to talk him into walking more or document it.
- as the patient was in hospital for only 4 days and he was completely independent before, he only had brief encounter with Case Management. CM asked, and was told, truthfully, that the patient lives with his wife in 1- level private house, no stairs, easy-in bath, bath stool, etc., etc. The patient was not asked, and so CM never got to know, that there was 200 yards walk from his garage and post box to the house's door, and that the walk was in fact, narrow thread made "rustic" by natural stone paving. CM wrote "no needs identified" note.
- POD#6 (48 h after he was discharged) patient walked out that 200 yards walk to get post and fell, hitting his head. He lost consciousness and was out there in sub-freezing temp for quite some time. ICU, LTACH, chronic vent, GCS 7, all the shabang.
- family sued, exactly the way Muno described it. They felt that lack of assessment of what patient could and couldn't do and therefore lack of recommendations constituted neglect, and that he was only carefully walked within his room before discharge and sent to d/c area in wheelchair showed that there were indeed concerns about his ability to walk independently but "nobody told us that, so we had no idea". Besides this, the discharge summary had note "activity ad lib, do not drive, do not raise/carry over X pounds" but nothing about "do not walk over X distance".
The case was presented as part of "Legal implications for Advanced Nursing Practice" workshop which I attended while in school. It was apparently settled out of court. I imagine that it was more than minor irritation for everyone involved.

MunoRN ruled out inappropriate discharge planning in an earlier post if I understood his post correctly when I said that the situation appears to me to be more a question of appropriate discharge planning.

ruby_jane, BSN, RN · Dec 18, 2017

Excellent point. Maybe this is one of those sacred cow things that evidence-based practice was supposed to eliminate.

Orion81RN · Dec 18, 2017

So if you feel they aren't able to safely ambulate independently at the time of discharge, why do we assume that something magical will happen in the 5 or 10 minute car ride home that will suddenly make them safe to independently ambulate?

Not every person who cannot ambulate more than a short distance requires care from an acute care setting. We wouldn't have enough hospitals if that were the case. People are discharged with home health, private duty, PT.....many discharge instructions to continue to heal once they no longer require acute care.

Flatline, BSN, RN · Dec 18, 2017

I believe there are several reasons why it is commonplace to take a patient out by wheelchair;

1) Regardless if the patient is fully capable of walking or running 12 miles, wheeling them out is a very minor intervention that may prevent harm

2) As previously stated, some ambulation is not the same as being able to ambulate long distances as typically required to leave a hospital

3) Tradition that has very little downside so has survived the ravages of time.

MunoRN, RN · Dec 20, 2017

Not every person who cannot ambulate more than a short distance requires care from an acute care setting. We wouldn't have enough hospitals if that were the case. People are discharged with home health, private duty, PT.....many discharge instructions to continue to heal once they no longer require acute care.

I'm not sure where it was claimed or even implied that everyone some degree of activity intolerance can't be discharged from the hospital.

Again, I'm referring to the blanket belief that no patient should ever leave the hospital on their own two feet. This is different than recognizing the patient's post-discharge activity level will be less than what is required to exit the hospital, and therefore discharging the patient via wheelchair.

MunoRN, RN · Dec 20, 2017

I'll give you one scenario:
AAOx3 normally completely independent with all ADLs, drives, works, etc. However, just had major abdominal surgery, discharged the next day home. The distance from the hospital room to the pick-up point is multiple city blocks in length. So, for pt comfort and safety, wheelchair is used.
At home, this pt doesn't have to walk multiple city blocks in her house, so is safe to ambulate there.

And that would be an example of a situation where the patient was discharged by wheelchair because the specific circumstances were considered.

To apply wheelchair-only discharges as a general rule, then these criteria would need to be generally applicable. And it's not typical for the distance between a patient's room and a generally utilized pick-up spot to be "multiple city blocks" away, and actually if the nearest exterior exit is that far away then the hospital is in violation of multiple building and safety codes.

The "typical" distance can be quantified. The median square footage of a hospital is 70,000 square feet, and is about 2.5 levels, so the "typical" length/width of a hospital level is 175 feet.

Munch · Dec 22, 2017

As others have said..patient rooms can be very far from where they are exiting. My hospital campus is HUGE as a matter of fact when I first started I was given a compass!