Discharging Patients on Holidays?

[blondy2061h, MSN, RN]

I'm not in any way asking for medical advice. I'll make that clear by not even using any specifics.

I work BMT/heme onc. Given the complex nature of our patients we do not discharge on holidays and have meds delivered to the hospital for discharge, where we make sure they have everything and help fill their pill containers for them.

This weekend I got to be on the other side of the bed with a fairly acute, very serious if left untreated condition. I was discharged at 1:30pm today. My pharmacy is open til 5pm today so I went right there to fill the new med I was discharged on. They both don't have it in stock, and it requires prior auth which my insurance has no one doing on the holiday. I was suppose to take the first dose tonight.

I'm wondering what other hospitals do to prevent issues like this from happening when discharges are done on holidays? Do you think you see more readmits as a result? If I were feeling worse, older, or less health litirate I'm not sure what I would do. Probably just skip it and get the first dose whenever the prior auth goes through and the order comes in, which will probably be some time on Wednesday, at which point I'll have missed 4 doses.

[Marisette, BSN, RN]

I have friends who work home health and it's very typical for them to do admissions on weekends or after the holidays. Perhaps, patients request discharge just prior to holidays. I think the patients just enjoy the holidays, miss the medication doses or whatever medical care is required until they can get back to someone who can assist them. It most likely leads to some re-admission for some acute conditions that require immediate follow up from the patient. Perhaps new medicare requirements or "obamacare" will put an end to this practice.

[jadelpn, LPN, EMT-B]

This is a case management issue. Prior to any discharge, there is a discharge planning meeting, a date set up, and that all the discharge instructions are understood, that the patient's pharmacy has the correct medication, and that all of the pre-authorization is done.

Hence why discharge planning starts on admission.

Seems as if the case manager dropped the ball on this one. A thought would be to contact the PCP, and see what alternatives there are. One should not go 4 days missing a medication. Perhaps if the hospital pharmacy has the medication in stock, that can be an outpatient visit or something. I would also call the case manager to assist in this.

You are correct, there are many re-admissions (and we all know that is a HUGE no-no) because proper discharge planning was not implemented.

[wooh, BSN, RN]

Discharge planning. We send plenty of people home on holidays. But we make sure that they can get their meds. It's a big deal for us in peds, even sending home on "common" medications can be difficult if it's a dose that has to be compounded because the common way it comes can't be taken by a little kid.

And pre-authorization, ugh. Can't tell you how many times we tell the MD in the days before a weekend/holiday that they need to start the pre-authorization if they're sending the kid home on something (because you don't even need to be a case manager to realize the common stuff that needs it), and they all of the sudden decide at 5pm Friday, "Oh they'll go home tomorrow on this." Ergh....

[KelRN215, BSN, RN]

Discharge planning. We send plenty of people home on holidays. But we make sure that they can get their meds. It's a big deal for us in peds, even sending home on "common" medications can be difficult if it's a dose that has to be compounded because the common way it comes can't be taken by a little kid.

And pre-authorization, ugh. Can't tell you how many times we tell the MD in the days before a weekend/holiday that they need to start the pre-authorization if they're sending the kid home on something (because you don't even need to be a case manager to realize the common stuff that needs it), and they all of the sudden decide at 5pm Friday, "Oh they'll go home tomorrow on this." Ergh....

Yup, common issue. Resident doesn't care that it's 10pm and PO Zofran requires a PA, he just knows that his Attending told him to discharge this patient and he doesn't want to deal with the Attending in the morning.

In my experience- both in acute care and now in home health, medical teams (other than oncology) don't really pay attention to if everything is set up or not. Surgeons are the worst. They decide on a random Sunday before a holiday "this patient can be discharged"... well, patient is going home with a PICC line on IV antibiotics so, actually, no they can't be. They need a VNA and an infusion pharmacy and they need to get their preliminary teach from the company prior to discharge and that can't happen till Tuesday at the earliest. We used to block discharges for that reason all the time.

There aren't "discharge planning meetings" prior to every discharge in acute care, though. These meetings only happened with patients transitioning to rehab, hospice or private duty care in my hospital. Many of our patients would be screened out by Case Management early on and then, as described above, the surgeon decides at 10pm that the patient who's still having a lot of nausea can be discharged and that he'll just write a scrip for PO Zofran... with nary a care in the world that this medication requires PA.

[blondy2061h, MSN, RN]

I was really surprised this happened actually, because I saw a case manager twice during my 4 day stay. I figured she was on it. She was, in some ways, I guess. The issue got resolved today, literally twenty minutes before the pharmacy closed. I got a partial fill using a free trial coupon. It took two trips to the pharmacy, a call to my insurance (unsuccessful- closed), two calls to the drug company, a call to the hospitalist group (no answer), and a call to the unit I was on (then two return calls from them). My discharge instructions included no phone numbers to call with questions, so I was Googlkng things and talking to operators. I can't imagine most people recently discharged being up for this.

Tomorrow I get to look forward to scheduling follow up appointments with 4 different doctors and a test.

[jadelpn, LPN, EMT-B]

This is a perfect opportunity to be sure on the survey that I am sure you will be getting in the mail to point out that the discharge instructions leave much to be desired. The only way it can be improved is to say something about it.

Re-admissions are a huge deal. And if there's not enough information on the discharge instructions, or it is not clear then it does not bode well for the unit.

Best of luck, and feel better soon!

[blondy2061h, MSN, RN]

I agree Jade. Overall my care was great, so they'll be getting good reviews, but to can receive good care that still leaves room for improvement. Being a patient really opens your eyes to how the small things you do for patients everyday can make or break their day.

[hikernurse]

We (NICU) try hard not to discharge on a holiday/weekend if possible--just in case something arises at home that parents aren't prepared for. Parents room in, get their home meds delivered to them at the bedside before discharge and have their doctor's appointments made before they leave and STILL there can be problems.

When my kids and parents have been hospitalized, though, discharge is often chaotic. We'll hear it will happen sometime during the day--could be at nine in the morning or eleven at night. Frustrating. My friend's child was discharged from an ICU at midnight, no way is that a recipe for success.

Blondy, I agree that people recently discharged in no way feel up to negotiating all that you needed to do--especially those who don't have a handle on nursing/medical knowledge.

Also, since nurses are the ones who interact with patients most, I bet most discharges that don't go well get blamed on them. My mom has said, "I don't know why the nurses won't let me go home." I explained that most nurses would be more than happy to get her out, lol, but their hands are tied waiting for doctor's orders, one last lab test, one more dose of abx, etc.

[Twinmom06, ASN, APN]

we had this issue last week (although it wasn't a holiday the insurance company was dragging their feet on PA for a specific med that one of our orthopedists uses exclusively) and the hospital pharmacy sent him home with 2 pills to hold him till they got the PA

[flyfarfaraway]

We have a case manager that stays on our floor and if she knows that a patient may be getting discharged over the weekend she will leave instructions for the nurse, precert, paper work, who to call etc.We are also piloting an infloor pharmacy where we give the patient's their meds before they leave the floor which may or may not be a good thing. We will see.

[JDZ344]

We try not to discharge on holidays because no additional services are open.