Discharging by Wheelchair

[MunoRN]

I've always been perplexed by the practice of discharging a patient, who will be independently ambulatory upon discharge, by routinely taking them to the hospital exit in a wheelchair. In my experience this opens up the hospital to significant liability issues, is there a rationale that justifies this that I'm not seeing?

[TriciaJ, RN]

If the patient was ambulating safely on the unit i.e. walking around independently up and down the corridors prior to discharge, and was discharged in the care of a responsible adult who would assist their walking at home if needed/assist their needs at home, with the offer of physical therapy and home services if needed, discharging the patient in a wheelchair so that they aren't expected to walk the often considerable distance from their room in the facility to the vehicle of their awaiting ride home in the facility parking lot is reasonable to me. It means they get to the vehicle of their ride home safely, which is to their benefit and the facility's.

And since this is standard practice at health care facilities everywhere, I can't see how this was a legal slam dunk for the plaintiff. There's more to this story.

[MunoRN, RN]

It's the distance involved. At home a person might be quite able to ambulate the short distances in his house and can rest when desired. Someone who's only a few days postop might have significant difficulty walking from his hospital room down the hallway, standing on the elevator and walking through a large hospital out to the patient pick-up area.

It's actually similar distances. Typical home ambulation is similar to the ambulation distance between a patient's room and the closest pick up area, which even in large hospitals is not usually more than 300 feet.

[MunoRN, RN]

And since this is standard practice at health care facilities everywhere, I can't see how this was a legal slam dunk for the plaintiff. There's more to this story.

It's definitely not "standard of practice".

"Standard of care/practice" is a legal term, and means a practice is universally accepted as the only way to do something. Requiring that all discharged patients exit the hospital by wheelchair does not have that level of agreement, or anywhere close to it.

[Fiona59]

In my province, you walk out if you are capable of walking, or using your crutches. Baby should be carried out in the car seat or pushed in the pram.

My favourite unit manager once said to a patient "you walked in, you walked around the unit, you are walking out the door".

What is it with Americans and wheelchairs? Too many TV medical soaps/drama?

[Cat365]

It's actually similar distances. Typical home ambulation is similar to the ambulation distance between a patient's room and the closest pick up area, which even in large hospitals is not usually more than 300 feet.

I have never been in a hospital that had an exit within 300 feet of an inpatient unit.

Actually I take that back. My county hospital which has less than 40 beds in the entire hospital does. I can think of 8 others that don't. Most of them the elevator is more than 300 feet from the majority of the rooms.

[JKL33]

It's definitely not "standard of practice".

"Standard of care/practice" is a legal term, and means a practice is universally accepted as the only way to do something. Requiring that all discharged patients exit the hospital by wheelchair does not have that level of agreement, or anywhere close to it.

"Standard practice" being a common thing that is often or usually done (colloquially "SOP," etc.). Maybe someone's standard practice for communicating with family at the holidays is to send out an update letter - it's what they usually do.

Standards of practice set forth by professional or trade organizations are different than "standard of care" (associated with tort law) and they are both different than just saying standard/usual/common practice.

[turtlesRcool]

How big is your house or apartment?

Because my house is considerably smaller than my hospital.

A person can be ambulatory for short distances, say the living room to the kitchen or the bedroom to the bathroom, but not be up for the long corridors and twits and turns it can take to get from a patient room to the lobby.

[blondy2061h, MSN, RN]

We don't discharge walkie-talkie patients in wheelchairs and the last time I was hospitalized they let me walk out on my own when I was discharged, carrying my bag and all, then drive myself home.

[NurseNeLz]

Yup thats why if they ambulate well I

let them

leave without a wheelchair. My exact rationale if it was ever questioned. Just make sure to document well.

[KelRN215, BSN, RN]

I got thoroughly chastised recently because I let a mother walk out of the hospital, CARRYING her newborn in her arms (she had a convertible corificeat in the car).

Pedi nurse here. When I worked inpatient we never routinely discharged patients in wheelchairs, only kids that are in a wheelchairs at home, but officially it was policy that parents could not carry their infants in their arms. When said hospital was featured on a reality medical program, it did not stop ABC from filming a "discharge" where the parents carried their baby out though.

I've typically refused wheelchair escorts when I've been discharged from the hospital.

[Susie2310]

Let's not forget we are talking about patients who usually have just been acutely ill and are going home to spend the rest of their recovery there; they are less sick than when they were admitted, but they are far from being well yet. In most of the hospitals I am familiar with the inpatient care floors are a considerable distance from the parking lots and require walking along multiple corridors, taking elevators/descending stairs and sometimes walking along still more corridors until one reaches an exit door to the parking lot. In my experience, ambulating in a hospital unit corridor or even around the unit does not compare to the trek the patient is often faced with to reach the exit door of the building if they don't make the journey in a wheelchair. And then, depending on whether their ride home has been able to bring the car close to the building or not, they may be faced with another walk across a large parking lot. The homes of the people I know require far less walking to get from room to room than the distance patients are faced with in getting from their hospital room to the exit door of the building.

[JKL33]

I think there's some confusion about what "liability" is. Liability is not determined by geographic location, liability is in action or lack of action which a prudent person would have taken that would have avoided harm or injury.

If a person falls while walking down the hall of the hospital after being discharged, and there was no clear basis for believing the patient was not safe to do so then there is minimal liability. If the patient falls at home shortly after discharge, and it can be shown that staff recognized this risk but didn't alter their discharge plan, then the liability is with that decision (a decision that occurred in the hospital by hospital staff) not where the fall occurred.

Basically, the question that will come up in court is: "In your assessment of the patient's readiness for discharge, you agreed with the plan which included the patient being independently ambulatory. If that was the case why do you direct the patient to be taken to the pick-up area by wheelchair?" The answer seems to be "because the patient can't walk that far (typically a few hundred feet) without an increased potential for falling", which completely destroys the "they were assessed as safe to independently ambulate at home" argument.

I'm not so sure that MMQs within our own ranks don't have something to do with this. I don't think it's an isolated phenomenon that nurses in recent history have become accustomed to discharging by w/c and may believe (due to having been told) that it's a liability to let the patient ambulate out. So, where did those ideas come from? At least in part, they come from people who weren't there, critiquing things after the fact and saying things like, "This was improper discharge planning, because, well....look what happened!"

I also don't think it stands to reason that if one is expected to get along in their own home then they by definition will have no problems walking out of a hospital. If they live in a small home/apartment, they can sit in a chair in their main room and be not much more than several steps away from kitchen, bathroom, or bedroom - this is why they don't use their walkers, too - why should they when all they have to do is hold onto the chair back/table/wall for 10 steps to get to the bathroom! :) Basically anyone who does well within their own home but doesn't leave it independently may also be a candidate for getting a ride to the door even though they're going to be fine getting around at home. Not to mention, "unfamiliar environment" is, itself, a fall risk.