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?

[JKL33]

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!

Yep. People can walk from parking lot into the local superstore (and then get a motorized cart to ride around in) with far fewer steps than they can get out of my hospital via a usual patient exit (such as a pick-up area), and we are in compliance with related laws.

[LadysSolo]

In KatieMI's example, what happened to "common sense?" If you are too weak or it's too cold/slippery to walk outside safely, DON"T DO IT! Everyone seems to want someone be responsible for thinking for them. When I worked in the hospital (on an oncology floor) everyone went out via wheelchair, it was hospital policy (I presume to reduce liability.) But "hospital policy" might have worked to prevent liability ("No one felt he/she was unable to walk that far, it was hospital policy to be taken to the door via wheelchair.")

[dudette10, MSN, RN]

"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."

No, it doesn't. Who lives in a house that is "a few hundred feet" long or wide? The woman next door with advanced COPD has a first floor bedroom and bathroom, with a living, kitchen, and sitting area. Her home is 30 feet long and 20 feet wide on the main floor. She can ambulate just fine at home, but to ask her to ambulate independently "a few hundred feet" would probably cause her to collapse.

[dudette10, MSN, RN]

But, for a potential solution, is it possible to compare the PT notes to the distance from the room to the main exit and make a decision from there? A SmartText feature could be put into the nurse's notes indicating distance walked with PT or recorded by staff ambulation without rest, then the distance to the exit, and wheelchair or ambulation device noted for discharge. It's not a straightforward decision...it's based on the condition of the patient at discharge compared with the size of someone's house and that a chair is usually no more than 10 feet away at home.

C'mon. It's hard to believe that a wheelchair used at discharge is the ONLY argument made for the plaintiff to determine liability. What about patients with COPD and CHF that still live at home. Don't we teach them energy conservation methods? What about patients who can walk from a wheelchair accessible spot but need a motorized wheelchair to shop? It's about distance. Not "wheelchair or no wheelchair" to determine independent ambulation ability given the environment!!!

[dudette10, MSN, RN]

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?

I ask this because part of my FTE is as a sort of liaison between our risk management and clinical practice. We had a case where a patient was suing for unsafe discharge after falling at home after discharge, all they have to prove is that hospital staff was aware they weren't safe to ambulate independently, and the fact that the nurse charted that they were discharged via wheelchair (because the nurse didn't think it was safe for them to ambulate to the hospital exit) made it a slam dunk for them.

It wasn't hard for them to find similar cases, mainly involving "ambulatory" surgery centers, in each case the plaintiff won easily, so I'm not sure why the practice persists.

I should clarify I'm not referring to patients where an inability to ambulate a reasonable distance has been a consideration in discharge planning, and where appropriate arrangements have been made to address this after discharge. I'm referring to considering this to be just a standard rule for everyone and where no reasonable argument can be made as to why they are clearly unsafe to ambulate to the pick-up area even though typical ambulation at home is about the same distance.

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.

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.

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.

I've re-read your posts, and I can't get a picture in my mind of exactly what type of patient you are talking about in the instance of YOUR facility and the lawsuit. At first, you stated it was a patient who fell at home and got a "slam dunk" decision because of the argument of distance. You claim it's similar distances (whose home are we talking about that is "a few hundred feet"?!), which is just definitely NOT typical. But, you also acknowledge that some people need a wheelchair for discharge but not at home if appropriate considerations have been made--sometimes, that consideration is the layout of their home without any special accommodations. Then, you go back to the blanket wheelchair rule.

I just don't understand your patient situation that allows you to continually say "well, that doesn't apply and that doesn't apply." So, to be clear in your patient's situation, the patient you are talking about in your facility was taken by wheelchair because the nurse thought the patient wasn't able to ambulate independently all the way to the exit. It was noted that the patient's home was mansion of a "few hundred feet", fell, and sued for inappropriate discharge? If the patient's home was smaller than a "few hundred feet," then the distance argument is relevant!

[3ringnursing, BSN]

I've been a pt and wondered this myself as a nurse. The only thing I could assume is that 1) they want your butt out the door ASAP because they have a bed to fill, and they presume some pt's left to their own devices would dilly-dally longer than acceptable to get house keeping in for a scrub down and timeliness of readmission, and/or 2) it's one of those hold over things founded in hospital beginnings (like bathe pt before MD eval, or massage on 2nd shift, et al).

I've had some admissions where I was completely ambulatory, and some where I could barely hobble around after being in the OR, so I'm thinking it's a bit of both 1 & 2.

Maybe hotels should start this practice too?

[Susie2310]

I've been a pt and wondered this myself as a nurse. The only thing I could assume is that 1) they want your butt out the door ASAP because they have a bed to fill, and they presume some pt's left to their own devices would dilly-dally longer than acceptable to get house keeping in for a scrub down and timeliness of readmission, and/or 2) it's one of those hold over things founded in hospital beginnings (like bathe pt before MD eval, or massage on 2nd shift, et al).

I've had some admissions where I was completely ambulatory, and some where I could barely hobble around after being in the OR, so I'm thinking it's a bit of both 1 & 2.

Maybe hotels should start this practice too?

In the US patients usually have to be very ill to be admitted to hospital and hospital stays often consist of only a few days even for very serious problems, with patients being discharged home to complete their recoveries. Did you even read the thread? This thread wasn't about the subset of well patients undergoing surgery being discharged by wheelchair.

Not all patients are fortunate enough (as you appear to have been) to have diagnoses and co-morbidities that make it easy or even possible for them to walk the usually long/very long distance to an exit door. This thread isn't about you. Put yourself in the place of a patient in their seventies with other co-morbidities, who has been admitted for sepsis (a common diagnosis) which resulted in acute renal failure, barely survived, had some return of renal function, spent three days in hospital, and was discharged home, very weak, to complete their recovery. You don't think that patient should be taken to the car in a wheelchair when they are just beginning to walk again on the unit? That they should be made to walk out of the hospital along multiple floors and long corridors until they reach the exit door on their own two feet? Your comment as an ICU nurse with 23 years of experience (per your bio) is surprising to say the least.

[Elaken]

If a patient is up independently and been walking around their room/the unit, I always let them walk out if they want and someone is with them. I am not the only one. As far as I know my hospital system doesn't have a hard and fast rule other than units like ortho and that is only if their patient is actually ortho and not a regular m/s.

[Ruby Vee, BSN]

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?

The "something magical" is that the family member who was fetching the car while you were wheeling the patient out in a wheelchair will be able to assist him in ambulating into the house.

[Daisy Joyce]

I just always thought it was the way of our people.

[Nunya, BSN]

Not in any of the hospitals my parents have been in. Room to exit is way more than 300 feet and often there wasn't a place to sit. In our house the farthest my Mom would have to walk without a place to sit and rest is maybe 12 feet

[NLLL16]

I haven't read all the responses so someone might have already said something similar. I work in an outpatient surgery unit of a hospital and it's our policy to take patients out by wheelchair. As the nurse responsible for that patient, I have to make sure he or she is at least able to stand on his/her own and ambulate around the room. Of course I keep in mind the original baseline mobility he/she was able to maintain before surgery. I chart exactly what I see. I don't say my patient can walk all around the house or up the driveway because I'm not responsible for the conditions of their house or driveway! I chart something like this "patient is able to transfer without difficulty to the wheelchair" and "patient is able to ambulate without difficulty observed from room to restroom" and then "patient was wheeled out of unit to exit by wheelchair". Most of my patients are still somewhat sleepy so it's safer to discharge them by wheelchair and like another poster said, the walk from our unit to the exit would be quite taxing on a lot of people!