Patients being discharged prematurely

[Patti_RN]

A popular post of the day discussed patients overstaying their welcome. This was quite a shock to me and in my region the problem is the opposite. My experience has been totally different, and possibly more shocking than the stories of needy patients who aren't acute but remain beyond the usual length of stay--sometimes months, sometimes even beyond a year. What I've seen are patients discharged to the street without a place for recovery. This happens to the homeless, to the elderly who live with a spouse as fragile as they are, it happens with children whose parents are unable to care for their complex needs, and it happens to otherwise healthy adults who are discharged post-surgery and live alone.

For an example that may be horrifying but not terribly unusual, I had a patient who was homeless who had been injured when a car struck him as he was (legally) crossing the street. (The driver was later arrested for DUI and hit-and-run.) My patient had a compound fracture of one leg, broken ribs, internal organ injuries, and deep abrasions. He was in surgery for hours repairing the breaks and debriding the wounds. Less than 24 hours after surgery he was discharged with written/ paper prescriptions for pain meds and antibiotics, wearing a hospital gown and anti-skid footsie socks (his clothes had been cut off by the paramedics), and his other belongings were in a plastic bag. The hospital graciously gave him a walker and $2.00 for bus fare. It was winter and he had literally no where to go. Another homeless man 'took him in' at an abandoned construction trailer and the patient stayed there for a couple weeks (without pain meds or antibiotics). At least the other homeless guy shared food and blankets with him.

Elderly patients are also discharged after a medical crisis when they were barely able to care for themselves before the hospital admission. It also happens when parents have severely ill or injured children; some of these parents are performing tasks that RNs and respiratory therapists are trained to do.

Does anyone else see this happening in their hospital? Do these patients return when their condition either deteriorates or when they are simply in too much pain or unable to care for themselves?

[Patti_RN]

Maybe it's because the kids I deal with are kids; maybe they automatically go to rehab regardless of their level of cooperation. It's a question I have no idea the answer of (but, being curious, I'll find out!)

The other thing I don't see in these kids is the Brush With Death Syndrome--people who cheated death and suddenly want to make the most of their lives. It might be because kids (being kids) feel they are invincible and although they may have gotten shot, they certainly weren't really going to die! I mean, they're sure they're going to live forever. Not only do they think they weren't going to die, they think they're destined for a full and total recovery... which might explain their lack of cooperation with PT--why go through all that pain and effort when the docs are going to fix you up like new and you'll be back to your 100% healthy old self? Maybe it truly doesn't register that that 9mm slug just ripped through muscle, bone, nerves and arteries and that body part will never be the same.

I had a 14 year old kid who was shot in the neck at C4; he had a tiny bit of sensation in his left arm and could move a couple fingers; he could barely breathe on his own and whispering was a major effort. He was admitted in mid December. I was shocked when he asked his mom for a basketball for Christmas. I was even more shocked when his mother brought him one on Christmas day. (Shocked in a very sad way. It made me realize what denial they were in.) A few months later, he was able to play a couple games on an iPhone (if the phone was placed on a gripper board so it wouldn't fall off his lap). Another nurse remarked to him that he had come along way since his injury. The poor kid burst into tears finally realizing that moving one finger on a small glass screen was a huge milestone in his recovery.

It's so painful and sad to see these lives destroyed by guns, car accidents, fires, and other stupid youthful mistakes. I wonder about these kids and imagine the lives they now lead in contrast to what they may have been doing if not for that one horrible moment.

[loriangel14, RN]

I don't see any of this but then again I am north of the border.We have a discharge planner that ensures that people are ready for discharge and where they are being discharged to, will they be taken care of and if not makes arrangements for them to go elsewhere.Being discharged to the streets or under the care of someone in worse shape than they are doesn't happen.She makes arrangements for a home OT assessment before discharge for advice on adapting the home and she also makes sure that home care is in place if needed (citizens are covered for a certain number of home care hours a month).They also get discharged to rehab or mental facilities if needed.If living conditions are not suitable then they stay with us until other arrangements are made.We also have people that stay with us while waiting for hospital beds.

[trauma_lama, BSN]

Thanks for posting this excellent thread. It's something most of us probably dont like to think about when we can avoid it. Also, just a note, a great many of the homeless people (in my area at least) have varying degrees of mental illness... It's not a matter of "well just get a job you bum!" A very large mental health facility close by recently was shut down ($$$$$$$$$$$$!!!!!) so the residents were either transferred to a facility a couple of hours away (very super- convenient for any family support system nearby, obviously) or simply released back into the community. They will yell at you walking down the street, they sing strange songs, the have conversations with unseen others on the street corner. These are not people who can work. Ignorant or obnoxious college student from nearby universities will fear them and call the police to press harassment charges, or pick on them, laugh at them, throw things at them. They've been forgotten by the world. They have it so hard when they are in good health- I can't imagine how hard it would be for them during acute physical illness. It breaks my heart. I am not saying I have a solution to this problem, but the problem itself seems unacceptable to me. :-( okay ramble over.

[VICEDRN, BSN, RN]

Not to challenge you, VICEDRN, but how many homeless people do you actually KNOW? It takes awhile to actually 'know' them and gain their trust enough for them to share their stories. (These are people who have some serious trust issues, and all of it stems from their being victimized as children, teens, or adults). Each and every homeless person has a story, and each one is more heartbreaking than the last. These are not folks who woke up one morning and decided it would be fun not to pay rent. It's easy to blame others for mistakes they made. Hindsight is 20/20, especially when you're looking at someone else's life.

1. Just to stay on point...the question posed by your original post was premature discharge. I see no evidence in any of your additional posts that suggests that this patient required additional medical care.

2. Further, next time you want to express your views on an issue rather than ask a group of nurses what they think, you should try " general nursing articles" rather than "general nursing discussion." You seem to write really nicely and its clear that you feels strongly on the topic. I don't fault you that, I have topics I feel very strongly about and am likely to take a dismal view to others opinions even though sometimes there are philosophical differences that account for differences in opinion.

3. As for how well do I know my homeless patients? I think I know our homeless patients very well. Some of them check in to triage 3 times a shift. When they present with a psych complaint and I am assigned to that area, I must sit with the patients in a small room for hours on end with relief only to pee and eat. The longest time I have spent locked in a room with two homeless patients was 8 hours 46 minutes straight. One of the patients had pressured speech and talked at me the whole time.

Most of the time, I know the patient by sight when they present to me. I know their whole history, can guess at vitals, where they are from, where they like to stay, how many children they have, if any. I know what shelters they visit and under what circumstances. In short, I think I know them pretty well for whatever its worth.

I know that they have in the past stayed with a relative but left of their own accord because of their behavior or their choices. I know they CHOOSE to sleep in the waiting room rather than a shelter because they don't find the shelter's hours agreeable with their preferred sleep schedule or because they believe it to be unsafe.

I know that they are in and out of prisons and psych hospitals. I know that they don't keep their appointments, sometimes because they forget, they get distracted, they oversleep, etc and I know that these are problems for psych patients.

However, motivation and choice come in to play. If you choose not to sleep in the shelter, stay with your daughter because you can't comply with her wishes, etc, then you choose the alternative. If you allow yourself to be so distracted, you will never make it to your psych appointments (but we both know you can organize yourself because you manage to make here at night to sleep).

[Patti_RN]

Suffice to say that everyone has a role in this world; some are accountants, some are handicapped, some are mothers, some are criminals, some are teachers, some are affluent, others are meek... it's not just a person's job, it's who they are, and what they do, and how they fit into the world. We all can't be leaders, some are followers. We all can't be educated, some for lack of opportunity, some for personal inability; we all can't be rich, and some won't even be able to rise to the level of lower middle-class, and some won't enjoy a life of good health, either physically or mentally. But, regardless of our position in life, we all deserve fairness and justice.

Our system is set up that citizens' basic needs are met: education, housing, health care and nutrition... even for those unfortunate souls who will never get into Harvard or make a million dollars. Yes, we pay taxes and a portion of our of our tax dollars fund programs so hungry families have food, the elderly can remain in their homes, and children have access to education. Non-profit hospitals and other organizations do not pay federal, state or local taxes and the expectation is they will provide care for the needy in exchange for the tax breaks. Part of this free care is given to the homeless (a disproportionate number of whom are veterans of our military). Yep, they talk to themselves, talk to you, and show up every night at the ED. If they hadn't shown up at the recruiting office and shown up in Viet Nam or Iran or Afghanistan, they might not be wandering into the ED bothering those working backshifts.

[tokmom, BSN, RN]

I'm not up on all the details but Medicare regs are now tracking hospital readmission and I believe they won't pay (as in the case of medical errors) for care received on the readmission. This will probably make discharges more conservative. In my experience (mostly suburban hospitals) DCs are delayed. The patient is ready but the MD hasn't had time to come around and do the paperwork.

I really hope this is true. We can keep many pt's another day according to our URDP, but the MD's do these massive discharge days, where half the floor is leaving. Nurses then get called of because there are no pt's. I see pts leave to home that don't qualify for home health that are a 2 person max assist.

No surprise to see them back in a day or two and this time staying for free.

[Patti_RN]

I could never understand why some docs do that. It's as if they keep all the patients until some mysterious date, then discharge them all, so it seems some are kept an extra day and the unfortunate others have to leave early. And, you're right, after they all get wheeled out and when the dust settles two hours later, nurses are being sent home.

[canned_bread]

Thank you for mentioning this, it's something I often wonder about. I recently worked in an adult surgical ward and was shocked and horrified that an elderly man with no home support who had uncontrolled diabetes had an above leg amputation and then was discharged 3 days later. There was no one to help him at home, he hadn't seen a diabetes educator yet, and he was at a high risk for infection for his amputation, and he was simply discharged with a nurse to come deal with his wound and weekly physio... I felt he needed more intervention at the hospital, and to have more organised for community discharge. Surely he wasn't able to have even a shower by himself yet, let alone how he could get around to cook for himself...gosh. This happens all the time because there simply isn't enough beds!!

[VICEDRN, BSN, RN]

The purpose of providing charitable care is to provide care to those who actually need it. It is not meant to be spent on triaging someone x3/shift so they can sleep in the waiting room. This is not a shelter, its an ER. No health care is provided when someone's real intent to seek social services in the ER.

I have no problem with giving the patients actual patient care when they require it though I will note that these patients are more likely to have a funding source than the working poor. Many homeless patients are eligible for disability, medicare/medicaid because of mental health problems they have. Thus, they are sucking needed resources away from the working poor, who need them the most.

Here, I refer to people who are young trauma patients, nursing home aides, part time clerk and cashiers who suddenly find themselves with appendicitis or cholecystitis or some other emergent need that can not be covered by these other programs.

I assume you refer to the VA and I think VA nurses should be insulted that you somehow think they should provide social services when the badge says RN and the job is health care, not social work.

Noted again that you do not address what services you think your trauma patient needed.

Non-profit hospitals and other organizations do not pay federal, state or local taxes and the expectation is they will provide care for the needy in exchange for the tax breaks. Part of this free care is given to the homeless (a disproportionate number of whom are veterans of our military). Yep, they talk to themselves, talk to you, and show up every night at the ED. If they hadn't shown up at the recruiting office and shown up in Viet Nam or Iran or Afghanistan, they might not be wandering into the ED bothering those working backshifts.

[RainMom]

Discharging so quick after what was likely extensive surgery for that compound fx is ridiculous. Just so they can come back in a week with sepsis or other complications? And did the driver not have insurance to take care of everything anyway? Seems like DC less than 24 hrs is not even sufficient time to look into all the possible payers for the case.

[WannaBNursey, ADN, ASN, RN]

I working as I home health aid, I took care of a patient who had a fall, broke her hip. A short time later, she was back home and really wasn't able to do anything for herself, while before the break she did almost everything herself. The patient insisted on going home early, but it was obvious she wasn't ready, I don't think it was a safe discharge.

[Patti_RN]

Most premature discharges seem to be insurance company driven. There are tons of research and data concerning the readmission rates for patients following various lengths of hospital stays. Most correlate premature discharge with subsequent readmissionion--typically the total inpatient time is in excess of what the usual and customary would have been for the initial admission. Did your elderly patient regain mobility and independence? It's really tough with the elderly.