Premature discharges from hospitals

MunoRN, RN · May 12, 2019

Preferably the hospital would have sent the patient back to you with a foley in place and an outpatient urologist referral, but no that doesn't really justify hospital admission.

What you're seeing isn't new, and really isn't avoidable. As it is, we can't continue to spend the amount we are now on hospital care, much less keep up with the rapidly growing population requiring acute care services, so we'll have to continue to figure out how to take care of conditions we used to admit patients for outside of the acute care environment. This certainly puts more strain on places like LTCs to have patient populations that 20 years ago might have mostly been hospital inpatients, but they're going to have to do better at keeping up with the pace, there aren't really other options other than that.

Misstika · May 13, 2019

9 hours ago, MunoRN said:
Preferably the hospital would have sent the patient back to you with a foley in place and an outpatient urologist referral, but no that doesn't really justify hospital admission.
What you're seeing isn't new, and really isn't avoidable. As it is, we can't continue to spend the amount we are now on hospital care, much less keep up with the rapidly growing population requiring acute care services, so we'll have to continue to figure out how to take care of conditions we used to admit patients for outside of the acute care environment. This certainly puts more strain on places like LTCs to have patient populations that 20 years ago might have mostly been hospital inpatients, but they're going to have to do better at keeping up with the pace, there aren't really other options other than that.

They didn't place a foley, we did after he was sent back. He didn't have referrals either. The initial admission was for psych reasons. I didn't want to say everything that happened, but I thought they would of at least done a psych eval. What he done endangered the well-being of another resident. All they did was straight cath to eliminate what he was retaining during his hospital stay.

I am not familiar with protocol at hospitals but it seem as if people are getting discharged sooner than before.

Persephone Paige, ADN · May 13, 2019

They must meet a criteria. I don't know the resident, but if they aren't dying or very ill and are in anyway refusing treatment, they won't waste time on them. And yes, it's much sooner than before. Also, what about the ones who demand to be released (too early) and wind up back in the ER 2 days later? It never ends.

allnurses Guide · May 28, 2019

Not every hospital is equipped to deal with a psych situation and there is a large gray area as to what would require an admission for such. Added to that, many major US cities are seeing psych beds dwindling in availability at an alarming rate, so finding a patient a psych bed is next to impossible. Without a reason to admit, the hospital isn't responsible for that. You guys are.

There must be a definable medical need/cause for the psych behavior to result in admission, such as elevated ammonia in the blood stream different from baseline or a raging UTI that requires IV antibiotics. Without something like this, there was no reason to admit the resident. Urinary retention is not cause for a hospital admission, nor should it be with the increased risk of hospital acquired infections. That needs consultation with an outpatient urologist. If the patient is having psychotic episodes with potential harm to self or others, your doctor at your facility should be referring him or her for a geri-psych consultation and the family should be notified that he/she may need a level of care your facility isn't qualified to offer. That isn't the hospital's role if the patient isn't acutely ill.

Misstika · May 30, 2019

On 5/28/2019 at 1:14 PM, not.done.yet said:
Not every hospital is equipped to deal with a psych situation and there is a large gray area as to what would require an admission for such. Added to that, many major US cities are seeing psych beds dwindling in availability at an alarming rate, so finding a patient a psych bed is next to impossible. Without a reason to admit, the hospital isn't responsible for that. You guys are.
There must be a definable medical need/cause for the psych behavior to result in admission, such as elevated ammonia in the blood stream different from baseline or a raging UTI that requires IV antibiotics. Without something like this, there was no reason to admit the resident. Urinary retention is not cause for a hospital admission, nor should it be with the increased risk of hospital acquired infections. That needs consultation with an outpatient urologist. If the patient is having psychotic episodes with potential harm to self or others, your doctor at your facility should be referring him or her for a geri-psych consultation and the family should be notified that he/she may need a level of care your facility isn't qualified to offer. That isn't the hospital's role if the patient isn't acutely ill.

The person came to our facility from the hospital in question. When a psych eval is needed and they are not equipped to do so, the patient can't be sent to a hospital who can? He really needed it because what he done endangered another resident. I was told when the resident was originally admitted to our facility, he initially had a hard distended abdomen. Therefore it was our fault for accepting him.

After he had a urology appointment. We found out he had an enlarged prostate, which caused the urinary retention. He had the TURP procedure done and now he is fine. What I wanted to know is why the hospital couldn't of found this out beforehand. I'm just not familiar with what the hospital is responsible for before discharging a patient.

allnurses Guide · May 30, 2019

58 minutes ago, Misstika said:
The person came to our facility from the hospital in question. When a psych eval is needed and they are not equipped to do so, the patient can't be sent to a hospital who can? He really needed it because what he done endangered another resident. I was told when the resident was originally admitted to our facility, he initially had a hard distended abdomen. Therefore it was our fault for accepting him.
After he had a urology appointment. We found out he had an enlarged prostate, which caused the urinary retention. He had the TURP procedure done and now he is fine. What I wanted to know is why the hospital couldn't of found this out beforehand. I'm just not familiar with what the hospital is responsible for before discharging a patient.

If the patient wasn't actively psychotic, there was really no grounds to transfer him. If he was, he should have been sent to a psych facility to begin with. Most community hospitals are not equipped to deal with this type of problem unless it is coming from a medical issue. Chronic psych issues that escalate is an ongoing gap in our healthcare system. The hospitals cannot keep these patients - how would they ever get discharged and who would take care of them, since the facility doesn't have the staff or resources? The chronic management falls to the physicians that manage their chronic problems. That would be the LTC facility they came from. The hospital looks for something to treat. If there isn't anything to fix, the patient gets discharged. Sometimes that is woefully inadequate, but it is the best that our modern medicine is capable of.

An enlarged prostate doesn't happen acutely most of the time. I would question the patient being discharged without a Foley having been placed for this and was likely an oversight, but to be honest I question him not having had one to begin with if this was the case. It would not have been a cause to the keep the patient in the hospital. Often if a patient goes to the ER for an escalated issue (an existing psych problem, such as dementia etc) and there is no cause found for it, another issue can be easily overlooked (ie: a distended bladder). Honestly, if the patient was having urinary retention at the hospital he was most likely having it at your facility as well. It is hard to say when this originated. Should it have been caught? Probably. But a busy ER investigating an acute psych issue may not have done a head to toe assessment. I do question whether they did a urinalysis, which on acute psych escalation is my first thought for possible medical cause, looking for a UTI. Was a urinalysis done?

Generally speaking, the hospital is responsible for acute medical issues. You sent him to the ER for an acute episode of a psychological origin for which there was no acute problem found. Therefore he got sent back to you, because there was nothing for the hospital to "fix". Overlooking the urinary retention was unfortunate and should have been treated with a Foley and the patient discharged back to you if there was no urinary tract infection.

Misstika · May 31, 2019

On 5/30/2019 at 2:04 PM, not.done.yet said:
If the patient wasn't actively psychotic, there was really no grounds to transfer him. If he was, he should have been sent to a psych facility to begin with. Most community hospitals are not equipped to deal with this type of problem unless it is coming from a medical issue. Chronic psych issues that escalate is an ongoing gap in our healthcare system. The hospitals cannot keep these patients - how would they ever get discharged and who would take care of them, since the facility doesn't have the staff or resources? The chronic management falls to the physicians that manage their chronic problems. That would be the LTC facility they came from. The hospital looks for something to treat. If there isn't anything to fix, the patient gets discharged. Sometimes that is woefully inadequate, but it is the best that our modern medicine is capable of.
An enlarged prostate doesn't happen acutely most of the time. I would question the patient being discharged without a Foley having been placed for this and was likely an oversight, but to be honest I question him not having had one to begin with if this was the case. It would not have been a cause to the keep the patient in the hospital. Often if a patient goes to the ER for an escalated issue (an existing psych problem, such as dementia etc) and there is no cause found for it, another issue can be easily overlooked (ie: a distended bladder). Honestly, if the patient was having urinary retention at the hospital he was most likely having it at your facility as well. It is hard to say when this originated. Should it have been caught? Probably. But a busy ER investigating an acute psych issue may not have done a head to toe assessment. I do question whether they did a urinalysis, which on acute psych escalation is my first thought for possible medical cause, looking for a UTI. Was a urinalysis done?
Generally speaking, the hospital is responsible for acute medical issues. You sent him to the ER for an acute episode of a psychological origin for which there was no acute problem found. Therefore he got sent back to you, because there was nothing for the hospital to "fix". Overlooking the urinary retention was unfortunate and should have been treated with a Foley and the patient discharged back to you if there was no urinary tract infection.

Thank you for your response. I'm pretty sure the situation was simply overlooked by both the hospital staff and staff at the LTC facility. I looked at the nursing notes from when he was admitted and it stated that he had the hard distended abdomen. It just got worse over time. I think the psych issue stemmed from the urine retention. After he had the TURP procedure, this was a whole new man. He was very pleasant. I start my clinicals in September, so I guess I will get to experience nursing from the Hospital's POV.

allnurses Guide · Jun 1, 2019

On 5/30/2019 at 12:04 PM, not.done.yet said:
…….. (an existing psych problem, such as dementia etc)…...

Just wanted to point out that dementia is not considered a psych problem. It's a medical diagnosis! Psych facilities don't get reimbursed for treating dementia.

Hppy