Question about a patient refusing discharge

[ixchel]

I live in the US, and here, if a doctor writes a discharge order and a patient refuses to leave, insurance (private or public) may choose not to pick up the bill if the patient can't justify a medical need to stay.

(To be honest, though, the doctors I've worked with are often open to listening to the reasons why a patient doesn't feel ready to leave. Case managers will help, as well. I haven't seen this get too ugly, yet.)

How is this handled in the UK?

How might your facilities respond?

The doctors you work with - how do they tend to handle patients who don't want to leave yet?

How is it handled if a patient has orders for discharge, but they (and maybe even nurses) do feel there is a strong medical need to stay?

If a patient is not private pay and is not privately insured, who pays the bill beyond the medically indicated inpatient stay?

As I'm typing this, I'm thinking, "I wonder how many people reading this think it's for homework?" lol

It's not, I promise. I've been "virtually" holding the hand of a British friend who has had extensive surgery recently, with multiple complications. She still has a long road until discharge, but she got herself a little panicked asking if they can kick her out. As in, now. She is nowhere NEAR discharge in my estimates. But, it did make me wonder how this scenario would play out differently on your side of the pond.

[ixchel]

Bumping :)

[Hollybobs]

Hi Ixchel, there's a few questions there, they might require quite a lengthy reply!

In my experience, in the NHS (non-private) hospitals, patients don't often refuse to leave hospital but it can happen. It isn't that comfy in our hospitals, there are no fitted sheets or comfy blankets- everything is clean but minimal. There is often a lot of noise at night and during the day with new admissions or transfers taking place at any time in the med/surg equivalent. Patients are mostly in shared rooms, there can be 8, 10, 12, maybe more in a large area called a "bay". Bathrooms are often 1 per unit. TV is very expensive. Food is often not to people's tastes and there aren't always cold or hot drinks offered between meals, depending on staffing. Snacks are in theory always available 24/7 but not always offered. Water in jugs on bedside tables gets warmer throughout the day and isn't automatically topped up, again it is dependent on staffing and there often isn't ice. There are usually very strict visiting times. Our top priority as RNs is the patient's clinical/medical health and safety. There are rarely resources for more than this.

However! Sometimes patients prefer hospital with regular meals and cheerful nurses for company to home. The nurses and Dr's explain to them that it is medically time for them to go. That they are better at home and there is a greater risk of infection in the hospital. They explain the bed is needed for another person who is unwell as they were. That they cannot justify the use of national resources when there is no medical indication. More and more senior staff are brought in to explain this and talk through the patient's worries until the patient agrees it is time to go. Security can be called if needed but senior staff have excellent communication skills rendering this unnecessary- I haven't seen this used.

Sometimes "bed-blocking" occurs where it isn't possible to discharge someone as there is no appropriate place to discharge them. For example, a patient might require a nursing home after hospital and cannot safely return to their usual house. Relatives have been known to drag out the process of choosing a nursing home so the patient will stay in hospital for many months. Social workers are involved and many meetings are held to try to fix this situation.

Sometimes people are discharged too early and return to hospital unwell. The incidence of this is monitored in an attempt to keep "unsafe discharges" to a minimum. If an RN feels the patients needs to stay for medical reasons but the MD says the patients needs to leave, the RN needs to produce valid concerns and a meeting can be held for a discussion. Ultimately, the Consultant decides and is responsible for an adverse incident that might occur after discharge if it could have been predicted to happen. The RN's role is to flag up any concerns and advocate for the patient. Physio's and OT's also play a very important role, they can assess and assist in planning as safe a discharge as possible.

If your British friend were in the UK and had strong concerns about being discharged too early after surgery, they would be encouraged to voice their specific concerns. If for example the concern was pain management, their meds would be reviewed, they might be reviewed by the pain management team, expectations would be checked, the wound site would be inspected, an x-ray or scan might be called for if the pain was disproportionate to that expected, we'd work with the patient to see what helped or hindered etc. If something could and should be changed, it would be. If the pain was as normal for that stage of recovery, after advice was given we'd reassure the patient that was normal for many patients. That's just one concern, but it would work the same for anything.

We don't discharge until the patient is clinically well enough (i.e. staying in hospital won't make them any better than being at home) and until they will in all likelihood be safe at home. If you considered a patient not ready for discharge in your opinion as an RN, we wouldn't either, for the same reasons as you.

Edit: Just realised I had said nothing about medical bills. We do have some hospitals for privately insured patients in the UK and we have a very few patients in the NHS who pay privately- I don't know how payment works at all, I'm sorry. Who pays the bill for those in the NHS who stay over what is medically advised? The same people who pay for ALL the treatment and hospital stays; the tax payers.

[ixchel]

Hollybobs, thank you so much for your response! And thank you for satisfying a curiosity!

[Hollybobs]

No probs! I really like the WILTW threads btw :)

[ixchel]

No probs! I really like the WILTW threads btw :)

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