Sent Home Too Soon? The Difficult Art of Hospital Discharge

Most hospital patients might agree that the best part of being hospitalized is going home . But determining the best time for discharge is a difficult task -- both for the patient and the health care team.

"Medicine is very much a team sport," with the attending physician serving as captain joined by other players including social workers, nurses, nurses' aides and so forth, says Katherine Hochman, assistant professor of medicine at New York University and director of the NYU Hospitalist Group. "Medical readiness is determined by the attending physician, who has input from all the members of the team," Hochman says.

The patient also has a big say in when it's time to go home. "Sometimes the best marker [for discharge] is a patient saying, 'I feel so much better.'" Whatever the case, "We really love engaged patients. Gone are the days of a paternalistic relationship where the doctor says what to do and the patient follows," Hochman adds.

There is a distinction between a patient's readiness for discharge, however, and his or her hitting the medical milestones necessary to go home, Hochman adds. It's also important to note that while most discharged patients are on the road to recovery, they aren't always fully healed when a decision is made to release them.

"As a generality, patients may appear to meet the criteria for discharge, which doesn't mean that they are fully recovered," adds Evan Fieldston, a pediatrician at the Children's Hospital of Philadelphia. "There are good clinical reasons why we feel patients do recover better outside the hospital and are less at risk of infections," he says. "But it's a balancing act. Doctors and nurses don't have crystal balls."

Rules of the Game

Still, some general rules apply. "Our discharge planning starts on the day of admission," Hochman says. "I will say to the patient, 'We expect from lab data that you have a community-acquired pneumonia ... Our best guess is that you will be here for three days,'" Hochman says. But a lot needs to happen in three days for that to occur. If that patient is hospitalized with a high fever, cough and an inability to walk, at the time of discharge, "I would want to make sure the patient can walk around and is not short of breath, that their oxygen level isn't down and that their elevated white blood count and fever have gone down."

But the social worker, care manager and other members of the team are also intimately involved in the discharge equation, Hochman explains. That means the social worker of the pneumonia patient might point out that the patient lives on the sixth floor of a walk-up building, so even though she may appear medically ready to leave the hospital, special arrangements must be made before that can occur.

And all members of a patient's care team, regardless of the institution, should be on the same page about four basic questions regarding readiness for discharge, Hochman says:

-- Why was the patient hospitalized?

-- Why is the patient still hospitalized?

-- What has to happen for this patient to leave safely?

-- Where is "home" for this patient?

The Role of Caregivers

It is also ideal to have caregivers in the room when discharge plans are being discussed, Hochman adds. Indeed, the availability of caregivers plays an important role in determining optimal timing to send a patient home. Fieldston recalls caring for a young patient with sickle cell disease. Like many patients, this individual could not control the time he landed in the hospital, which happened to be late in the evening, around 11 p.m. His blood culture was taken three hours later, at which time he was also given antibiotics to stave off infection. After 24 hours, the patient was free of infection and was technically safe to be discharged. But nighttime hours aren't generally preferred discharge times.

"Typically we would not send patients home at 2 a.m.," Fieldston says. Most patients would in fact be disgruntled to be sent home in the middle of the night. But this patient's father preferred to get his son home, no matter the hour, so arrangements were made to honor his wishes. "This particular father really valued getting home," he says.

Another family Fieldston took care of couldn't easily go home when the time came. A mother arrived with three young kids, all under age 4, who required hospitalization for asthma and related respiratory infections. When the two eldest children were ready for discharge, the infant still needed to be in the hospital. But the mother had no other relatives to help care for her children, and the two eldest needed to be given medications every four hours.

"The mother took the eldest kids home, and she wasn't able to spend as much time with the infant in the hospital," Fieldston says, adding that if family members aren't available to be caregivers, the family should consider hiring home health aides. "To do this well, the country as a whole needs to recognize the role of caregivers," Fieldston says, adding that President Obama's recent nod to paid family and medical leave is a step in the right direction. "Using an expensive hospital bed and expensive hospital-based nurses is not the best use of our resources," Fieldston says.

Reducing Hospital Readmissions

One of the biggest incentives to getting discharge timing right is that it should, in theory, reduce hospital readmissions. Even so, "the idea that there's a perfect science to knowing what keeps a patient out of the hospital" is erroneous, Fieldston says. "But sometimes the natural history of an illness means that the patient may get better, and worsen again, even when perfect care is delivered," Fieldston adds.

"Doctors are always making their best predictions ... At the time of discharge, you are balancing what you think will make the patient recover in the best way possible. But in some cases that may not turn out the way you want," Fieldston says.

Annamarie Saarinen, founder of the Newborn Foundation, an advocacy group for newborns and their mothers based in St. Paul, Minnesota, says she learned about the pitfalls of premature discharge the hard way. Saarinen's daughter, Eve, was born with a congenital heart condition that kept her in the neonatal intensive care unit for a month after she was born. When Eve was finally cleared to go home, her parents were tasked with giving Eve medications and performing complicated medical maneuvers. The family was back in the ER shortly thereafter. "The cardiologist said we should not have discharged her," Saarinen says, adding that she and her husband should have fought the natural instinct to want to take their baby home as soon as possible.

Babies with congenital heart disease are frequently readmitted to the hospital because of disease complications, and some parents are now concerned that the new rules launched by the Centers for Medicare and Medicaid, designed to deter people from unnecessarily using the hospital instead of their primary care provider by penalizing hospitals for readmissions within 30 days of discharge, may have the unintended consequence of redirecting patients to primary care physicians or specialists when readmission would be appropriate.

Hochman says that personalized, precise discharge scenarios can help potentially reduce readmissions. She conducted a study showing that discharging patients earlier in the day -- and with the input of everyone on the patient's medical team -- decreased both the patient's length of stay as well as the 30-day readmission rate.

Still, reduced readmissions aren't a strong measure of appropriate discharge, Fieldston says. "Most [readmissions] are not preventable. Just because someone is readmitted does not mean it's a failure of the system."

At-Home Recovery

What is fairly clear, Fieldston says, is that patients generally recover better at home. "There's less noise, fewer interruptions, the food is probably better at home," he says. Furthermore, you reduce patients' chances of getting a hospital acquired infection, as well as the excessive use of medications. In hospitals, a patient might take IV medications for pain versus oral, which can prolong a patient's stay.

The best thing patients and their family members can do to ensure a timely discharge is to be armed with the right information upon entering the hospital, and ask good questions when discharge is being discussed, Hochman says.

For starters, that means patients should come armed with: an advocate who can help them navigate their hospital stay; medication names, dosages and any known allergies to those medicines; and contact information for their primary care doctor, Hochman says. When it comes time to go home, "make sure someone is in the room with you who can fully understand the next steps in your discharge," Hochman says. Being in the hospital can be confusing; but so too can recovering at home.

Kristine Crane is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at kcrane@usnews.com.