The hospital discharge race: is sooner always better?

by Carolyn Thomas   ♥  @HeartSisters

They say that if you can remember the 1960s, you weren’t there. I do remember this about 1966, however:  I spent my birthday that year in a hospital bed, where I’d been a patient for a full month recuperating from a ruptured appendix and a nasty case of peritonitis.  Back then during the dawn of civilization, it was common for patients to spend far longer in hospital than we ever would now. For example:

• For North American maternity patients during the same era, the average length of stay in hospital for uncomplicated vaginal deliveries was about seven days. Today, that stay is more likely to be just 1-2 days(1).

• For hospital patients treated for heart conditions in the 60s, the average length of stay was between 13-16 days – and this was before doctors were even doing bypass surgery. (That didn’t happen until 1967 when the first coronary artery bypass graft surgery was performed at the Cleveland Clinic by an Argentine surgeon named Dr. Rene Favaloro). Today, having bypass surgery will likely mean just 3-5 days in hospital for most people.(2)

• For patients undergoing an abdominal hysterectomy in the 60s, the average length of stay was approximately 11 days in hospital followed by an estimated 52 days of total convalescence! Today, the average hospital stay for vaginal hysterectomy is about two days.(3)  
  

We know that length of stay at acute care hospitals has been steadily decreasing since the 1960s for many reasons. These include advancements in medical technology, changes in customary medical practice, and financial pressures.

And during those good old days during the dawn of civilization, patients would remain hospitalized, as the Journal of General Internal Medicine described it, “until the majority of their medical issues were diagnosed and treated to resolution.”(4)

But today, the emphasis seems to be on:

• stabilizing the patient
• minimizing length of hospitalization
• postponing complete diagnosis and treatment for the outpatient setting
• booting that patient out the front door of the hospital as quickly as humanly possible

Turns out, however, that there may be a big fat price to pay for ticking all those efficiency boxes that hospital administrators like to spend their days doing. The U.S. Agency for Healthcare Research and Quality (AHRQ) puts it bluntly:

“Being discharged from the hospital can be dangerous.

“A classic study found that nearly three-quarters of post-discharge complications could have been prevented. Other discharge hazards arise from the fact that nearly 40% of patients are discharged with test results pending.”

Another example: more than 40 percent of all patients who experience serious medical complications after surgery experience them when they’re back at home, according to research published in the journal Archives of Surgery(5). 

And half of those complications occur within the first nine days of patients leaving the hospital.  Researchers suggest that the most common surgical complication patients experience after leaving the hospital is a localized infection at the site of the incision.

In an NPR interview, Dr. Eli Adashi, a professor at Brown University who’s also written about post-discharge complications, believes that bringing down the rate of these complications will require a sea change in the way surgeons — and the entire medical community — think about their patients. For example:

“Physicians, for all too long, have essentially viewed their responsibility as ending at the hospital door. There wasn’t a whole lot of thought given to what happens once [patients] leave the four walls of the hospital.”

Earlier this year, here’s how Toronto emergency physician, author and host of CBC Radio’s “White Coat, Black Art” Dr. Brian Goldman described early hospital discharge:

“A seemingly unstoppable trend that is increasingly associated with risks as evidenced by rising hospital readmission rates.”

He also cited Canadian research on nearly 1250 patients from l’Université de Montréal that found early discharge from hospital following heart surgery was associated with severe persistent pain for as long as two years post-op. 

Consider also that early discharge after a cardiac event simply didn’t happen decades ago. Spending a couple weeks in hospital meant that both patient and family members had time to adjust to what had just hit them, to gradually meet with dieticians, social workers, rehab staff, hospital chaplains and others who could help with this adjustment under ongoing professional supervision. Personally, I have long suspected that early discharge may also be impacting the often-dismissed incidence of post-cardiac event depression, as outlined in a British Heart Foundation study published in the journal Heart(6):

“The early discharge period is the time at which the patient is the most vulnerable; psychological distress at this stage is a predictor of poor outcome and increased use of hospital services independent of the physical damage to the heart.”

“A hospital is not exactly the safest place in the world. Most patients would much rather sleep in their own beds and not be exposed to infections in a hospital.”

Instead, he suggests that doctors need to do a better job of monitoring their patients in hospital, and also of making sure these patients understand what they need to do at home to prevent infections and other complications.

In addition, the AHRQ recommends beefing up a systematic approach that’s now generally lacking before hospital discharge.  Three key areas must be addressed prior to discharge:

• Medication reconciliation: The patient’s medications must be cross-checked to make sure that no chronic medications were stopped and to ensure the safety of new prescriptions. 

• Structured discharge communication: Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians. 

• Patient education: Patients (and their families) must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems after discharge.

Meanwhile, I like the National Patient Safety Foundation’s Post-Discharge Tool For Patients to help lower your risk of readmission to hospital.  If you or somebody you care about will be hospitalized soon, print off this useful tool and follow these instructions carefully.  For example:

• Before being discharged from the hospital, make sure your doctor or nurse gives you the information you need to carry out your care plan.  Carolyn’s note: Make sure you actually HAVE a care plan (some studies suggest that over 90% of chronically ill patients leave hospital without one).

• Make sure you understand how to care for yourself at home. Learn what potential complications may happen and who to call if they should arise, and when to make that call.

• Familiarize yourself with the warning signs and symptoms of complications that you must let your doctor know about immediately.

• If you are prescribed any medications, make sure you understand what they are/what they do, or if they’re different than before hospitalization, as well as instructions for when and how to take each one. Take all medications as prescribed.

• Ask if you’ll have any activity restrictions involving returning to work, driving, exercise, heavy lifting, travel, having sex (and if so, for how long) or if you should be making any modifications to your meals.

• Ask your providers any questions you may have and if anything is unclear to you, do not hesitate to get clarification.

• Once you get back home, avoid others who are sick.

• Make sure you wash your hands often and encourage others you are in close contact with to do the same.

• Make sure you are getting enough sleep to recover.

• If you have had surgery, learn how to properly care for and keep clean your surgical site.

• Schedule and keep your follow-up medical appointments. Even if you feel fine and seem to be recuperating successfully, having your recovery progress assessed by a health care professional can help you avoid setbacks.

• Tell your primary care physician and other providers that you were admitted to a hospital. Ask them if they have received all of your tests and medical reports from the hospital. Do not assume that they know what’s happened. Help them by sharing information they may not have.

♥

UPDATE:

Harvard physician Dr. Ashish Jha told The New York Times in a 2016 interview:  “Sometimes doctors overestimate how much support is available at home and discharge a patient too soon”.

In many countries, The Times added, when lengths of hospital stay get shorter, readmission numbers get bigger.

Since 2010, when almost one in five Medicare hospital patients returned within 30 days, hospital readmissions have fallen considerably. As The Times reported, however, some people are seeing evidence that hospitals are gaming the metric.

For instance, patients who are placed under “observation status” are not counted in the readmissions metric, even though they may receive the same care as patients formally admitted to the hospital.

Similarly, patients treated in the ER and not admitted to the hospital do not affect the readmissions metric either. As readmissions have fallen, observation status stays and returns to the emergency department after a discharge have risen.

“When asked by hospital administrators to keep patients in observation status, many physicians comply,” Dr. Jha told The Times.

♥

(1)  Jill Klingner et al.  How Satisfied Are Mothers with 1-Day Hospital Stays for Routine Delivery?  Effective Clinical Practice. November/December 1999. Volume 2, Number 6.

(2)  Daniel Lee Kulick. Coronary Artery Bypass Graft Surgery. MedicineNet. 2/5/2014.

(3)  Length of Convalescence After Surgery. National Center for Health Statistics. National Health Survey. Series 10, Number 1. 1961.

(4)  Amit D. Kalra et al. Decreased Length of Stay and Cumulative Hospitalized Days Despite Increased Patient Admissions and Readmissions.  Journal of General Internal Medicine. September 2010. 25(9). 930-935.

(5)  Hadiza S. Kazaure et al. Association of Postdischarge Complications With Reoperation and Mortality in General Surgery.  Archives of Surgery. 2012;147(11):1000-1007.

(6)  Thompson DR et al. Coronary disease. Management of the post-myocardial infarction patient: rehabilitation and cardiac neurosis. Heart. 2000 Jul;84(1):101-5.

(7)  Stephen Jencks, Mark Williams, Eric A. Coleman.  Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine 2009; 360:1418-1428April 2, 2009

♥

NOTE FROM CAROLYN:   I wrote more about being admitted – and discharged – from the hospital in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (and use their code HTWN to save 30% off the list price when you order).

See also:

Post-hospital syndrome, revisited

Study: “91% discharged from hospital without care plan”

The simple tool that predicts how well you’ll do after discharge from hospital

Who will take care of you at home if you’re seriously ill?

Convalescence: the forgotten phase of illness recovery

Is your doctor talking to your other doctors?

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Q:  Have you ever experienced being discharged too soon after a hospital stay? If so, how did you know?

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