Why can’t we be more proactive in discharging patients?

The recent hurricane in New York City and the closures of some hospitals requiring the transfer of a large number of patients reminded me of something that happened on 9/11/2001.

I was working at a hospital near New York. You may recall that among the many problems that day was a breakdown in communications. Reliable information on the number of casualties and extent of injuries was hard to determine.

Late on the morning of 9/11, a meeting was held at my hospital. We canceled all elective surgery and decided to discharge as many patients as possible in preparation for the injured who, sadly, never arrived. Victims either got out of the World Trade Center and walked away or perished. Injured patients were few and were cared for by hospitals in New York.

Unaware of what was really happening in the city, we made rounds on every patient and discharged nearly 50 who otherwise would have stayed a day or two longer. As far as I know, there were no complications related to what seemed to be a premature departure from the hospital for many.

The next day someone wondered why, if we were able to discharge so many patients on the day of a disaster, could we not do so more often?

Granted, once a wholesale cleanout took place, there would probably not be 50 patients eligible for discharge every day. But it might be 10 or 15. Multiply that by a few thousand hospitals and you might see quite a savings in the cost of medical care.

Will it happen? I doubt it. For one thing, ours was not the only hospital to have that experience. If it was going to happen, it would have caught on by now.

Why not? On 9/11, the inpatients were motivated to leave. They were scared. They wanted to be with their families. They felt like they were helping others—the potential victims who never materialized. It would be hard to muster those feelings every day.

I have written before that hospital length of stay is not simply a matter of the physician deciding that a patient can go home. The patient may not want to leave. There may be no support at home. There may be no one to drive the patient home. The nursing home or rehab center may not have an available bed.

Still, it is interesting to contemplate what occurred on 9/11/2001 and why we can’t be more proactive in discharging patients.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Suzi Q 38

    Is “sooner the better” release from the hospital better for the patient?
    Especially considering nosocomial infections, and the cost savings to the patient and insurance company?

    • SarahJ88

      Wouldn’t rehiring all that laid-off housekeeping staff to keep the place clean be a better approach? Our local hospital is filthy, with cleaning staff few and far between.

      • Suzi Q 38

        I admit that I never thought of that, but yes, that probably would help a great deal.
        Wiping counters, equipment, cleaning floors and restrooms may stave off the growth of some nosocomial organisms that can cause infection in patients….. just guessing here.
        Good thought.

  • Elizabeth Eckstein

    Suzi Q 38 You spoke exactly what I was thinking. Get ‘em out of there as quickly as possible. The weakest are the most “at risk.” My Mom contracted MRSA and never recovered…

    • Suzi Q 38

      Many years ago, I remember staying in the hospital for 3-4 days after my C-Section in the late 80′s. I am not sure I would do that today if I had to. There are websites that list the infection rates for certain organisms at most hospitals….I don’t want to scare myself, so I haven’t looked.
      All I know is that Pseudomonas Aeruginosa used to be fairly nasty.
      Now the big deal is MRSA.
      My mother went in with a very rare condition named “Giant Cell Arteritis.” and contracted C. difficle during her stay at the hospital.

      Granted, she was about 85 at the time and had been in the hospital for about a month on high doses of steroids….The doctors were in and out, with no one truly taking responsibility for her. She was hallucinating 90% of the time…talking about Osama Bin Laden hiding under her bed, etc. They dropped the steroids and she got worse. I read on the internet from other patients (bad, I know, but I was desperate. The doctors were not that familiar with treating this condition at the small, local hospital) that the better thing to do was to titrate down very slowly, rather than stop “cold turkey.” I asked the doctor on call nicely if we could try that and he yelled at me on the phone….”Are YOU a doctor???” LOL.
      “No.” I said, “but look at it this way, doc, what you are doing is NOT working, so what the heck. Since you are not here to watch her go nuts all day, how about we give this experiment a try?”
      I realized why the nurse handed me the phone immediately when she dialed his phone number. He was a jerk, and SHE didn’t want to have to talk to him.
      I figured that I would never see him anyway, as we were always missing each other. I just needed treatment for Mom.

      Well, they tried it, put her back on the steroids and she got much better. We got her out of there, then to a rehab center, then home.
      She is doing much better now.
      Last I checked, we celebrated her 88TH birthday.
      She is just that tough.

    • Suzi Q 38

      Sorry about your mother.

      • Elizabeth Eckstein

        Thank you… it’s been a bit over a year, and my heart is still so full.

  • http://twitter.com/dixiesez Dixie Sez

    One interesting thought from the “up” end: I work in an ICU and the ED is constantly sending us patients, whether we have a nurse for those patients or not (a whole other issue…). Many times we are holding telemetry patients because the floors are full; so our ICU is by default a tele unit and critical patients can’t get in. Another great reason to discharge patients with a vengeance!

  • SarahJ88

    “As far as I know, there were no complications related to what seemed to be a premature departure from the hospital for many.

    The next day someone wondered why, if we were able to discharge so many
    patients on the day of a disaster, could we not do so more often?”

    Because there’s something called good nursing and medical care between health and death. Did you learn nothing from the drive-by delivery debacle?

  • http://twitter.com/Skepticscalpel Skeptical Scalpel

    Thanks for all the comments. Sorry for the delayed response but I was out of town for a few days.

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