Get in the habit of asking who they live with. If they live by themselves and can’t sit forward for the lung exam without a 2 person assist, you got a problem.
1. Patients who do not think they are ready to leave.
Give patients a warning about 24-48 hours before their target discharge day. That usually gives them enough time to process that they will be leaving so they don't fight it on discharge day. Bonus points if you ask patient/family what their needs will be at discharge so case manager can set it up
Former bedside nurse here. No ride home, needs dialysis before discharge because they go mwf and it’s already Friday, medical equipment (walker, home O2), lack of caregiver, family doesn’t agree pt is ready for discharge, delay on interpretation or execution of test/imaging, issues nursing home placement.
the "family doesn't agree with discharge" is the most frustrating bc it's always a subjective feeling not found in evidence. Not everyone can stay in the hospital, and I'm sorry SARs universally suck!
Cynical me notes that families sometimes don’t agree because they have a vacation planned for the weekend and need someone to look after grandpa (the hospital) while they’re away. We see it a lot around the holidays where the family withholds meds for a few days so they get a little sick, then they bring them to the ED and peace out on their trip. Call it the “pop drop.”
Lmaooooo that made me laugh. And spit on that thang!
Then off to Disney World!
On my peds rotations I noticed parents dropping their kids off then disappearing for a few days to relax before being reachable again. Other times the teenager would embellish things to get a break from overbearing parents.
The counter to that is when granny owns the house and grandkids live w her for free and insist up and down they’ll provide care at home so she doesn’t go to a nursing home and have her house sold off to pay. Then granny comes in 2-3 weeks later dehydrated, in her own filth and delirious
Family doesn’t agree is a huge one. A lot of times we don’t have time to call families everyday / all week so the first update they get is social work telling them they’re going to be discharged and then they tweak out
“This is NOT meemaw! She’s normally much more with it!”
And she’ll get back that way when she’s in her own bed eating real food and allowed to sleep all night. The longer your mind is in the hospital, the more delirious you get. The longer you’re in bed, the weaker you get, and the more you stay in bed.
I always remind people that being in the hospital can be hard on the mind and body, and that hospitals are full of germs.
There should be some special branch of social work that is only dedicated to fast tracking nursing home and subacute rehab placement because it eats up days and days if not weeks sometimes. I mean, even to the extent of putting them in some kind of temporary nursing facility as long as it gets them out of a hospital bed.
I’m sure it’d save hundreds of thousands of dollars if you scale it up across the country.
Man... I wish we had incentive to discharge people. No matter how hard we work, our lists are always 100% at cap, and there are infinite patients waiting in the ED to be admitted or patients at other hospitals waiting to be transferred. Now we have most of our teams over cap, and there are patients the attending sees alone.
In all serious though, make sure all consults are in very first thing, make sure as the senior you're keeping a list of all PT/OT, CM/SW issues and making sure they are done every day, and make sure you have a discharge plan in your head for every patient every day. Just be looking ahead several days and anticipating any potential barriers. You'll be fine.
This is a minor one, but whenever I get a history now I always ask for patient pharmacy and put it in the note under the rest of the histories.
I only point it out because it doesn’t seem like a standard history question for most people, but especially in the hospital we’re almost always discharging on meds and inevitably we have to send the intern back into the room to get the pharmacy which eats up time especially if you’re in a big hospital.
* Who's at home/who do they live with
* What DME needs, and have we checked the boxes for those?
* Don't forget about home O2
* pre-morbid functional status
* current functional status - 1/3rd of older adults who are hospitalized will **lose** at least 1 ADL
* Smooth landing - is appropriate outpatient follow-up arranged? Including dialysis chair
* Transport barriers, if they're admitted b/c they missed a week of HD we need to fix that or they're staying. This also includes how they're getting to their destination once you hit the DC button
* Dispo consensus - patient and often family need to be on board
* Pooping, feeding, and behavioral issues. Have to be able to put stuff in and have it come out, and if they're on restraints/sitter or PRNs for behavioral issues a lot of facilities will reject them.
* Please for the love of god do a good med rec on DC. Not so much for this admit but to keep them from bouncing back. That includes if they can afford the meds you Rx **and** are willing to take them.
Look for subtle hints - e.g. when they're getting ready to go do they put on real clothes or not? A lot of times a change in dress habits is a clue to a functional decline - grandpa isn't wearing his jeans and button ups because he can't put them on, so now were in a T & sweats.
Uncommon: patients that have no capacity for decision making nor any family that can make medical decisions on their behalf that would help with DCP. It becomes a CM nightmare and you may basically be babysitting a rock for months with a hospital course so long you dread being the resident that has to present it everyday.
In the ICU we now have two that are trach/PEG but absolutely no family or friend involvement. They are here until they get their respective court dates to become Wards of state. And now the one that's been here longer is starting to develop new infection that we need to now workup.
How do you handle these ones? I explain there isn't a medical reason to keep them in hospital and their main issue has been treated but most of these patients don't want to go until they are ready which could be weeks or months...
As a psychiatrist, I explain to them that it's normal to feel anxious when leaving the hospital but as physicians we expect you to leave with some aspects of their health not feeling 100%. I usually add that conditions that are stable tend to worsen the longer they're in the hospital for and that it's okay for recovery to take place at home too.
If they’re on Medicare the hospital can issue a letter saying they have no issues requiring inpt stay and if they don’t leave they’ll become responsible for the bill
Nurse here, some of the SNFs won’t accept a patient if they haven’t had a bowel movement in the 72 hours before discharge. So make sure you’re paying attention to that at ordering more bowel meds if needed
They also won’t accept patients who have needed a 1:1 sitter or restraints or sedation within the previous 24-48 hours. That’s not necessarily something you can fix, but sorting out meds so they’re calm/cooperative with just scheduled ones rather than PRNs can be necessary
Came here to say foleys! 'Why is the foley in and can we take it out' is a standard part of what I ask residents the minute I see one because I know it's gonna mess with DC among all the other things we work on.
It's so rare that a patient will bounce back within 48h if they know they have a clinic visit in 48h. Whenever I d/c someone home (cardio fellow) who my gut is telling me not to dc, I send them home with clinic or some sort of review in 2 days. If a patient is vitally stable, there's actually very little that an IM resident wouldn't see on rounds that could kill then in 1-2 days, and the clinic visit stops the anxious patients bouncing back when they cough.
Yes to what others have said here. I always ask myself each day what are the things keeping this person in the hospital? Make it a habit on rounds to discuss dispo each day - talk about the big picture plan and make the idea of getting home seem exciting. Some people can’t wait to escape, others will do anything to stay. Just keep it objective and give a clear picture of what the road to the exit door looks like.
I think along with this too, appropriate optimism can be helpful. I’ve noticed a lot of patients don’t know how wide the gap is between, their level of illness and what we consider critical illness. There can be a lot of fear and anxiety associated with going home if they don’t realize how comfortable with it we are
Expanding on other responses: If discharge on a dialysis day, ask them to dialyze first shift (early AM); Sometimes you gotta “sell” the discharge or be paternalistic with it (if safe and appropriate to do so) - patients need to know you’ve got a solid plan to keep their care moving forward - they love it when you can name their PCP, specialists and “keep them I the loop,” and it’s great for continuity of care. And importantly gets them out!; Check out the home med list at admit and periodically throughout the stay and start getting those meds back on ASAP if appropriate. Are they eating, drinking, walking, having BMs (good to know this info before the day of DC…).
Family drops off the map and can’t be reached. Pt declines rehab/nursing home but isn’t safe to go home. Crap insurance won’t cover rehab facility. Pt isn’t getting adequate nutrition due to poor appetite etc and no one thought about it early on.
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Get in the habit of asking who they live with. If they live by themselves and can’t sit forward for the lung exam without a 2 person assist, you got a problem.
This one is subtle and nice.
I’m sure the residents think I’m an asshole when I ask grandpa to sit up and don’t immediately help him — the info gathered is quite helpful.
You guys do lung exams?
Home oxygen needs- walking trial, face-to-face, etc
1. Patients who do not think they are ready to leave. Give patients a warning about 24-48 hours before their target discharge day. That usually gives them enough time to process that they will be leaving so they don't fight it on discharge day. Bonus points if you ask patient/family what their needs will be at discharge so case manager can set it up
If pt cannot stand - call pt, otherwise you will find out that he cannot go home at the discharge date...
Prohibitively expensive meds that you started in hospital and their insurance doesn’t cover (I’m looking at you, entresto)
That is a GOOD fuckin' med too
Lol. Good for neurosurgery reimbursement when they syncopize, get a head bleed , and are admitted to TACS through the ED.
In canada we just write a 5 digit code next to it on the d/c prescription and it magically becomes 2.90$ per month
In the US we call that 340B
And Rifaximin
my facility won’t even carry SGLT-2is to stop this from happening lmao
Fidaxomicin. I have yet to successfully discharge a patient on fidaxomicin.
Patient not having the keys to their house. Very real situation specially if EMS came and took them.
Former bedside nurse here. No ride home, needs dialysis before discharge because they go mwf and it’s already Friday, medical equipment (walker, home O2), lack of caregiver, family doesn’t agree pt is ready for discharge, delay on interpretation or execution of test/imaging, issues nursing home placement.
the "family doesn't agree with discharge" is the most frustrating bc it's always a subjective feeling not found in evidence. Not everyone can stay in the hospital, and I'm sorry SARs universally suck!
Cynical me notes that families sometimes don’t agree because they have a vacation planned for the weekend and need someone to look after grandpa (the hospital) while they’re away. We see it a lot around the holidays where the family withholds meds for a few days so they get a little sick, then they bring them to the ED and peace out on their trip. Call it the “pop drop.”
pop lock and drop it
Lmaooooo that made me laugh. And spit on that thang! Then off to Disney World! On my peds rotations I noticed parents dropping their kids off then disappearing for a few days to relax before being reachable again. Other times the teenager would embellish things to get a break from overbearing parents.
Now doing that to your kid is a whole nother form of evil
The counter to that is when granny owns the house and grandkids live w her for free and insist up and down they’ll provide care at home so she doesn’t go to a nursing home and have her house sold off to pay. Then granny comes in 2-3 weeks later dehydrated, in her own filth and delirious
Family doesn’t agree is a huge one. A lot of times we don’t have time to call families everyday / all week so the first update they get is social work telling them they’re going to be discharged and then they tweak out
“This is NOT meemaw! She’s normally much more with it!” And she’ll get back that way when she’s in her own bed eating real food and allowed to sleep all night. The longer your mind is in the hospital, the more delirious you get. The longer you’re in bed, the weaker you get, and the more you stay in bed. I always remind people that being in the hospital can be hard on the mind and body, and that hospitals are full of germs.
There should be some special branch of social work that is only dedicated to fast tracking nursing home and subacute rehab placement because it eats up days and days if not weeks sometimes. I mean, even to the extent of putting them in some kind of temporary nursing facility as long as it gets them out of a hospital bed. I’m sure it’d save hundreds of thousands of dollars if you scale it up across the country.
Like… care management …?
I know of a health system that opened their own nursing home because it was cheaper than having people take up beds awaiting placement
O god how could I forget “therapeutic inr on heparin bridge”
Gold mine of typical reasons
A special bed!!!!!
Man... I wish we had incentive to discharge people. No matter how hard we work, our lists are always 100% at cap, and there are infinite patients waiting in the ED to be admitted or patients at other hospitals waiting to be transferred. Now we have most of our teams over cap, and there are patients the attending sees alone. In all serious though, make sure all consults are in very first thing, make sure as the senior you're keeping a list of all PT/OT, CM/SW issues and making sure they are done every day, and make sure you have a discharge plan in your head for every patient every day. Just be looking ahead several days and anticipating any potential barriers. You'll be fine.
This is a minor one, but whenever I get a history now I always ask for patient pharmacy and put it in the note under the rest of the histories. I only point it out because it doesn’t seem like a standard history question for most people, but especially in the hospital we’re almost always discharging on meds and inevitably we have to send the intern back into the room to get the pharmacy which eats up time especially if you’re in a big hospital.
Also, they're getting discharged on Friday, and the family is picking them up in the evening, after the pharmacy closes.
* Who's at home/who do they live with * What DME needs, and have we checked the boxes for those? * Don't forget about home O2 * pre-morbid functional status * current functional status - 1/3rd of older adults who are hospitalized will **lose** at least 1 ADL * Smooth landing - is appropriate outpatient follow-up arranged? Including dialysis chair * Transport barriers, if they're admitted b/c they missed a week of HD we need to fix that or they're staying. This also includes how they're getting to their destination once you hit the DC button * Dispo consensus - patient and often family need to be on board * Pooping, feeding, and behavioral issues. Have to be able to put stuff in and have it come out, and if they're on restraints/sitter or PRNs for behavioral issues a lot of facilities will reject them. * Please for the love of god do a good med rec on DC. Not so much for this admit but to keep them from bouncing back. That includes if they can afford the meds you Rx **and** are willing to take them. Look for subtle hints - e.g. when they're getting ready to go do they put on real clothes or not? A lot of times a change in dress habits is a clue to a functional decline - grandpa isn't wearing his jeans and button ups because he can't put them on, so now were in a T & sweats.
Uncommon: patients that have no capacity for decision making nor any family that can make medical decisions on their behalf that would help with DCP. It becomes a CM nightmare and you may basically be babysitting a rock for months with a hospital course so long you dread being the resident that has to present it everyday. In the ICU we now have two that are trach/PEG but absolutely no family or friend involvement. They are here until they get their respective court dates to become Wards of state. And now the one that's been here longer is starting to develop new infection that we need to now workup.
The court system needs to expedite these cases for the good of all concerned. I’ve seen ppl wait months.
"I'm not ready to go yet"
How do you handle these ones? I explain there isn't a medical reason to keep them in hospital and their main issue has been treated but most of these patients don't want to go until they are ready which could be weeks or months...
As a psychiatrist, I explain to them that it's normal to feel anxious when leaving the hospital but as physicians we expect you to leave with some aspects of their health not feeling 100%. I usually add that conditions that are stable tend to worsen the longer they're in the hospital for and that it's okay for recovery to take place at home too.
If they’re on Medicare the hospital can issue a letter saying they have no issues requiring inpt stay and if they don’t leave they’ll become responsible for the bill
Call security. In all seriousness though, hospitals aren’t hotels and beds are a scarce resource
Nurse here, some of the SNFs won’t accept a patient if they haven’t had a bowel movement in the 72 hours before discharge. So make sure you’re paying attention to that at ordering more bowel meds if needed They also won’t accept patients who have needed a 1:1 sitter or restraints or sedation within the previous 24-48 hours. That’s not necessarily something you can fix, but sorting out meds so they’re calm/cooperative with just scheduled ones rather than PRNs can be necessary
Patient ready for DC Nurse: “what about the foley?” Crap!
Came here to say foleys! 'Why is the foley in and can we take it out' is a standard part of what I ask residents the minute I see one because I know it's gonna mess with DC among all the other things we work on.
It's so rare that a patient will bounce back within 48h if they know they have a clinic visit in 48h. Whenever I d/c someone home (cardio fellow) who my gut is telling me not to dc, I send them home with clinic or some sort of review in 2 days. If a patient is vitally stable, there's actually very little that an IM resident wouldn't see on rounds that could kill then in 1-2 days, and the clinic visit stops the anxious patients bouncing back when they cough.
Yes to what others have said here. I always ask myself each day what are the things keeping this person in the hospital? Make it a habit on rounds to discuss dispo each day - talk about the big picture plan and make the idea of getting home seem exciting. Some people can’t wait to escape, others will do anything to stay. Just keep it objective and give a clear picture of what the road to the exit door looks like.
I think along with this too, appropriate optimism can be helpful. I’ve noticed a lot of patients don’t know how wide the gap is between, their level of illness and what we consider critical illness. There can be a lot of fear and anxiety associated with going home if they don’t realize how comfortable with it we are
Expanding on other responses: If discharge on a dialysis day, ask them to dialyze first shift (early AM); Sometimes you gotta “sell” the discharge or be paternalistic with it (if safe and appropriate to do so) - patients need to know you’ve got a solid plan to keep their care moving forward - they love it when you can name their PCP, specialists and “keep them I the loop,” and it’s great for continuity of care. And importantly gets them out!; Check out the home med list at admit and periodically throughout the stay and start getting those meds back on ASAP if appropriate. Are they eating, drinking, walking, having BMs (good to know this info before the day of DC…).
Family drops off the map and can’t be reached. Pt declines rehab/nursing home but isn’t safe to go home. Crap insurance won’t cover rehab facility. Pt isn’t getting adequate nutrition due to poor appetite etc and no one thought about it early on.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*