Why Hospital Discharges Are Risky: Insights for Safer Care

Inefficiency Insights #56

Author

Jared Dashevsky, MD
November 07, 2024 • Estimated Reading Time: 9 minutes

INEFFICIENCY INSIGHTS

Why Hospital Discharges Are Risky: Insights for Safer Care

In the inpatient setting, what’s the most dangerous thing we can do?

Give the wrong medication? Absolutely.

Operate on the wrong leg? No doubt.

Miss a critical lab? Certainly.

But even more dangerous than all of that?

Discharging a patient.

Discharging patients is something we do all the time. I write about the discharge process frequently because it’s a massive bottleneck in hospital patient flow. I encourage all providers to keep discharge planning front of mind. But really, discharging a patient is a risky process.

Think about it. A patient is admitted because they’re unwell. They spend days lying in bed, sometimes without natural light, which can lead to delirium. We start them on new medications. Various specialists consult on their case, ordering imaging, procedures, tests.

And then, once everything settles, we discharge the patient into what can feel like an abyss. They’re handed discharge papers with automatically populated instructions and little context on what actually happened during their hospital stay.

Once they leave the hospital, no one is there to ensure they take their new medications as prescribed. Even worse—do they even understand how, when, and why they should take them? They may have appointments with new specialists, expected to follow up on inpatient findings. If they miss these, who will follow up on abnormal results? Do they know to repeat the CT scan that revealed an incidental pulmonary nodule?

Discharge is absolutely essential, but it’s also unavoidably complex and often chaotic.

Several months ago, I created a discharge checklist to help streamline this process and address some of these issues. It’s a small step, but it gives me confidence that I’m covering all the bases for a safer discharge. Here’s an outline:

  • Barriers to Discharge: What’s preventing this patient from being discharged? Is family unavailable? Do they need imaging first? Are follow-up appointments confirmed? Knowing these barriers helps focus on key tasks to get the patient safely out the door.

  • Social Work Needs: Can social work assist with setting up home services? Does the patient need approval and coordination for rehab? Social work can often be the linchpin in safe discharge planning.

  • Physical Therapy Recommendations: What are the therapists advising? Are they safe to go home, or should they go to a subacute rehab facility?

  • Nutrition Recommendations: Has the dietitian provided guidance? For patients on continuous enteral feeding, does the rehab facility need specific instructions?

  • Wound Care Recommendations: If the patient has wounds and is going to a nursing home, what care instructions should be communicated to the facility?

  • Primary Pharmacy: Where does the patient usually fill their prescriptions? Knowing this helps ensure continuity of medication access.

  • Outpatient Follow-Ups: Are follow-ups with their PCP and specialists scheduled? These are crucial, especially the PCP appointment.

  • Family/Caregiver Updates: Has the patient’s main caregiver been updated on the discharge plan?

At a minimum, I ensure every patient has a PCP appointment scheduled and send the discharge summary to their PCP, so they’re aware of recent developments. Working both inpatient and in primary care, I see the importance of this continuity. When a patient comes to me post-hospitalization, I review their medications, confirm they understand any specialty follow-ups, and make sure they’re set for the next steps. It’s just one more way to make the discharge process safer, smoothing the transition of care.

Ultimately, a safe discharge process requires proactive planning, coordination, and communication. Each step we take to ensure a patient’s understanding, follow-up care, and access to support can significantly reduce the risks they face after leaving the hospital. Discharge isn’t just about freeing up a bed. It’s about empowering patients to continue their recovery confidently and safely at home. When we prioritize a thorough discharge process, we’re not only improving patient outcomes but also strengthening the bridge between hospital care and the outside world.

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