David Oliver: The stress of sending patients home
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2094 (Published 16 May 2019) Cite this as: BMJ 2019;365:l2094
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No, David, you are not alone.
I trained in the 1990s and at no time in my career has there been available training on managing patients with multiple morbidities and on huge numbers of medications, some of which I have never heard of. The lack of training is due to the lack of knowledge -- these patients didn't exist 20 years ago or even 10. None of us really know what to recommend for the best for these cases -- every day that I am on call I am aware that I make many risky decisions. Effectively we are all winging it, and bed pressures inevitably influence decision making. Most of the time experience does give the right answer, which is often intuitive, but we need to cut ourselves (and each other) some slack when occasionally we get it wrong.
As a previous respondent has said, there are risks with early discharge but also with delayed discharge too -- the difference is that you can't identify an individual as the decision maker for the latter.
It would help if there was ready data to back up how many right decisions we make and what we think an acceptable error rate is........perhaps that's achievable and the Colleges should take the lead?
Competing interests: No competing interests
David Oliver tackles another very important but a much less recognized issue. Every clinician who deals with patients at the front line (primary care, emergency medicine, acute medicine, surgery, etc) would understand the stress associated with discharge decisions. Even though many teams (especially therapists, social workers, etc) work very hard to help with discharges from secondary care, they would still need a clinician to say that a patient is medically fit for discharge.
Adverse events following a discharge from secondary care or from a decision made not to refer to secondary care by primary care colleagues is everyone’s nightmare. For some patients, adverse events following discharge are probably due to discharging them too soon. We do a snap shot assessment of patients in the emergency department (ED) and make a decision based on the information we have. Frequently we do not correctly predict the trajectory of the disease or the illness. And we do not have the luxury of observing patients for a few more hours or a day like what we did many years ago. Also, many patients would prefer to go home rather than waiting in the emergency department for hours or even days.
Why do we make premature discharges? Because we are acutely conscious of 25 plus patients lined up in trolleys and another 15 plus sat in chairs for hours waiting for a bed. So, we make a decision to send the ‘walking wounded’ home. The current management mantras like, ‘discharge to assess’ and ‘think of how soon you could discharge a patient as soon as you see them’ doesn’t help.
How can we improve this? We do need to take a step back and think whether we are managing the patients or the bed crisis? There is no doubt that we need extra capacity in appropriate places and not in ED trollies where we can’t even assess patients appropriately. And when an adverse event happens following discharge, there should be a reasonable and a balanced assessment of the discharge process by clinicians who are well versed with what happens in the frontline. At the present climate neither the patients nor the systems we work in would look favorably towards the clinician who made the decision to discharge a patient.
Competing interests: No competing interests
This is an important debate. "Discharge" whether it be from a ward or ED is loaded with expectation that any untoward event after discharge is blamed on the discharging doctor. This despite that we know that the therapeutic content of admissions and ED attendances is often quite thin. Doubt is met by admission or continued presence in the hospital which causes blocked beds and packed ED departments. "As long as I don't discharge, I cant' be blamed" is the mantra. Tests are ordered just to put off the discharge.
Patients maybe need to be more reasonable about events after discharge. Safety netting and communicating how things might go well or not well is also important.
However, we need to stop loading the discharge decision as a cause of morbidity: it creates anxiety, guilt and risk averse behaviour which bedevils health care. Of course the consequences of not discharging are rarely attached to anyone.
Competing interests: No competing interests
Re: David Oliver: The stress of sending patients home
Thank you for your article.
The decision to send a patient home sometimes is difficult because the balance benefits / harms between the two options is not always easy to evaluate.
To make it easier and less stressful, I would strongly recommend to prepare it early enough and to take it in partnership, involving the patient, the carers and the family doctor. Besides, this would prepare and improve the following community care.
Competing interests: No competing interests