The hospitalist service at the University of Wisconsin Hospital and Clinics in the Department of Medicine recently admitted a patient with altered sensorium, which the team determined most likely was narcotic-related. Going the extra distance, they did a spinal tap to rule out meningitis.
Within a day of changing the medication, the patient got better and was ready for discharge. However, says Julia S. Wright, MD, director of the Madison-based service, an important test remained from the spinal tap. “We thought that those results would not change the medical management of the case, but we knew if it were positive, it would be a big deal,” she recalls.
Not all medical-legal experts would agree the responsibility for patient care ends when patients leave the hospital. Often there are extenuating circumstances that may warrant the hospitalist’s continued communication and contact with patients and/or their providers and caregivers. Although there are no universally accepted standards of care that define these post-discharge issues, several hospitalists recently discussed their institutions’ and groups’ guiding principles for managing the nuances of post-discharge protocol.
Hospitalist Jeffrey Greenwald, MD, associate professor of medicine at Boston University School of Medicine, is a member of SHM’s Hospital Quality and Patient Safety Committee and also has been investigating pre- and post-discharge interventions through a grant-funded project from the Agency for Healthcare Research and Quality (AHRQ) called “Project RED” (the Re-Engineered Discharge, online at www.ahrq.gov/qual/pips).
One reason the post-discharge period is a “gray zone” of responsibility for care, he believes, is that the hospital system was designed to have a finite endpoint—the discharge. “This ‘out of sight, out of mind’ mentality has existed forever in the inpatient service, but it has become more highlighted in the post-hospitalist era,” he notes.
That mentality can sometimes take over in the hospitalists’ minds. “I think a lot of hospitalists are burying their heads [in the sand] about how these patients are being sent home and the chances for miscommunication and a ‘bounce-back,’ ” notes David Yu, MD, FACP, ABIM, medical director of hospitalist services, Decatur Memorial Hospital, Decatur, Ill., and clinical assistant professor of family and community medicine, Southern Illinois University School of Medicine. “This is going to be more of an issue as hospitalists become increasingly busy. The temptation is to squeeze time on discharges, because it takes an effort to reconcile medications and tie up loose ends at time of discharge. It is not acceptable to write, ‘resume current medications and follow up with PCP’ and think the job is done. It is magical thinking that discharge medications and follow-up instructions will be figured out somehow by the patient and discharging nurse.”