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May 6, 2014

A rush to discharge?

Your hospital has announced a "length of stay initiative" accompanied by e-mails and presentations at staff meetings in which you're lectured about hospital-acquired infections, thromboembolism, deconditioning and all the other bad effects of prolonged hospitalization. But the bottom line is, well ... the bottom line: Medicare and Medicaid keep an ever-more watchful eye on "avoidable days" complete with penalties, and other payers are cracking down on over-long stays too.

If your hospital's computer system isn't keeping track of how much time and money you spend on your patients, it will soon. And you or your group leader will be getting calls about your "performance."

If you have a contract to admit unassigned patients via the ER, you are in trouble, my friend, because people who don't get regular medical care tend to have more conditions that need to be addressed before they leave the hospital. You can't ignore the heart murmur in an illegal immigrant with pyelonephritis or relieve the bronchospasm overnight in an asthmatic who tried to treat himself with drugstore medications. So your cost per diagnosis is going to go up along with your average length of stay.

So it's Saturday morning and the weekend case manager has already called you to point out that two of your patients no longer meet InterQual criteria for hospital treatment. The echocardiogram on the pyelo lady shows she needs a cardiology consult and the asthma guy still has expiratory wheezes. It's decision time.

If you can justify discharging these people, you'd better have a plan for their outpatient care. Maybe a kind-hearted cardiologist will agree to see the first one in his office, and the second one wants to go home anyway. But you had better document why you think these patients no longer require hospital care, based on the results of your examination, because there's a good chance that one of them will get sicker after discharge.

I am looking at the fifth case this year sent to me by a plaintiff's attorney regarding a hospitalist whose patient returned to the hospital sicker than he or she was at the time of discharge. Sure, this might have happened anyway in somebody with poor health at baseline. But the documentation in all these cases fails to support the hospitalists. One postop patient with a declining hematocrit didn't have a lab rechecked in the last two inpatient days, a guy with lung problems had no physical exam findings recorded (except by the respiratory therapist), and someone whose neurologic problems had not improved was told that she would have to get an important test as an outpatient because it was too expensive for a tech to come in on the weekend.

Yes, we're under pressure. And we don't want to read that our hospital is cutting important services for financial reasons. But when our name is on that patient's chart label, we are responsible. Let's make sure that we are putting the patient first and keeping accurate records of what happens on our watch—not to cover our @#$% or please third-party payers, but because it's what doctors do.
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7 Comment(s)

Martin wrote:
Great article. The "wind of change" for hospital performance is blowing. We can either flow with it or get crushed by going against it.
Corpus Christi, Texas | Mon, Oct 13 2014 08:19 AM

Gilfred Ubina wrote:
Better to be fired then lose your hard earned medical license!!!
Chester Springs, PA | Wed, Oct 22 2014 08:39 AM

Lee Chemtob wrote:
I am truly hoping that telemedicine physician groups in the future will play the role of continued outpatient follow-up, which will be more dependable.
Brooklyn, NY | Wed, Feb 11 2015 07:21 AM

Chandra Dinas wrote:
Always check labs on last day if not checked so that if WBC or Cr is going up, I can address it before patient is discharged.
-Founder of
Harrisburg, Pennsylvania | Mon, Aug 3 2015 15:03 PM

Elsie Bass wrote:
Great post...thank you !!!
Sheridan, Wyoming | Tue, Oct 27 2015 07:08 AM

Pankaj Kumar wrote:
Yes this indeed is a dilemma that needs to be addressed soon. Mainly medicare has been pushing towards this initiative. I believe that to some extent it may avoid a patient getting readmitted.
Winston Salem, North Carolina | Fri, Jan 29 2016 21:09 PM

Chandra Dinas wrote:
I always do blood work on the day of discharge to make sure patient is not deteriorating. If WBC is going up, I will address it before discharge.
Harrisburg, PA | Fri, Feb 12 2016 13:27 PM

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About Stella Fitzgibbons, MD
Stella Fitzgibbons, MD, has been a hospitalist since 2002. She currently divides her practice between a surgical hospital and a general one on the north side of Houston.
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