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Who let the patients out?

January 2009

Hello readers! I hope 2009 augurs well for you, and wishing you the very best life has to offer.

I did take a sabbatical from writing. Whether you call it writer’s block or plain ole laziness, I have to admit that I did enjoy my time between my work weeks, practically goofing off! There is certainly something to be said for letting the days slide by, watching clouds drift by, listening to music, and getting hooked on pundits pontificating about all the issues swirling about during the recent, historic presidential election, or simply reading a gripping novel. Here I am spilling my thoughts into cyberspace–and it feels good.

Not too long ago, we had an interesting team meeting and a spirited discussion about how to best manage patients with underlying addiction issues–typically to nicotine or other substances such as cocaine, heroin, etc.–who insist on leaving the medical floor to go outside for a short time, ostensibly for fresh air.

On the one hand, this is fairly simple and straightforward. Hospitals are non-smoking facilities, and quite a few states and cities have laws prohibiting smoking in public places. When a patient who is a smoker is admitted, he or she is informed about the no-smoking policy and offered assistance in the form of a nicotine patch, etc. to combat cravingS.

Typically, most patients stay only two to four days, are compliant with the no-smoking policy and are then discharged after receiving the smoking cessation counseling that is now a core measure requirement. So far, so good.

But there can be problems. One problem is when we are dealing with specific personality types, and you know what I am talking about, don’t ya? The antisocial, the borderline, the histrionic, the narcissistic, the avoidant, the dependent and finally the obsessive-compulsive!

Another problem is when patients have to stay longer in the hospital. And another big challenge is when patients who are addicted to heroin are admitted for long-term intravenous antibiotics and are sneaking outside with their fully functioning PICC or triple lumen catheters–and not looking too hot on return.

Some of us have come across situations where patients who have 1) addiction issues, and 2) a complete inability or antipathy to comply with rules or imposed structure–and who did end up harming themselves. This is not only a patient safety issue, but it can also affect the safety of the staff. Patients with behavioral or personality issues, especially under the effect of street drugs, have been known to endanger staff well-being.

What’s the best way to deal with such patients? Beyond the usual finger-wagging and ad nauseum counseling about the deleterious effects of smoking or injecting street drugs into their bodies, how does one get such patients to be compliant?

Should we opt for a three-strikes policy where a patient’s third infraction would get him or her discharged from the hospital? Or a zero tolerance policy where any infraction means you are out? Or should we choose less draconian measures: withdrawing a la carte menu privileges–no unlimited hamburgers and French fries!–or TV privileges? No more Jerry Springer!

We give our patients a behavioral contract to sign if we think they may be likely to sneak out of their rooms and/or partake in activities inimical to their medical condition. Partnering with the administration and nursing staff to deliver a unified message about that policy is essential for its success.

But the big question remains: What do you do when the patient breaches either a verbal or written contract and repeatedly fails to heed good advice? Is it morally or ethically right to discharge a patient who is yet to complete their treatment or reached reasonable goals for a safe discharge?

Should we clamp down on any patient with an addiction and restrict his or her privileges during a hospital stay? I have had intravenous drug users who were in the hospital for six weeks or more, cooped up in one room and going stir crazy! If such a patient wanted to leave the floor to get some fresh air, is that such a bad thing? And how do we get over the inherent suspicion that an indwelling venous catheter in a patient with IVDA history translates into the guaranteed misuse of the IV line in an unsupervised setting? Are we stereotyping each and every patient with addiction issues as an untrustworthy participant in their medical care?

Hospitals certainly do not have the manpower to send staff out with patients during out-of-the-room sojourns. And investing heavily in security or technical paraphernalia for an otherwise small cohort of patients does not make sense either.

I am pretty sure that a lot of the hospitalists have had both vigorous as well as pleading discussions with their patients, and given them good counsel to stay put in their room. I am curious to find out if other hospitalist teams have had such discussions and if they have come up with any creative approaches.