Glad to. To be (very) brief:
A. A delayed discharge has no bearing whatsoever on whether hospital staff has the ability to respond appropriately to an emergency situation. These two situations are (rightfully) managed very differently.
B. The last thing a hospital wants is “an extra days stay out of patients”. Quite the opposite, as there in no reimbursement for “extra days”. In fact, there are staff members specifically trained and paid to prevent this from occurring.
mmm
As a nursing student, I was told (unofficially, not in the classroom, but by RNs during clinicals) that we should lie to the patient and tell them insurance wouldn’t pay in such a situation. But it was clear that it was a lie, and that insurance would pay, it’s just one of those things you say to patients to get them to do what you want them to.
I won’t do it. Nor have I ever seen any evidence that it’s true - except maybe in the case of mental health treatment, where I don’t know a thing about it and insurance often works differently, and leaving AMA is a very different kettle of fish.
Pediatrics is a different story, however. I’m not sure if states differ, or if the age of the patient is important, but here in Illinois, at least, a parent may not sign out a young child AMA. They may insist on a transfer of physician (that is, fire their doctor and get another from the same hospital) or a patient transfer to another hospital, but they may not take the child home against medical advice. It’s part of the legal tangle when dealing with minors - the state has an interest in the welfare of children, and backs the doctor’s opinion with the weight of law.
Interestingly, there are times when the hospital *hopes *you’ll leave AMA. I had one patient who was a “frequent flyer” with a very specific pattern: she’d come in for some complaint, usually dizziness or a cough. She’d deny any pain on admission. Then, over a period of a few days, would develop pain in the hospital, and she’d get the doctor to prescribe Dilaudid in increasing amounts. When they’d suggest that perhaps she’d had enough and could go home now, she’d threaten to commit suicide if they sent her home. What do you do? If you keep her in the hospital to chug Dilaudid, she’s taking up a bed someone else needs (not to mention her insurance/Medicaid will run out eventually) and not effectively treating her real issue of substance abuse. If you send her home and she *does *attempt suicide, your doctors, nurses and hospital as a whole are open to a huge liability. The way they generally handled it was to instruct the nurses to ignore her call light, unplug the TV and call it “broken”, keep increasing the time between medication dosages, and basically bore her into leaving AMA, getting them off the hook if she did harm herself later.
MMM, I think you may be using the term “extra day’s stay” differently from other posters. Certainly the insurance won’t cover a day not approved, but they often approve days not used. That is, on Sept 31, the doctor makes a request for admission and the insurance may approve Oct. 1- Oct. 5 for inpatient care. Things go well, and the doctor may tell the patient on Oct. 3 that he can go home. Delaying paperwork can indeed roll that over into the next billable day, already preapproved by the insurance, for which the patient has no medical need. I don’t know that it’s a common strategy, mind, but it’s not exactly in tinfoil hat territory.
This part is absoutely typical of the experience at every hospital I’ve ever been to in the United States. And unfortunately I’ve had a lot of experience with hospitals, not just for myself but for members of my family. They always say you have to wait for the doctor’s OK to be released, and it always takes hours for the doctor to come by.
This part I have no idea about.
Is there a Doctor on the SDMB that would be willing to give reasons why a doctor would repeatedly tell patients at 07:30 that they could go home today and then not sign the paper work until after 16:00?
Also, what reasons could / would a doctor with privileges at a hospital usually give if someone with power asked him why the release form could not be done during the entire 8-9 hour period? Are the papers in the sub basement and the doctors have to walk around the hospital 3 times before going down the stairs and through all the halls to get to the only person in the whole hospital who has the papers filled out so he can sign them?
Maybe the management of the hospital is not so good after all if doctors are that busy and they make no provisions to be able to contact the doctor and get the OK to discharge without taking an hour of the doctors important life saving time to track down the one with the papers.
Sound like the 4 “P’s” to me.
Piss
Poor
Prior
Planning
Why can’t a doctor stop at any computer terminal and enter his ‘pin’ number then “gusnspot” is cleared for discharge? The computer spits pout the paper work in the admin office and a docent is dispatched with a wheel chair to come get me & roll me out.
Doc says it a 0700 and I’m out the door at the curb at 0730…
I personally have never had the actual attending physician tell me “ready for discharge today” at 7:30 and not sign the paperwork until hours later. What has happened in every hospitalization I have been involved in is that some other doctor tells me “should be ready to go home today” early in the morning, and then I have to wait for the my actual doctor (who is not a hospital employee and doesn’t work there 8-9 hours a day ) to actually discharge me. When my kids were born, I had to wait until the OB discharged me and the pediatrician discharged the baby. The pediatrician took care of it before going to his office to see patients, and the OB/GYN took care of it when he was done with surgery
It’s as **doreen **says: Some other doctor or nurse might say that you probably can go home today, but it’s your specific doctor that has to release you. And your specific doctor is probably not even in the hospital right then. He may not make his rounds until sometime in the afternoon. It’s whatever his schedule for the day is. Typically on routine days he might see patients in his office in the morning, then go to the hospital in the afternoon.
Sounds like a good conversation to have with your doctor on your way in, before he or she disappears. Get a firm commitment (and maybe a cell phone number) that they will be around when you’re ready to leave.
Not a doctor, but a nurse who has worked on a med-surgical unit.
These days, a hospitalist ( a doctor hired by the hospital to care for hospitalized patients) is usually your doctor while you are in the hospital, unless you were admitted by a specialist (surgeon, cardiologist, etc.) Most Primary Care Physicians (PCPs) do not see their patients in hospitals. Each hospitalist has many patients to see each day (35+, frequently including patients on various floors) For each of these patients, he or she has to visit and evaluate the patient, review the chart for results since the last review, consult with family members, write new orders, and sign any verbal orders from the day before. At any moment he could get called away from his planned schedule by a patient with a sudden problem or a Code Blue. Writing discharge order require considerably more than simply writing “D/C home today” like in the old days. Now, they have to review all meds, decide which the patient will continue to require at home, make decisions about diet, activity, bathing, wound care, ordering home health or physical therapy, when to follow up with your PCP,on and on. Case management is next, they set up home health, make sure the patient has someone to take them home, if needed; set up follow up appointments, see that patients get oxygen at home, a walker, a social worker, whatever. Now, in between her or his other duties, the nurse has to type up these discharge instructions, including a list of some 20 to 30 medications, how often to take them, and when they were last given (this is not an uncommon number of medications) and teach the family needed skills such as how to do wound care, how often to give Grams her nebulizer treatment, how to recognize a worsening of congestive heart failure or the signs of infection. At the same time, the nurse might get a new admission. A new admit has to be assessed and a health history taken within one hour, this process takes an hour or more to do properly. Med rounds, call bells, prepping a patient for surgery, pain meds have to be fitted in there somewhere. Meanwhile, someone is calling the nurse to their room to ask her when they can leave!
It’s not as simple as it used to be.