When patients won’t leave or families won’t let themBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1127 (Published 13 March 2018) Cite this as: BMJ 2018;360:k1127
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Admission and discharge of "difficult patients", experience in Ambito sociale XXIV of Marche Region, Italy
Admission and discharge of patients seem to become not only a clinical choice, but also an economical question, more and more restraining for all subjects involved in health management. But what does "economical" mean in health management? Clinicians and administrative staff of hospitals are concerned about te value of DRG, often in different ways: the clinician needs to have the maximal bed utilization, administrative staff can look for a balance between optimal bed use and optimal link of hospital teams with GPs and home care systems to avoid expensive revolving door hospitalizations. Relatives are concerned about personal costs during hospitalization i.e. the lost work days. Elderly relatives get more and more difficulties in hospital and home care because of their own physical and psychological status. It is a complex system of many economical values, with subjective and objective relevance, often mutually in contrast, with relevant distress and conflict.
In mental health care, discharge is a daily concern: it is disputed by families “tired from continuous crises” and by community mental health centers facing a discharge from acute wards, which is always “too early” because patients “don’t have any sure and safe compliance to therapies”; sometimes also staff in sheltered facilities feel impotent in the face of “difficult patients”.
We need to consider also further elements: the age and health status of family; older parents and relatives have a difficult or progressively impossible task with home care for physical and cognitive reasons. Does the family’s economical status allow or hinder the help of an external nurse or caregiver? Has the family cultural and personal possibility to accept a person at home with prolonged and increasing care needs? What kind of social, parental and institutional networks surround patients and family in a comprehensive home care system? That means, community mental health facilities and home care services can help to have a continuous therapeutical “prise en charge”? The frustrations of caregivers dealing with repeated acute psychotic crises or facing a progressive worsening of physical status have an impact to be considered in an economic balance of emotions when it seems there is no hope of improvement. Sometimes this happens more between operators than between families.
Admission and especially discharges from hospital are a complex challenge to be faced by all involved subjects. Health care has a strong relation with social and institutional networks and with personal resources. All these are not incommunicable or compartmentalized services, every one seeking the reduction of costs, without observing the real person and the personal care needs. Sparing health services can induce sometimes increased social and welfare costs, and sometimes reduction in welfare and social support can only induce more personal and family costs in a time of regressive economics, which does not give sure evidence of recovery. So we have a net saving in the global system, but only by shifting costs to the person and family. These are economic and psychological costs not always easily distinguished but destined to worsen.
The experience in Ambito territorial XXIV of Marche Region, Italy, during the last 20 years shows the relevance of cooperation between mental health dept GP and socio-institutional networks of patients in reducing hospital costs (4-5 acute hospitalizations a year and 4 admissions in sheltered facilities during 20 years) but it shows also that the ageing of patients and families begins to induce an increased need for facilities.
Competing interests: No competing interests
I applaud Dr Oliver for writing about the issue relating to patients who overstayed the acute need to have hospital based management, something that has been well known in the industry but hardly talked about and even whispered in the corridors of the trust management and executive.
But surely this is not a new thing, and most carers in the community would know that they can obstruct the process to send their charge back home using various means, including threats of legal prosecution "if anything happens to mum if you send her back when she (or the home) is unsafe/not ready" some months or even years after discharge.
This is threats made even more significant since the Bawa-Garba case has demonstrated that individual practitioners can be held liable even when the main contributor to a poor outcome is systematic in NHS.
I am sure Dr Oliver is aware of the Friday evening phenomenon colloquially called the "weekend special" in which people (particular older patients under active care from health professionals often nursing facilties, or with stay in carers) who have problems brewing for days (sometimes weeks) somehow end up presenting at hospital Emergency Department (ED) on Friday afternoon/evening. Previous diagnostic terms used by various clinicians (albeit inappropriately) also include "acopia" or "social admission"
Often for some reasons, they present to ED via ambulance even if the condition is stable and not acute.
This is perplexing since, in my opinion, many of these "weekend special" presentation does not need hospital admission, since all they really need is good community care and nursing support and timely outpatient review at specialist clinics if required, both which are near impossible to organise on a Friday evening.
Data from Meacock et al (ref 1) demonstrated that although Friday sees the lowest ED presentation volume of all weekdays (and the entire week for that matter), it has the highest admission rates of all days, but the lowest mortality rates in patient admitted via ED compared to the rest of the week.
Compound this with the 4-hour-target ideology and the all-powerful ED admitting officer who decides to admit a patient under a inpatient service "in good faith" (regardless whether this service agrees the working diagnosis is correct or the admission is appropriate or not), there is no choice but to deal the situation created by the system.
The irony is that these "bed sitters" (another politically incorrect term, but far closer to the truth than acknowledged) significantly contributed to bed occupancy and hospital overcrowding, the real reason for poor outcome from access block rather than the 4-hour-target itself.
In this case these patients, in musical bed game created by the 4-hour-target fiasco, do not go anywhere (for some time).
Just to let you know, Dr Oliver, the orthopaedic service get quite a few of these referrals on Friday afternoon, because the patient cannot walk and/or there is a fracture found somewhere in the body and ED deems it an orthopaedic issue because "there is a fracture" (even though there is nothing to fix).
In Australia, there are several avenues to consider for patients who are unable/unwilling to be discharged home:
1.Even within capital cities, there are still some step-down hospitals which are not rehabilitation units but have nursing and allied health support with contracted GP Visiting Medical Officers (VMOs) to provide care for patient with low acuity conditions.
There are obstacles, of course, with both carers and patients complaining these sites are often too far away from their friends and relatives; with the right support from hospital executives, we gently remind them we are not providing hotel services here (unlike popular beliefs, Ref 2) and we are placing them in facilities with adequate supervision we deemed appropriate (not essential), while we use acute medical beds for other patients who needed them more.
2. Patients with stable subacute or non-acute conditions can be reclassified as nursing home type patients (often > 35 days admission) and the Commonwealth (Federal) government allows the hospitals to charge a fee (about AUD 58+ a day), this patient contribution/co-payment is deemed not covered by the national health insurance scheme.
3. Australia has a paid carer scheme for people providing care to their loved ones. For paid carers (particularly those who are not drawing an aged pension), when their charge is in hospital/nursing home care >65 days, may have their payment allowance "adjusted" since they are not entitled to such payment while their charge is being cared for by other paid professionals.
Granted the latter 2 options involved perverse financial "disincentives" for patients who have prolonged stay in hospitals, these are real-world-proven effective measures to motivate people to the right things.
The basic act of providing a bill for nursing-home-type hospital charges facilitate the process of relatives looking and choosing a nursing home for placement of their loved ones; I recall the initial days that relatives who rarely visited and are somehow uncontactable by phone/mail regarding nursing home placements, suddenly turning up in the ward demanding to know what these charges are, and "isn't public hospitals meant to be free?"
I am not sure if Dr Oliver have similar experiences given the differences in NHS but I would say at the end of the day, money is a real incentive even when it shouldnt be.
1. Meacock R, Anselmi L, Kristensen S, et al. Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission. J Health Serv Res Policy2016. doi:10.1177/1355819616649630.
Competing interests: No competing interests
Oliver highlights an important but often poorly appreciated issue burdening a fragile healthcare system struggling for sustainability. Although many potential reasons may exist for patients or carers not agreeing with medical plans for discharge, there is usually a secondary gain involved. This may be related to homelessness, medication access or stressful situations at home. Apart from these are less common reasons such as psychiatric disorders, malingering or somatisation.
Despite refusal to leave not being a common occurrence, most physicians and nurses have at some stage experienced such challenging situations. Finding a suitable, acceptable and non-confronting solution is often very difficult. Once medically cleared it should be non-negotiable that the patient is discharged from hospital as soon as possible. Health systems can no longer support a delayed discharge when medically this is not indicated.
In the current climate of increasing opioid use, the proportion of patients in hospital on strong analgesics is substantial and in addition, a number of admitted patients also use illicit drugs. Red flags should be raised if there are repeated requests for strong analgesics in conjunction with a refusal for discharge. Such patients are often repeatedly admitted either to the same institution or to nearby health services and background and collateral history is therefore extremely important. These patients often create multiple challenges and stress for staff.
From a health services perspective, it is essential to ensure that patients have good understanding of their health issues, treatment plan and the follow up that is required. Considering that the majority of patients have either basic or intermediate levels of health literacy, it is important that every interaction during the hospital stay with the patient is fully utilised to reinforce patients’ understanding of their diagnosis, management and discharge plans. Discharge planning needs to be initiated on admission and not decided abruptly. Better communication in the form of a clear and simple letter for the patient outlining their admission, management and follow up plan can be very useful.
It is by no means an easy feat when faced with a challenging patient or relative that refuses to allow discharge when medically directed. Negative emotions and dissonance can be generated in health care providers where empathy is being challenged with such elicited responses. Nevertheless safe, effective and decisive discharge promptly upon completion of all necessary inpatient medical care must remain a priority. Although the patient may represent through the emergency department soon after discharge, having appropriate alerts on file can assist in proactively manage these readmission attempts more effectively.
Competing interests: No competing interests