A closer examination of usual hospitalist discharge practice reveals too much similarity for comfort. Similar to how the USS Indianapolis was removed from the plotting board on Guam, discharged patients are removed from the hospitalist’s census list. Follow-up becomes the responsibility of the patient and primary care physician.
Communication with the primary care provider is recognized as a best practice for discharge, but research suggests direct communication occurs less than 20% of the time.2 These dismal statistic suggests the “port of arrival” is unaware our patients are expected in a significant percentage of discharges. Outpatient physicians, like the junior port director in Leyte, may assume that patients who do not call or arrive for appointments have been readmitted, seen by another physician, or otherwise diverted.
Even a superficial review reveals significant deficits in the feedback provided by our current discharge practice. When patients don’t arrive at follow-up appointments, most hospitalists lack any ability to recognize this failure of their transition plan. The assumption in most hospitalist groups is that patients who leave the hospital will achieve follow-up as directed. This “presumption of success” is ill-founded and may expose the patient to potential harm—and the physician to liability.
The case of Shirk v. Kelsey offers parallels to discharge situations hospitalists commonly encounter.3 In this malpractice case, a procedure was unsuccessful in terminating a patient’s pregnancy. The performing physician left follow-up of the pathology results to the patient’s usual outpatient obstetrical provider. The patient’s lack of follow-up was not recognized by the discharging obstetrician. This provider—not the practitioner with whom follow-up was intended—was found liable.
The American Medical Association’s code of ethics states: “Once having undertaken a case, the physician should not neglect the patient.” Hospitalists form physician-patient relationships with hospitalized patients that usually terminate on discharge. Our duty to not abandon or neglect a patient diminishes significantly after discharge, when we are no longer responsible for ongoing hospital care or exchanging information with patients on a daily basis.
But our duty does not disappear. Certainly, the responsibility falls to the hospitalist to be aware of and ensure a follow-up plan for important results such as pathology reports that return after discharge.
Allegations of improper post-discharge communication or failure to pass along critical results that become available once the patient has left the hospital, are common in medical malpractice claims.
Most are settled out of court, and many do not find the physician liable for malpractice. However, legal consequences are far less relevant than the safety and quality of care compromised when patients are failed by a system that lacks feedback loops to ensure safe transitions.
The ultimate goal of medicine is to improve the health and quality of life of our patients. Whether or not a lawsuit results, we need to recognize the commonality of patients who have their care compromised, delayed, or mismanaged because of our inability to recognize a foundering transition plan. Instead of looking at this as a failure of individual physicians to communicate, the problem needs to be addressed by creating effective, reliable systems.
Solutions
Providers discharging patients with follow-up needs should have a mechanism to identify those at highest risk for problems with transition. For these patients, follow-up with a post-discharge telephone call may be an effective feedback step.
One study looking at post-discharge phone contact found that 20% of patients had not filled new discharge prescriptions. Another post-discharge study revealed that a quarter of patients had medication questions that required clarification.4,5 Other research indicates more than one in 10 patients had new or worsening symptoms in the first five days after leaving the hospital.6 Despite these symptoms, 39% of these patients did not have a follow-up appointment established.