Bouncing back to the hospital refers to patients who were discharged from the hospital but return during some defined period of time. This is important as Medicare has now stopped paying for some patients who get readmitted within a 30 day readmission window. When hospitalist groups were first coming on the scene and they were showing reduced length of stays, many folks falsely believed that hospitalists must have had a higher percentage of patients bouncing back into the hospital. I have yet to see any research that indicates such trend ever existed. For me, the first thing I ask myself when I learn a patient of mine is bouncing back or has bounced back during the overnight shift is why? Did I miss something? Are they back for the same reason? Is the reason bogus? Are they here as the path of least resistance? How long has it been since I discharged them?
I once had a patient bounce back four times in less than two weeks because they were weak and drunk and lonely and refused all efforts for outpatient placement and assistance. I ultimately learned they enjoyed their time in the hospital because we had a cook and they didnt'. Why are most patients bouncing back into the hospital? An article in January 2013 New England Journal of Medicine (NEJM) described post hospital syndrome, an acquired transient condition of generalized risk. The most common conditions I see for patients bouncing back into the hospital are:
- Congestive heart failure exacerbation
- Diabetic ketoacidosis
- COPD exacerbation
- Nonspecific abdominal pain
- Drug seeking behavior
- Substance abuse with sequella
- Decompensated alcoholic liver disease
- Drug overdose and suicidal attempts
- Mental health hospice
- Too old to go home
When I learn a patient of mine is bouncing back in the emergency department or has bounced back on the night shift, I want to know how long it has been and what was their condition when I discharged them. What were their vital signs when I let them go? How severe was their underlying illness? Were there recommendations for hospice or placement into a nursing home that were declined? There are many questions that I wonder about when I learn a patient is being readmitted. In my experience, rarely if ever has a patient ever returned because a diagnosis was missed or mismanaged or their condition was not stable for discharge. So why are my patients bouncing back? The most common reason is because they have a condition unrelated to the original admission. In addition my patients are bouncing back from
- Unforeseen medication complications such as acute renal failure or gastrointestinal bleeding
- Outpatient anticoagulation complications
- Dietary indiscretions such as high salt intake during the holidays in a heart failure patient
- COPD patients who continue to smoke and don't use their oxygen as directed
- Lack of insulin compliance in type I diabetics
- End stage disease with unmanaged patient expectations and poor compliance of medical management requirements
Rarely do I see patients bouncing back because of poor hospital care. What I see are patients with poor lifestyle choices and poor economic demographics who suffer the consequences of their choices. What I see are patients with complicated disease states, polypharmacy and poor reserve, which even under the best monitored circumstances, have poor prognostic indicators. What I see are patients who are unable to care for themselves or choose not to take care of themselves. What I see are patients who know that no matter how they choose to live their lives, the hospital will be there to save them again...and again...and again...
When you know your choices have no consequences. When you know your choices will be paid for by others around you. When you falsely believe that doctors and medicines and fancy technology will always be there to save you one more time, there is no reason to suffer through the necessary self motivation to remain hospital free. When you know you next bounce back has no consequences, bouncing back becomes just another normal day in the life cycle of your disease process. I have patients every day with 5, 10, 15 admissions a year for decompensated disease. For them, it's just a normal part of their existence.
What was one of the fastest bounce backs I've every seen? A 500 pound man originally admitted with multiple complaints was being discharged by ambulance to a small town nursing home when he was suddenly diverted to the nearest emergency department with complaints of chest pain and nausea. What the heck do you think is gonna happen with that? The easiest answer is the most expensive answer which is also the path of least resistance. You call the hospitalist to readmit them. Five thousand dollars, one green goddess and a day later and the patient was back on road till next time.
What's the solution to preventing patients from bouncing back into the hospital? I don't know. I do know it's not bad hospital care. Perhaps it's complex discharge planning. Maybe it's polypharmacy. Maybe it's patient ignorance out of choice or genetics. Maybe it's bad lifestyle compliance. Maybe some are just hospital junkies. I'm sure every situation is unique. What ever the answer, I know it's not bad hospital quality causing patients to bounce back. We're just paved with good instructions on how to get back, as these original Happy Hospitalist ecards help to explain.
This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.