Hospital Floor Sign Another Clinical Clue To Patient Discharge Stability.

During every hospital discharge, I always ask myself the same question: Is the patient safe for discharge?  Safe is a relative word.  Safe from what?  Safe from credit collectors?  Safe from abusive husbands?  Safe from falling down?  Safe from disease  decompensation requiring readmission within 30 days?  We can define a safe discharge in many ways.

As physicians, I think we have an obligation to provide optimized medical therapy that reduces the possibility of bad outcomes to the best of our medical judgement, based on accepted treatment standards.  However, ultimately, patients who are admitted voluntarily to the hospital have the right to discharge at any time, even against the advice of their medical physicians.  What is the physician responsibility in AMA discharges?  The same as it is for all other discharges.  Hospitalists have an obligation to provide all necessary medication recommendations and prescriptions, even if our patients choose to leave against our medical advice.  And for the love of God, stop telling our patients that insurance won't pay for AMA discharges.  They will. Physicians should bill the AMA discharge just as they do all other discharges using the routine discharge codes.

While we can't control everything about a patient's prognosis after discharge, we can control our medical judgment on whether the patient is ready to be discharged.  One of the biggest complaints I hear from families of patients I readmit is that granny got discharged too soon.  In fact, sometimes I readmit patients who's loved ones picked them up from one hospital and drove them to another.  Sometimes patients discharge to nursing homes only to return  within 24 hours.

What drives the process of readmission is a huge area of research in hospitalist medicine.  It could be a lot of things, including but not limited to poor systemic processes in hospital discharge planning, bad follow-up care, end stage medical disease, lack of transportation and medication side effects, interactions or miscompliance.  Bad doctor decisions are one very small possible component of hospital readmissions.

I was trained as an internal medicine physician that if no extubated patients were ever reintubated, then we we were too conservative with our management.  There will always be some people who fall outside our expected course of action.  That means some people will be reintubated despite our belief they would succeed on their own.  And some people will get readmitted despite our best efforts.

However, I have discovered one hospital characteristic that has a 100% positive predictive value for determining safe discharge.  I call it the Floor Sign.  The Floor Sign is just one in a long list of signs I have developed over the last decade of hospitalist medicine that carries great weight in defining my medical decision making.

What is the hospital floor sign?  If a patient has 12/10 abdominal pain while also capable of  traveling down five hospital floors to walk outside on their own power to smoke a cigarette despite a hospital smoking ban, there is a 100% probability that the patient will not experience a bad outcome after discharge. This sign gains additional confirmation when patients first enjoy a double serving of their 150 gram CHO restricted diet prior to finding their way to the nonsmoking smoking area.     I can't guarantee they won't be readmitted to some other hospital or to some other service, just not mine.  With this powerful predictive sign in hand, I often explain to patients that I am offering them the opportunity to go home and experience the 12/10 pain in the comforts of their own home.

In addition, the hospital floor sign allows me the liberty to explain, with great confidence, why I will not recommend opiate pain management on discharge, because, as I like to point out, the patient received enough intravenous therapy to kill a quadricorn and despite these heroic measures, their pain seems only to respond to tobacco receptors.

This post is for entertainment purposes only and likely contains humor only understood by those in a health care profession. Read at your own risk. 

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