Thread: More discharged patients are returning via the ER

More discharged patients are returning via the ER

Posted 24m ago
By Mary Brophy Marcus and Marisol Bello, USA TODAY

CHARLOTTESVILLE, Va. — When you have heart bypass surgery, you don't want to find yourself pulling up to the hospital's ER entrance two weeks later.

But William Sclater, 79, had exactly that experience just last month. Shortly after he was discharged from University of Virginia Medical Center following triple bypass surgery, chest pain drew enough concern from his doctor and in-home nurse that they recommended he head back to UVA, to the emergency room for a double-check.

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"It was a madhouse out there at the time," says his son, Greg, 39, who drove his father to the ER that Monday afternoon at about 3:30. Since heart patients are priority cases in the ER, Sclater was ferried to an exam room within 30 minutes of arrival. But the ensuing hours and days — while staff awaited lab results and tried to puzzle out his symptoms, keep him comfortable and negotiate a hospital bed for him — were frustrating to Sclater and his family.

"You can't get any rest in the emergency room," Greg says. "There's noise 24/7 there."

An open hospital bed was finally nabbed 35 hours later, at 1:30 a.m. Wednesday.

Readmissions can be costly

Sclater is among many patients who find themselves right back on their hospital's doorstep shortly after being discharged, says surgeon Jeff Young, chief quality officer and the director of UVA's trauma center.

Readmission is not unique to the Charlottesville medical center, though. A recent New England Journal of Medicine study reported that on average, almost one in five Medicare beneficiaries who are discharged from a hospital will re-enter it within a month. Some are planned, but the majority are not.

Young says unplanned readmissions often come back through hospital emergency departments, and research suggests such hospital visits drain billions from the health care system annually. But many hospitals are working on turning that statistic around, Young adds. And the issue has garnered attention from the Obama administration, which has proposed health care reform that would include lowering readmissions.

"Readmissions are in general a very complicated issue," says Nancy Foster, vice president for quality and patient-safety policy for the American Hospital Association.

At UVA, the 30-day readmission rate is around 5%, which adds up to about 1,300 patients out of 26,000 annual admissions, Young says. On the day Sclater visited the ER, USA TODAY was in the middle of a 24-hour reporting stint there. He was one of 10 people, out of 197 total patients who visited the ER that day, who was tagged a "readmitted patient" — back at the hospital for the same complaint — according to hospital data.

Doctors are now better at keeping patients with chronic illnesses alive, says UVA assistant professor of medicine and ER attending physician David Burt, but the fallout is that this population creates many more unplanned readmissions, which place a big burden on ERs. "We see many of these patients. We also have to board readmitted patients in the ED (emergency department) since the hospital is full."

Just where to make changes that would improve patient outcomes and reduce hospital readmission rates is difficult to determine, experts say. One reason: There is no single profile for readmitted patients, says Eric Peterson, vice chairman for quality with Duke University Medical Center and head of performance improvement at the heart center there. It's difficult to predict who will be readmitted, he says. "The models we have, whether they are based on clinical or claims data, haven't really yielded a good ability to reveal who's going to be readmitted. They aren't much better than a coin flip."

In Sclater's case, it turned out that he was dehydrated, possibly because of his body's reaction to the new mix of drugs he was prescribed after surgery, says Greg, who believes his dad was sent home too soon and is concerned that insurance companies limit hospital stays to cut costs. "He didn't feel well the day he was discharged," he says. "He was cut from here to here (drawing an invisible line from his clavicle to his bellybutton) and … four days later, he was sent home."

Young says UVA doctors and nurses do not let insurance-company policies dictate when a patient is discharged. In fact, he says, they rarely know if a patient is insured or not.

Emergency medical technician Cindy Garrett, who was running 911 ambulance calls the day Sclater was readmitted, says that during her seven years as an EMT, she has been called to transport discharged patients to rehab centers who did not appear ready to leave.

"Patients are only discharged if the reason they've come to the hospital is under control and no longer putting them at risk. If the patient isn't well enough to go home, I don't send them home," says Young, who oversees hospitalized trauma patients.

Yet, says Garrett, "I've seen a lot of cases where a patient is discharged from the hospital and really shouldn't be."

Communication, follow-up key

What could drive down readmission rates: clear-as-a-bell, detailed discharge instructions; better communication between the hospital and a patient's primary-care physician and home-health workers; and follow-up calls in the days after a hospital stay, Peterson says.

Duke has recently upped its post-discharge support and communications, including a hotline, not just for recently discharged patients but also for primary-care physicians to call if they need information from the hospital where a patient recently stayed.

"Our early findings show, on follow-up, a quarter of our patients (post-hospital stay) have had issues that needed addressing," Peterson says.

Providing financial incentives to hospital and primary care physicians who follow-up with patients after they exit the hospital also could reduce readmissions, says Christopher Queram, president and CEO of non-profit Wisconsin Collaborative for Healthcare Quality, whose mission is to improve quality and reduce costs of health care in Wisconsin.

Sclater is doing much better since his second hospital discharge, Greg says. "He's at his doctor's right now for a follow-up visit."

http://www.usatoday.com/news/health/200 ... sion_N.htm

First tip: don't drive anyone with Medicare and supplemental insurance to the ER. Call an ambulance.
I have been through this so many times in the past three months with my elderly relative--the last time she was admitted, even with the ambulance we sat in the waiting room for nine hours, while almost all of the visitors to someone in there came out speaking another language. Even though she could have suffered a stroke, there were no beds available. Then she got to spend the night in the ER as there were no rooms available, finally getting a room and spending 12 days there. But she got little rest at night with the nurses running in to sample blood and run blood pressure. When she finally fell asleep, someone would come in to clean the floors, then there was the breakfast order, then breakfast, someone coming in to remake her bed, someone coming to give her a bath, more blood taking and BP monitoring, a few doctors roaming through, the lunch order, lunch, etc., etc.
I appreciate everything they did at the hospital, but she lost 10 pounds there, and is doing much better at home with home health-care nursing. This means that any home-healthcare needs to stay in this bill, whatever bill comes out of committee.

If anyone thinks the quality of health care is bad now and/or the waiting time is too long and/or the cost of health care is way too high and/or there is too much paperwork and/or tedious documentation and/or the medications are not effective and/or oftimes generic, they will be in for a very rude and painful awakening, when they realize how good we had it and how horrible and ineffective our health care system will be with this new health care system..........that was stuffed into the Stimulus bill that we never voted for.

The people that support this bill say that we need reform but the reform we need is not the kind of reform they are suggesting.
Some Reform that really IS needed is as follows:

1. No illegals/anchors health care covered by ER's and/or our tax dollars (thereby hsps. would have more money and would not close. And Dr's would have the time to spend with American citizens so they would get better care and consequently not be sent home from hsps. prematurely.

2. Tort Reform/ so patients will not be getting so many extra tests/ and Dr's would not have to pay exhorbitant liability insurance fee's.

3. Open up the market so Americans can shop across states for insurance

4. No insurance company can turn away people with pre- existing conditions.

5. Expand the use and practice of Alternative modalities

6. Place more emphasis on Prevention (not required by law but encouraged by some positive incentives)

7. Obama's Special Interest groups/thugs ( like La Raza and Acorn, etc.) don't get top rate benefits and health care on our dime any longer. The bill will give them an even bigger chunck out of our taxes if it passes.