1. The patient is a space-occupying lesion. If your service has caps, you really appreciate this reason, especially on a Friday afternoon when you have a hot date later. If you were to actually ever discharge a patient, you would be faced with the grim reality of having to admit one. You know how much easier a follow-up visit is than a discharge and an admission; compare a few minutes to a few hours. Of course, if you have no cap, like most real-world non-resident service hospitalists, this strategy would only lead to astronomical service sizes, premature balding and piles.
2. You go off service tomorrow. You are currently doing the one-week-on/one-week-off mambo, and it's Sunday. Tomorrow you are going to an intensive review course in Hawaii, where you plan to spend every waking hour concentrating on the course material. The patient has been in the hospital for 27 days and nobody has touched the discharge summary since a compulsive colleague did an update on day 3. You could spend the next three hours teeing up discharge plans, but it's Sunday, so everything is closed. You could write 15 prescriptions, review the entire chart and summarize it into concise, meaningful, hospital-course prose. You could convince the patient that this is the window of opportunity to leave, and be a hero to your partner coming on tomorrow. Or you could come up with some lame excuse for not discharging and go home now to iron your Speedo and practice your ukulele. You choose.
3. The patient's been in the hospital for 90 days. What's one more? The patient just came out of the ICU a few days ago and the transfer summary was 12 pages long, written by a second-year medical student. It could take hours to really understand what's going on. Think of a test they might need, maybe an electromyography or a positron emission tomography scan that can't be done till Monday, then order it. Then go up to the call room and take a nap. You've earned it.
4. Nobody is paying attention to your length of stay. You are not employed by the hospital; their bottom line is not your concern. You're independent, baby, and you do what you want. When that pesky case manager comes a-calling, quoting utilization review criteria and telling you it's time to discharge, you order a random glucose level assuring it's postprandial, then point out the RMG of 251 does not meet discharge screens. It's great to know the rules. It might be a few thousand bucks a day to the hospital, but it's a neat $37.50 SH2 to you!
5. It's too much effort. Discharging a patient properly is a bucketload of work. You've got to reconcile medications; communicate with the patient, family and primary care provider; write prescriptions; author discharge summaries; speak with the rest of the family that wasn't present the first time; write the prescriptions you missed; fill out return-to-work forms; handle “Just one more question doc….” Why go to all the trouble?
6. The patient is just going to get readmitted anyway. A low readmission rate is the Holy Grail of hospital medicine. If you discharge, you run the risk of readmission, and there goes your rating. Your management is so suboptimal that most of your patients spend more time in-house than out-of-house. This may begin to affect the hospital's Medicare payments. If you don't discharge them, they can't bounce back. End of story.
7. You have no idea what's wrong with the patient. It's very hard to pick a billing code when you don't have a diagnosis. After a while, discharging every patient with a diagnosis of fatigue might raise a red flag. Leave the patient in the hospital so one of your more clinically adept colleagues can come up with something. Maybe it's Lassa fever or leprosy.
8. The patient does not want to leave. Ever. There is nothing harder than a “sticky” patient. He just loves the food and personal service and talking with you three times a day. You could go through the drama of calling the utilization or legal office and serving him with a letter of non-coverage...or you could take the passive approach and hope the next one on service has more strongly girded loins than you. Besides, the patient does not want placement, his family is out of town till next week, and he forgot his car keys.
9. One more day and the patient will get nursing home coverage. OK, nobody would ever do this. There is not a hospitalist in good standing who would ever keep a patient an extra day so they would qualify for coverage of post-hospital care. When they are ready to leave, they leave. Really.
10. You are a foreign agent trying to sink the U.S. health care system. Perhaps you are not really an agent from Lower Slobovia trying to undermine the sanctity and fiscal soundness of the American health care system (cue patriotic music). However, every little bit makes a difference. Unneeded testing, extra days in the hospital, unnecessary procedures, they all add up to drain the well, and the level's pretty low right now as it is. In the words of the late singer Otis Redding, “You don't miss your water till your well runs dry.”