When patients won't leave

Strategies to achieve a timely discharge.

Usually when inpatients disagree with their recommended length of stay, it's a matter of leaving against medical advice. But some patients present the opposite challenge: They are reluctant to leave the hospital even though there is no medical reason for them to remain.

“This sadly happens more than I'd like,” said ACP Member Hyung (Harry) Cho, MD, director of quality and safety and assistant professor of medicine in the division of hospital medicine at Mt. Sinai Hospital in New York. “Occasionally they are malingering or seeking a secondary gain, but sometimes we get surprising stories, like the environment here is more comfortable than where they live, they are homeless and would rather be here than a shelter, or there are family issues at home. Unfortunately there has to be a certain amount of stewardship on this because there is a finite amount of resources.”

Photo by Thinkstock
Photo by Thinkstock

Patients who don't want to leave the hospital can also drain a hospitalist's mental reserves, said Nader Najafi, MD, assistant clinical professor and associate director of quality and safety in the division of hospital medicine at the University of California, San Francisco. “If someone takes 2 hours of your time and chews up your emotional energy, that's not fair to your other patients. You owe it to them not to let that happen.”

Talk early, talk often

One way to smooth the process is to give patients time to get used to the idea of being discharged, said Dr. Cho.

“Ideally you want the conversation to start before the day of discharge,” Dr. Cho said. “Explain the workup, and that pending how well the patient does, you'll get them ready for discharge. There should be a dialogue in which you ask the patient if there are any concerns.”

If a patient expresses reluctance to leave the hospital, the onus is on the physician to find out why, said Dr. Najafi.

“It's possible it's something you can solve very easily by talking through their anxieties and fears,” Dr. Najafi said. “We often don't wait for everyone to be 100% back to normal before discharge, and they have real fears about becoming sick again, being a burden to their families, or not being able to manage pain.”

Dr. Cho agreed. “Sometimes we see something as simple to treat, but for the patient, it's not. Remember that it has been 23 hours and 50 minutes since the last time they saw you. They've had time to think and have a lot of questions,” he said.

During this conversation, hospitalists should sit down with the patient and review care and status, said Robert Chang, MD, ACP Member, clinical assistant professor of internal medicine at the University of Michigan in Ann Arbor.

“The patient may not understand the diagnosis or what has been done so far. Explain everything, and explain what's next—if there are more tests to be done, or, if not, why not,” Dr. Chang said. “Even if you don't have an answer, you can explain that while ideally you would be able to tell the patient what's wrong, sometimes all we can say is that we did not find the dangerous things that we have been trained to look for. Emphasizing the shared perspective that both the patient and I desire answers but cannot always get them can redirect frustration away from the physician.”

Dr. Chang encourages hospitalists to pay attention to how patients react to the news that there appears to be nothing serious going on.

“If you tell the patient you've ruled out something like a stroke and they do not have the slightest bit of relief…you may need to coach the patient to move from ‘I need answers' to ‘At least there's nothing bad.’ Or be prepared that the patient may not be satisfied with anything you say,” Dr. Chang said. Such a response could suggest the patient has nonmedical reasons for seeking to remain in the hospital such as access to narcotics or a comfortable environment, he added.

Communication should also extend to families, said Dr. Najafi. “This is especially true with older patients whose caregivers are their children, when their children also work. They aren't there at the hospital all the time, and when they arrive, they bring certain expectations about their parent's condition.”

If those expectations aren't met, families will often challenge the hospitalist. “They'll come to you and say, ‘Look at my father. He looks terrible. How can you think of discharging him?’ So you need to loop them in so they know what to expect,” Dr. Najafi said.

Close communication will help hospitalists learn about any challenges families might face in providing postdischarge care, Dr. Cho said. “If someone's mother has to go to a facility, or if she will be by herself because insurance only covers a portion of home health aide or visiting nurse services, of course they're going to worry about her.”

Sometimes there are safety issues at home underlying a reluctance to be discharged. “I have the family leave the room and I ask the patient if someone is hurting them at home. The patient may be going home to a dangerous place or to food insecurity, or the patient may be homeless,” Dr. Najafi said.

Discharging homeless patients presents a unique challenge. “If they have a skilled need like wound care or IV antibiotics, they might go to a skilled nursing facility. They might also go to a medical respite facility where they can stay for a short period of time, but those beds are hard to come by,” Dr. Najafi said.

Other strategies include arranging for transportation to a shelter, providing a taxi voucher, and planning discharge for early in the day so the patient can get to the shelter in time to get a bed for the night, Dr. Najafi added.

If there is pushback

When patients refuse to leave, it may be tempting to talk about the financial costs of hospitalization, but Dr. Najafi encourages hospitalists to tread lightly there.

“I get nervous when I hear people talk about insurance and payment as though to threaten patients. Stick with medical explanations. It's the truth and the easier way to go. Explain that you can't justify to the hospital why the patient needs more inpatient care,” he said.

Hospitalists should work with the care team in presenting a unified front to the patient on the timing of discharge. “First make sure you're all on the same page, and then go into the room together—the nurse, care manager, social worker, whoever works with that patient—so everyone hears the same thing and the patient can't split the team,” Dr. Chang said. “Then write it out on the whiteboard so no one is confused and other team members have a point of reference to reinforce the conversation that does not just rely on the physician.”

Documentation is important, said Dr. Cho. At Mt. Sinai, patients are notified about plans for discharge 24 to 48 hours in advance, by law. An implement discharge plan (IDP) notice is initiated from the physician to the nurse, then to the patient. If the patient refuses to sign it, he or she can appeal through IPRO, a federally designated quality improvement organization.

“IPRO oversees the record. They're a second opinion, and sometimes they do call with feedback that changes our decision,” Dr. Cho said. “But if the patient loses the appeal, then they have to leave.”

The University of Michigan Health System also has a plan in place should communication strategies fail. There is a nurse practitioner designated as a liaison to the psychiatric consult service who serves as a “behavioral rapid response team,” Dr. Chang said.

“We also work closely with our security force and have defined who has what responsibilities in different scenarios,” he explained. “We're a teaching hospital and a lot of our interns and new faculty have never been in [these situations] before, so we explicitly created a menu of options an officer can provide to the provider, rather than the officer passively waiting for the provider to call for their help.” For example, one option is to have the security officer interrupt the patient when the patient raises his or her voice or uses foul language.

The team involved can also expand to include other hospital personnel. “Our risk management group—the Office of Clinical Safety—would often talk through complicated cases. We developed an algorithm where we review whether the patient has an unfulfilled medical need, whether that requires inpatient care, and whether additional resources are necessary to address an expedited discharge,” said Dr. Chang.

The care team may also have to set boundaries with family members being aggressive on this issue, including occasionally having them removed by security, Dr. Chang said.

While it's important to have a plan in place should conflict arise, hospitalists should also give patients the benefit of the doubt each and every time they are in the hospital, even those who have history of malingering or disruptive behavior. “Treat everyone as innocent until proven guilty, and assume that everyone is actually sick until you determine they aren't,” said Dr. Cho.

Dr. Chang agreed. “Just because someone is mean, that doesn't mean they're not sick. Be sure you've done your due diligence and aren't just angry at the patient,” he said. “When you go to bed at night, you should know that you've done right by that patient as a physician.”