Common hospital discharge barriers to recognize

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NATIONAL HARBOR, Md. — Hospitalists should be aware of several common barriers to discharge, such as overtreating hypertension, according to a presentation at Hospital Medicine 2019.

“Discharge planning starts at admission,” Steven Knuesel, MD, hospital medicine physician at Massachusetts General Hospital, said during his presentation.

The main components of discharge planning include educating patients about post-acute care, levels of care and barriers to discharge, he said.

Hospitalists should be involved in the multidisciplinary discussion of discharge to help make meaningful change in the way that patients experience hospitalization and the discussion should start early on, Knuesel said. They should consider population health and social support issues in discharge plans, he said.

Previous research indicated that pain, lack of understanding of recovery plan and dailyliving activities were the most common barriers upon admission and discharge, he said.

Hypertensive urgency

There are no data to support that failure to aggressively lower BP during hospitalization is linked to higher short-term risks in patients who present to the ED with hypertensive urgency, according to Knuesel.

The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure has stated that the term urgency has resulted in overaggressive management in many patients with severe, uncomplicated hypertension, he said.

In patients with hypertensive urgency, hospitalists should rule out end organ damage, search for common causes, allow for rest and reassess, avoid IV medications, consider modifying chronic regimen and coordinate early post-discharge follow-up with the outpatient care team, Knuesel said.

Atrial fibrillation with tachycardia

“The American Heart Association and American College of Cardiology say that there is no good definition for heart rate control in atrial fibrillation,” Knuesel said.

The AFFIRM trial found that patients with atrial fibrillation with tachycardia should have less than 80 beats per minute at rest or 110 beats per minute with moderate activity, he said.

Knuesel recommended that hospitalists try to find if there is a driver of the tachycardia, such as pulmonary embolism, sepsis, anxiety or withdrawal.

“If we can satisfy ourselves that there is no underlying driver of the tachycardia, then we can consider being more lenient in discharge,” he said.

Antibiotics

Patients who achieve hemodynamical stability and are improving clinically should be switched from IV to oral therapy, he said.

It is not necessary to observe inpatients receiving oral therapy, Knuesel said.

Patients on antibiotics can be discharged if they are clinically stable, do not have other active medical issues and have a safe environment for the continuation of care, he said.

Predicting readmission

Meaningful factors for predicting 30-day readmission include age, marital status, chronic renal disease, prior malignancy, chronic heart failure, nursing home residence, oral corticosteroids, number of ED visits the year before, prior admission, number of clinic visits in the year before and length of hospital stay, he said. – by Alaina Tedesco

Reference:

Knuesel S. “Can I go home?” Who is safe for discharge; Addressing common discharge dilemmas in hospital medicine: A lightning-fast review. Presented at: Hospital Medicine 2019. March 25-27, 2019; National Harbor, Md.

Disclosure: Healio Primary Care Today was unable to confirm relevant financial disclosures prior to publication.