Staying Out of the Hospital — Dennis Rosen
The following post is by Dennis Rosen, author of Vital Conversations: Improving Communication Between Doctors and Patients
Hopefully, all of you will live long and healthy lives that will end peacefully in your sleep sometime after seeing your youngest great-grandchild head off to college. Unfortunately, it will be a lot less rosy for most of us. Disease and illness are natural parts of our lives, and as science and technology advance people now live longer—and with more coexisting medical conditions—than ever before. As we get older we tend to consume more medications, and the likelihood of being hospitalized because of an acute health crises increases.
Unfortunately, the high cost of health care has resulted in growing pressure to shorten the length of stays in hospital as much as possible. And while there are many good reasons for doing this—reduced expense, lower likelihood of picking up a secondary infection or experiencing a medical error)—there can be significant downsides as well. Among these are the risks patients face when sent home from the hospital before they are well enough to care for themselves or before they understand how it is, exactly, that they are supposed to do so.
Almost one in five Medicare patients discharged from the hospital will be readmitted within the next thirty days. Interestingly, this also corresponds to the percentage of patients who experience an adverse medical event or complication, two thirds of which involve the medications they are taking. This suggests that better pre-discharge patient education needs to take place. And yet, one study of adult patients being discharged from a large academic hospital in New York found that only 28 percent could name all their discharge meds (on average, fewer than four), and that almost two thirds did not understand why they had been prescribed the medications in the first place.
Although this information is supposed to be included in a printed discharge summary, it is often not as clear as it should be, or even that easy to find among the many pages of small-font verbiage. Let’s not forget as well, that many patients are too anxious, in pain, or simply hazy from the meds they’re on to make sense of the discharge summary as carefully as they should. When you add in the fact that more than one third of Medicare patients possess marginal or insufficient health literacy skills, it’s surprising that the rate of adverse medical events following discharge is as low as it is.
So what can you do if you (or a loved one) is getting ready to be discharged from the hospital, and really don’t want to be one of the almost 20 percent who bounces back? Here are some ways to achieve this not-too-lofty goal:
Ask the right questions: If possible, having someone else to assist you in asking—and writing down the answers to—these very important questions can be very helpful. These include: What meds am I supposed to take, when, and how? Do I take them on an empty or full stomach? In the morning or in the evening? Do I take them for symptoms such as pain (such as might be the case with ibuprofen); to keep symptoms from appearing (such as with blood pressure meds); or in response to testing I’ll be doing at home (such as insulin shots for diabetes)? Which meds that I was previously on do these new ones replace? I’m allergic to XXX: Will this be a problem with any of these meds, especially the new ones? What are some of the common side effects or interactions between my meds that I should look out for? Where will I be receiving my meds/medical supplies from? What should be cause for concern after I’m home? Under what circumstances should I call you/my doctor/come to the emergency room for further assessment?
Make your own list—separate from the discharge summary—that includes all of these details. Make sure it lists clearly which meds you need to take and when, as well as any treatments (such as wound care) or testing (blood sugar) you might need to start doing after discharge. You’ll need to make sure it doesn’t leave room for confusion: you’re the one who’s going to have to organize your pill box, after all.
Review your list with your doctor/nurse/discharge coordinator to make sure you’ve gotten everything right. Not only will this ensure you’ve not overlooked or misunderstood an important detail (which often happen when patients are cared for by multiple specialists during a hospitalization, each focused upon her or his specific organ system), but it will reinforce the new care regimen you’re embarking upon, and prompt you to ask additional questions that may not yet have occurred to you.
Once home, make at least three copies of your list. One to put on your fridge door, one to give and review with your doctor, and one to keep in your wallet at all times in case you need care unexpectedly (take a picture for your phone as well). There are some things that are fine to commit to memory: this isn’t one of them.
Schedule a follow-up visit with your doctor for the near future, ideally before you walk out the hospital door. Although your doctor should receive a copy of the discharge summary shortly after you leave, until there is universal access to electronic medical records in this country, you won’t ever really be able to count on that happening in time for it to be of use to her (or you) should there be problems. At the visit, update her about what has happened to you and what has changed with your. This is a good opportunity as well to discuss any side effects from the medications you’ve started, so that if necessary, these can be changed.