Dr Krishna Prasad Pathak
As we know, currently a very numbness news that dozens of white- coated health professionals also have positive case of Corona Virus. We believe life is given by God and life save by doctor and their team. Therefore, the medical profession is accepted as a noble profession because it helps in saving life of patients- “doctors are always making their best predictions. A patient generally approaches a doctor/hospital based on his/her reputation and the patients do the expectation in two folds: first, both, doctors and hospitals are able to provide medical treatment with all the knowledge and second, they will not do nothing harm to patient in any ways because of their carelessness, financial affordance, negligence, or reckless attitude of their staff- it is not debatable questions. Though a doctor might not be a life saver position of patients at all times, he/she is expected to use his/her expertise in the most appropriate way keeping in mind the interest of the patient who has entrusted his life to him. Furthermore, it is expected that a doctor carries out a very essential diagnosis, management and care from the patients unless the patients do not leave hospitals. These days we are more concern about the doctors’ qualification and reliable hospitals but we never think of art of hospital discharge and its significant effect-it is hiding factors in public- a very important hidden issue. The term of Hospital Discharge is used when a patient leaves hospital once they are sufficiently recovered.
During the civilization the staying in hospital was longer, for example: in Northern America the duration of maturity patients used to stay about 7 days but today they stay 1-2 days, likewise in 60s the heart disease patients were spent 13-16 days. Now days even bypass surgery will take 3-5 days in hospital- Cleveland Clinic said. Patients of abdominal hysterectomy patients in 1960s were occupying approximately 11 days and 52 days of total convalescence! Today, the average hospital staying duration for vaginal hysterectomy is 2 days. The rate of lengthy staying at acute care hospitals significantly is decreasing from the 1960s due to the advancement of medical technology, financial pressure, civilization of community and knowledge of public and modern medical practice. The journal of medicine further added accordingly: stabilizing the patient, minimizing length of hospitalization, postponing complete diagnosis and treatment for the outpatient setting, booting that patient out the front door of the hospital as quickly as humanly possible.
According to the Ministry of health population Nepal, Nepal has around 2,000 hospitals and 700 ICU beds, of which about 150 are public, and about 4,000 health centers across the country. There are 155 isolation beds in various hospitals in Kathmandu valley which is capital city. This means beyond COVID-19 patients must be removed from ICUs even to treat a single coronavirus patient. Therefore, Government decided preparedness and response Plan (NPRP) based on the trends and developments of the global COVID-19 pandemic to set up 235 ICU beds amid coronavirus fears. Further, the government has decided to set up 1000 isolation beds, 25 hub and satellite hospital network across the country, arrange medicines and mobilize specialized health workers to check the spread of the disease as preparedness and response.
In comparison, the Italy has available 3.2 hospital beds/1000, and 5200 intensive care beds. The USA has 2.8 beds/1000 people, China has 4.3, South Korea 12.3, Germany 8 France 6 but Nepal has only around 0.9 hospitals beds per 1000 people. Even if, with such capacities of health services these countries are struggling with COVID-19 than Nepal. In contrast, with the others countries of hospitals and facilities the Nepal’s health services capacity can only manage only a few hundred COVID-19 patients properly. Additionally, all hospitals’’ ICU beds are already occupied in Nepal. Each COVID-19 patient ICU beds need not less than 10 days approximately 15 days for recovering. But a Chinese study has shown that the incubation period could be 24 days which was concluded after the examination more than 1000 COVID patients. Neither these algorithms could change nor were able to set Nepal’s health system immediately on the aspects of COVD-19. All of the sceneries shows extremely less numbers of bed are available tin the nepalese hospitals.
Likewise, if we talk about dementia the people with dementia usually need further long-term care after leaving hospital, and some may move into a care home. Others need support in their own home or in the home of a relative or community care institutions. The Royal College of Nursing, 2013, reports that around a quarter of hospital beds are occupied by dementia patients because it is not wise to discharge soon. At the end of their life older people with dementia (two thirds) spend their final years in a hospital. Dementia patients have a higher mortality rate during hospital admission compared to similar people without dementia. Likewise, people with dementia receive less palliative care compared with similar individuals without dementia. Health Professionals need to be more aware of palliative care frameworks that have relevance for dementia patients. More than 13% of people require long term care and it is estimated that somewhere between 101 to 277 million dementia patients will need care between 2010-2050. Again, in the UK, if dementia specialist nurses could reduce even for one day the hospital occupancy rate of older people, the amount to be saved almost £11,000,000 nationally. On the other hand- “if dementia care were a country, it would be the world’s 18th largest economy.”
The above mentioned fact arises the questions that does early hospital discharge beneficial for doctors, patients and hospitals? Or raising risks readmission rates? Or is sooner always better, the hospital discharge? Hochman pointed out the basic four points on regarding for discharge: 1. why the patient is hospitalized? 2. What has to happen for patient to leave safely and early? 3. Where is “home” for this patient? 4. Why patient is still hospitalized-not discharged?
There are many studies those showed the importance of effective discharge planning and care, and have focused the actual advantages in improving patients’ outcomes and re-hospitalization rates. Several studies have illustrated benefits, however, until healthcare financing systems are changed to support such innovations in care, they will remain unavailable to many people. hospitals, caregivers, patients and their family and others are continuing their efforts to alter our healthcare system to make discharge planning a priority. With our dramatically increasing population, these changes are ever more necessary
Thus what should have the discharge planning?
In general, we understand that discharge process used to decide what a patient needs to move from one level of care to upper level care.” but the doctor can define /decide a patient’s release from the hospital, or needs more time but the medical conditions, a team approach, a social worker, nurse, case manager or other person might be actual process of discharge planning completion. The basics of a discharge plan are: Planning for homecoming or transfer to another care institution, Evaluation of the patient, Discussion with the patient, determining if caregiver training or other support is needed, Referrals to home care or care organizations, Arranging for follow-up appointments or tests.
Furthermore, the discussion on physical condition of family member before and after hospitalization; medications and diet , details of the types of care; and discharge facility or care home, information on patient’s condition; what activities is needed to help with the patients; including extra equipment; such as wheelchair, oxygen, commode, handle meal preparation tools/equipment, chores and transportation extra care services.
Benefit of discharge planning
Sonner or appropriate discharge planning can minimize the chances on the following aspects: readmission to the hospital, fast in recovery, to be ensure medications are prescribed correctly, and to care properly. However, very least hospitals are successful in this. The AMA and JCAHO points for discharge planning, there is no globally accepted guideline system in US hospitals. Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good care after release. Some studies have resulted that 40 % of patients over 65 had medication errors after discharging the hospital, and 18 % of Medicare patients discharged from a hospital are readmitted within 30 days. This result does not show a good neither for the patient, nor for the hospital. Also, not for the financing agency e.g.; Medicare, private insurance, and own funds and it helps planning and good follow-up of patients’ decrease the readmissions rate and healthcare costs.
Role of doctors in the discharge process
It is true that the health professionals/ staff will not be well familiar with all aspects of situation and his/her history but as doctors, certainly may know a lot information of the patient and abilities to provide care and a safety care home. The doctors can discuss patients’/families’ willingness and ability to provide care for example; physical, financial or other limitations and impact. Some complicated patients need some essential training of special care, techniques, i.e.; procedures for a ventilator, or transferring someone from bed to chair, wound, feeding tube or catheter care, Alzheimer’s dementia, stroke, or other neurological disorder, impaired memory, older people often have hearing or vision problems, language problem etc. All they need especial care and only doctors can provide an appropriate discharge process in hospital and after the hospital. Usually, most people look like in a hurry to leave the hospital and forget what to ask essential care at home. Doctors can teach on Personal care; bathing, eating, dressing, toileting; Household care: cooking, cleaning, shopping; Healthcare: medication management, doctor’s appointments, therapy, wound treatment, injections, medical equipment and techniques; Emotional care: laughing, crying, meaningful activities, social conversation, and community care: rehabilitation, transportation facility, language and cultural.
Typically, not to send patients home at 2 a.m. because night hours aren’t generally preferred to discharge. Sunny brook Health Sciences says -Early hospital discharge is a seemingly unstoppable trend that is increasingly associated with risks – as evidenced by rising hospital readmission rates. Therefore, the medical community should discuss on -does the early discharge leads the dangerous? Is it unstoppable trend of readmission? Is it true that “hospital is not exactly the safest place? Most patients would much rather sleep in their own beds and not be exposed to infections in a hospital? Do the doctors do monitoring their patients in hospital?
What should be considered before hospital discharge?
Mainly the following areas must be addressed before to discharge for instance: Medication reconciliation: to do sure that no chronic medications were stopped and safety of new prescriptions, secondly Structured discharge communication: Information on medication changes, pending tests, and follow-up needs must be accurately and promptly communicated to outpatient physicians, thirdly, Patient education: Patients, family member must understand their diagnosis, their follow-up needs, forth, whom to contact with questions or problems after discharge., Fifth; Post-discharge tool for patients; How to care at home, Warning signs and symptoms of complications, Medications and all medications as prescribed detailed and Sixth; Activity restrictions: for how long others misconception of meals personal contamination Surgical site infections and risks, Schedule of follow-up or appointments.