The questionable discharge

Scientific principles:

The decision regarding the need for acute hospital care is a combination of the acuity of the patient’s illness and the intensity of the treatment that is to be provided. Similarly, the discharge decision is related to satisfying the reason for admission. A safe discharge home typically requires patients to have the ability to perform basic activities of daily living independently or the presence of qualified family/personnel to provide assistance with such activities. There should also be assurance that the patient is able to obtain food and medications independently or with assistance from family or friends.

A final diagnosis or completely normal labs are not required for hospital discharge unless there are foreseeable consequences that such uncertainty or the degree and type of laboratory abnormality would lead to patient harm.

Complaint rebuttal and discussion:

Mrs. EG presented with a complex clinical picture at the outset for which a unifying diagnosis was uncertain. She was admitted for further evaluation and treatment, both of which she received. She was seen by several consultants and had numerous radiographic and laboratory tests. Dr. H1 testified that he considered secondary adrenal insufficiency as a cause for some of Mrs. EG’s complaints and her laboratory abnormalities (despite the historical lack of steroid exposure to the degree that one would expect to see secondary adrenal impairment); however, secondary adrenal insufficiency would not explain Mrs. EG’s thrombocytopenia or elevated serum aldolase. In addition, hypotension is associated with primary adrenal insufficiency. Mrs. EG did not demonstrate hypotension at any point in her first hospital stay. On the morning of discharge, Mrs. EG had a normal blood pressure (124/72 mm Hg) and heart rate (81 beats/min) without intravenous fluid support. Mrs. EG was afebrile with little evidence for systemic infection; her WBC was normal. She did not have diarrhea, cold sweats, or progressive abdominal complaints prior to her discharge. Her weakness was reasonably attributed to her documented myositis. In addition, Dr. H1 ordered a physical therapy assessment to evaluate Mrs. EG’s functional activities of daily living and to determine the need for inpatient rehabilitation prior to her discharge. The physical therapy assessment was limited as Mrs. EG declined to ambulate.

Despite Mrs. EG’s concerns about being discharged and her complaints of ongoing weakness, Mrs. EG herself was not interested in inpatient rehabilitation (that is, transfer to a skilled nursing facility) that would have provided a greater level of monitoring as opposed to going home. Further, the nursing staff documented that Mrs. EG was comfortable and resting in bed approximately 1 hour before she left the hospital.

The autopsy concluded that Mrs. EG died of severe systemic acidemia resulting from ischemic colitis secondary to profound hypotension. However, her ischemic colitis may have been the sole cause of the hypotension (via translocation of gram-negative bacteria and resulting sepsis) or may have resulted from it (hypoperfusion of the bowel, ischemia, and systemic acidemia). It is unlikely that her hypotension was due to adrenal crisis, as no mechanism for primary adrenal insufficiency was found at autopsy. In fact, the pathologist noted that the adrenal glands were normal (thus, autoimmune adrenalitis was ruled out).

Mrs. EG was discharged with laboratory abnormalities, but the differential diagnosis for these abnormalities did not include an immediately life-threatening entity. Dr. H1 had no basis for which to foresee Mrs. EG ’s return to the ED less than 10 hours later.

Conclusion:

Patients are discharged with laboratory abnormalities all the time. Patients have chronic conditions, and most patients will go home with laboratory abnormalities that may be unrelated to the reason for hospital admission. Hospitalists typically deal with the primary reason for admission, and once that is satisfied, the patient is transitioned to a lower level of care. However, all hospitalists need to recognize that abnormal vital signs, physical findings, or laboratory tests should be explained in the discharge summary.

Better documentation of the reason for discharge and the explanation and consideration of abnormal findings will protect the hospitalist from unnecessary litigation. Following a thorough expert review on behalf of the defense and a subsequent report outlining the questionable causation, this case was dropped without prejudice.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.