Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Appendix 2. Dispo Dancing Doc be nimble, Doc be quick, D/C them patients - quite a trick! Day and night and round-the-clock, Let’s all do the Dispo Rock! [25] So, what the heck is "dispo"? "Dispo" is short for "disposition"—that is to say, the disposition of the patient from the hospital. In a large number of cases, your patients will not be able to return to wherever they lived prior to their hospitalization. This may be due to pre-existing life circumstances (e.g. patient is homeless) or to the effects of the illness (e.g. frail elderly who’ve suffered a stroke and need prolonged physical therapy, and/or whose families can no longer take care of them, or an addicted patient who desires a shot at drug rehab). In the beginning of wards work, students and interns may work very hard to shepherd a patient quite expeditiously through an acute illness and recovery, only to find the patient cannot be discharged due to dispo issues. Patients may linger for as long as a week on a hospital ward despite having no true need for this level of care. This is a true bummer for all concerned: For patients, it means more time in the hospital, which puts them at risk for hospital-acquired infections, like pneumonia.[26] For students and residents, it means the team’s service remains larger, with continued pre-rounding and notes and more work for the team. For the hospital, it means increased expenses. Thus, getting patients promptly discharged from the hospital is a crucial skill. Unfortunately, there is utterly no formal training for students in this area, and minimal training for housestaff. On the plus side, your team will always have a social worker who can assist with these issues. Some wards will also have a "Discharge Planner" whose entire job is effective dispo. The following notes are intended to explain some basics about discharging patients. Consider the following Appendix background reading only - the main thing you should know is how to spot a "problem dispo patient" and get your social worker or discharge planner on the case as soon as possible. The information below is taken from "Dishcarge Planning 101," a hand-out written by a discharge nurse at a UCSF facility who donated these materials to this guide, but asked to remain anonymous.[27] Important for discharge (D/C) planning: client’s acceptance of/participation in plan client and family education/acceptance/participation education re: all alternative d/c plans client’s mental status client’s compliance with treatment/care client’s drug/alcohol abuse client’s insurance, or eligibility for insurance Discharge planning is a team effort beginning with the patient and involving social workers, physicians, acute care givers, family, possibly rehab therapists, dieticians, clinical nurse specialists (e.g. wound care nurse), psychiatry consult team, etc. Major d/c planning issues: Home: Does patient have a permanent address? Can patient perform ADLs (activities of daily living) independently? Can patient ambulate safely? (i.e. ataxic, wide-based or other altered gaits are unsafe) What is patient’s mental status? Is patient a danger to others? Consider substance abuse alcohol abuse psychiatric issues What is patient’s likely compliance with the rules of an accepting facility, should s/he be going someplace other than home? A client must be "safe" for d/c. If any treatments, orders, or notes document that the patient is NOT safe, the d/c plan must be re-worked. Options There are various types of places to which a patient may be discharged, depending on their health and circumstances. In order of intensity, they are: Post-acute hospital care options, no skilled care needs, non-structured: Home. Note going home does not preclude having home care aides or visiting nurses. Home-bound patients with skilled needs (e.g. recovering from stroke) can be visited by speech, PT, or OT, as well as RN’s and MSW’s (social workers). Hotel. Such as an SRO (single-room occupancy). No meals are provided, so client much be able to at least go out to St. Anthony’s or other charity center, since cooking facilities are not on hand. Hotels are not an option for wheelchair-bound patients. Respite (may stay 7 days or negotiate longer stay). Must leave after breakfast and not return until 5 p.m. Special cases—unable to walk, wheelchair bound, mental status issues--may be able to negotiate an all-day stay. Post-acute hospital care options, no skilled care needs, structured: Note: For these, clients must give all but $40/month for care from their SSI check. Intermediate Care Facility (ICF). Must have SSI (Federal social security benefits for medically indigent). One LVN or RN on site for 12 hours. No home care visits allowed in most cases, since a licensed care provider is on site. Thus, not a good option if patient still needs skilled visits by ST/PT/OT/wound nurse, etc. Board and Care (B&C). Less structure than ICF, although cliente of both site types may come and go as they please. No wheelchairs or walkers. B&C clients must be able to dress selves, appear at meals by themselves, and most must be able to keep track of their own medications. Hospital-based SNF (pronounced "sniff"; "skilled nursing facility). For patients who still require skilled care (e.g. IV drugs) but don’t require daily management on a regular ward. SNFs are for patients no longer needing daily doctor/nursing care but not ready for home. Examples: Laguna-Honda Hospital (LHH), SFGH Ward 4A, St. Luke’s, CPMC, St. Mary’s. For more detail on the SFGH SNF, Ward 4A, see end of this appendix. Generally will take homeless patients if a plan for d/c for post-SNF care has been worked out prior to entry to the SNF facility (e.g. hotel, B&C, etc.) Client must have insurance, or, in the case of LHH, the insurance issues are in the process of being worked out. Young clients are difficult to place as they are usually not happy with a majority of senior clients and may want to leave. These clients are more "rambunctious" and less compliant than the majority of SNF residents. Methadone: clients on methadone will be taken on a case-by-case basis. LHH takes all appropriate methadone cases. Care must be such that no licensed care givers are necessary for treatment more than once a day. This means RNs as well as ST/PT/OT. Visiting nurses can provide up to twice-daily outpatient care without insurance if a client is compliant and ambulatory and/or has transportation pre-arranged. Criteria qualifying a patient as needing SNF-level care include: Needing IV antibiotics q 4, 6, or 8 hours Needing dressing changes three times a day or more frequently All rehab services Diabetic teaching or anticoagulation—when in conjunction with other skilled needs such as wound care or PT. Free-standing SNFs. These provide subacute care, like hospital SNFs, and some have acute rehab services. They generally prefer Medi-care or private insurance, but occasionally accept short-term Medi-Cal patients who have a post-SNF d/c plan. All Medi-cal and some private insurance patients will require prior authorization before a free-standing SNF can be used. These SNFs often won’t accept patients with compliance problems, a psych history, or methadone use. They usually won’t accept a patient who may require long-term care (e.g. in persistent coma). Alternatives to a free-standing SNF include IHSS (in-home support services—see below), adult day care, moving in with family, or 12-hour shift unskilled home care (which requires private payment). Acute Rehab level of care. This level of care is intended for patients with one or more conditions requiring intensive and multi-disciplinary care in addition to the primary condition, and who are expected to improve with intensive therapy. Non-primary conditions may include cognitive dysfunction, communication disorders, incontinence, immobility, or dependence on others for ADLs. To be eligible for transfer, patients’ primary condition must be stable. Patient must be responsive to verbal or visual stimuli, i.e. not be in a coma—unless the facility has a coma stimulation program. Usually, the patient must be able to tolerate three hours of therapy per day. The expectation is that the patient will achieve a better level of function to be discharged home or to a board-and-care. If the patient is expected to relapse into needed more skilled level care after the rehab unit, they often will not take her. An example of a rehab facility is the Kentfield Rehabilitation Hospital in Kentfield, Calif., which has a "Pulmonary Rehabilitation Program" for patients with severe COPD and asthma, which educates patients about living with their disease, strengthens their accessory muscles of respiration, designs a home therapy program, determines equipment needs, etc. Subacute level of care. This level of care is intended for patients with significant skilled nursing or therapist needs. This includes patients who: have a "trach" or tracheostomy and need continous mechanical ventilation at least 50% of the day, or have a trach and aren’t on a vent but require respiratory therapist care, or require several of the following: total parenteral nutrition; inpatient PT/OT/ST for 2 hours a day, 5 days a week; tube feeding via NG tube or gastrostomy; inhalation therapy treatments 4 times per 24 hour period; IV therapy that is continuous or intermittent but frequent; debridement, wound-packing and wound irrigation, with or without whirlpool treatment. Examples of patients appropriate for subacute facilities include head trauma victims, spinal cord fracture patients on a vent, near-drowning survivors or others with anoxic brain damage, stroke survivors, those with ALS, severe pulmonary disease—any patient who needs an intensive level of hands-on nursing care to address their needs. Home therapy Rehabilitation is often most effective and comfortable when provided in the home. Experienced therapists develop a plan and provide direct care to meet the client’s rehabilitation needs. Clients and families/caregivers observe and learn skills at home where they will be used. Services include: Physical therapy Restores loss of motor function and mobility Establishes a program to maintain functional abilities Teaches the client and family techniques for improved functional activity Fits and trains with adaptive/assisting devices Adapts and equips the home for safety Occupational therapy Restores functional capabilities in personal care and ADLs Restores/compensates for sensory and body image lost in ADLs Designs, fabricates, and fits adaptive/assisting devices Teaches work simplification and energy conservation Improves cognitive functioning Speech therapy Teaches alaryngeal speech Retrains in language processing and oral speech Augments loss by manual communcation systems Medical social work Refers to community resources for food, medical care, housing, financial and social needs Counsels to minimize impediments to recovery Explores nursing home placement when needed In-Home Supportive Services (IHSS) IHSS is a program that provides funds to pay for various services needed by chronically ill patients. Eligibility for the services is determined by an at-home visit by a Dept. of Social Services worker. The services provided must be deemed necessary to allow the patient to remain safely in her home. Services available include: Non-medical personal services: feeding, bed baths, dressing, bowel/bladder care, ambulation, moving in or out of bed, bathing, grooming, oral hygiene, etc. Paramedical services: exercise, therapy, giving medications, wound care, sterile procedures, etc. Transportation to medical appointments Protective supervision: monitor/direct activities to safeguard a mentally disoriented, impaired, or ill client from injury, hazard or accident. Must have 24-hour need. Related services: Meal preparation, meal cleanup, menu, laundry, shopping, and errands. Domestic services-cleaning: When needed in combination with the above services. Heavy cleaning: One-time basis to remove hazardous debris, dirt. Restaurant meal allowance: (not allowed when the person receives SSI and does not have a kitchen). A spouse who does not also receive IHSS is considered "able and available" to perform all but personal care items unless there is medical verification to the contrary—i.e. it’s assumed the spouse can perform much of the above and so IHSS benefits would not be appropriate. Adult Day Health Care Services This refers to centers that provide daytime supervision for elderly or other adult patients with special supervision needs (e.g. mentally retarded). These services must get prior approval by Medi-cal. The patient has a medical condition that requires treatment or rehab services prescribed by a physician. S/he must also have mental or physical impairments which handicap daily living activities but which are not severe enough to require 24-hour institutional care. The expectation is that the services will maintain or improve the patient’s level of function in the community, and a high potential for deterioration and institutionalization without the adult day care. Details on the SFGH SNF: WARD 4A Who manages SNF patients? There are no housestaff on this ward. Instead, there is one MD for all 30 patients, who is not present weekends or evenings. Once they arrive, patients may not see an MD for as long as 72 hours after transfer from the main hospital, so they must be stable. The nurse-to-patient ratio is smaller than on the regular ward. There are no daily rounds, and vitals are taken twice daily. Labs are drawn twice a week only, not daily. To boot, the level of direct care is much less. Which patients are appropriate for 4A? Those who need: IV antibiotics (q 4-8 hours, maximum of 2 different antibiotics) extensive wound care short-term rehab short period of complete bed rest feeding tube, NG tube, PEG, T-tube tracheostomy, esp. if requiring care and teaching long-term care patients awaiting Laguna-Honda Hospital bed peripheral parenteral nutrition (PPN) pentamidine inhalation Foley catheter for a medical reason suprapubic tubes Penrose, Jackson-Pratt, or other surgical wound drains O2 by nasal canula or mask, when the source of hypoxia has been evaluated patients who need M.D. visit no more than once monthly Which patients are NOT appropriate for 4A? require MD visit daily or needing close RN monitoring unexplained clinical or lab abnormalities (e.g. fever, hypoxia, dropping HCT, electrolytes) need labs done more than twice a week fresh STSG total parenteral nutrition (TPN) non-compliant/refusing treatment have Foley/urinary cath for non-medical reason patient is actively infectious patient needs blood transfusions IV meds other than antibiotics e.g. morphine skeletal traction CPAP (continous positive airway pressure)[28] untreated active psych issues, or on psych meds without a prior psych evaluation patients who have no dispo plan in place for post-SNF care Common problems which compromise SNF transfer: incomplete transfer summary (no PMH, social history, or discharge diagnoses stated) wrong meds listed on the transfer summary wrong antibiotics prescribed; that is, resident did not check culture and sensitivity and patient has resistant bug such as MRSA inaccurate info about patient (e.g. no mention of new atrial fibrillation, new bilateral lower extremity weakness, hypoxia, etc.) no mention of lab abnormalities (e.g. HCT dropped or dropping) without prior evaluation and treatment fever occurring upon transfer to SNF (which had been masked by antipyretics on ward) no mention of psych or behavior issues prior to SNF transfer active drug use [25] Sung to the tune of "Limbo Rock," by Harry Belafonte. [Back] [26] While most patients can't wait to leave the hospital, some, such as some homeless patients, get more regular meals and care on the wards than they do on the streets and may be disinclined to leave. If patients seem to have true anxiety about leaving-perhaps they're a fall risk and are afraid of being home unsupervised-this should be explored with them to identify concerns and address them. But once the obstacles have been addressed to the best of the team's ability, patients should be reminded of the health risks of staying in the hospital. [Back] [27] Apparently this employee used to do teach-in's on discharge issues for housestaff, but those sessions were discontinued. This is too bad, since dispo is a tricky area for most docs-we could use the training. [Back] [28] "Continuous positive airway pressure"-not a ventilator, but rather a device with a facemask that delivers pressurized air into the lungs to help keep the airway from collapsing. Used, for example, at night in patients with obstructive sleep apnea or continuously in patients with severe COPD. [Back]