A new UT Southwestern Medical Center study of electronic medical records from six Dallas-Fort Worth area hospitals found 20 percent of patients had one or more unstable vital signs when they were released within 24 hours of discharge. Doing so can lead to serious consequences.
Highlights from the interview with Dr. Oanh Nguyen is an Assistant Professor of Clinical Sciences at UT Southwestern Medical Center:
How is it possible for 20 percent to leave with unstable vital signs? “Deciding when a patient can go home can be very challenging, and assessing vital signs is one part of that, although there are lot of other factors in deciding when to release a patient from the hospital: It might be a patient really wants to go home, their physical exam, or just what we call in medicine sometimes the “eyeball test.” The patient looks okay. And I think what we’re finding here should cause some pause, if your patients have had some type of unstable vital signs, to take a step back and say, ‘Well, maybe my patient is best served if we keep the patient in the hospital for a little bit longer and wait to see if things are a more normal.’”
Danger of releasing a patient with an unstable vital sign: “What we found is that patients who’ve had one or more unstable vital signs within 24 hours of discharge have a higher rate of needing to come back to the hospital within 30 days, or being released with abnormal vital signs also associated with an increased risk of dying within 30 days.
What prompted the study? “This has been an ongoing issue. Back in the 80s, there were a number of policy changes creating incentives for hospitals to shorten the length of stay within a hospital. Researchers wondered if this is creating an incentive to release patients before they’re ready. They found 15 to 20 percent of patients were being released a little earlier than they should be. In the 90’s, looked like things were about the same. We got interested in this issue because the Center for Medicare and Medicaid services now requires that hospitals publicly report rates of 30 day readmission and mortality. And so we thought maybe now’s the time where hospitals are really making some headway on this issue. To our surprise, we found that nearly 20 percent of patients, when they’re discharged, still have some abnormal type of vital sign within a day of discharge.
Why? “I don’t think anyone knows why. That would be a question merits further scientific study.”
Recommendations from the study:
- Discharge guidelines should include objective vital sign criteria for judging stability on discharge to improve disposition planning and post-discharge patient safety.
- At a minimum, patients with one instability on discharge should be discharged with caution.
- Close outpatient follow-up and appropriate patient education about warning signs and symptoms that merit urgent medical attention may be warranted.
- Individuals with two or more instabilities should likely remain in the hospital for continued treatment and observation in the absence of extenuating circumstances.
- Though post-acute care facilities are frequent sites of post-discharge care for those discharged with vital sign instabilities, patients sent to these facilities had still higher rates of readmission and death, suggesting that an alternate site of discharge may have been more appropriate for a significant subset of these individuals.
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