Conversations Around Discharge


In the last segment of the series, Jones offered his insights for when he considers discharging patients.

Contagion: What do you need to see from a clinical standpoint to begin thinking of discharging a patient?

Jones: Often, the process isn't as complicated as we might think. The first step is understanding patient expectations, and sometimes even the expectations of their family. This can vary greatly depending on the individual patient, but it’s a good starting point. For instance, what resources does the patient have available? What is their financial situation? These factors can influence the choice of treatment.

Beyond that, we need to assess the clinical improvement we've observed and the status of their cultures. One approach we've implemented over the past few years involves our hospitalists and internal medicine pharmacists rounding together as part of a larger team. This team focuses significantly on transitions of care and planning for patient discharge.

Communication is key. I often receive calls or texts asking about the status of a patient. Bridging the gap between different disciplines and getting everyone on the same page regarding the patient’s care plan is crucial. This collaborative approach helps ensure that all aspects of the patient’s needs are considered and addressed.

Contagion: Does the ability to transition a patient on the same medication from hospital to outpatient influence your initial therapy choice?

Jones: Sometimes it does, and sometimes it doesn't. Often, when we receive these patients, we're inheriting the treatments they're already on. Our main concern then becomes whether we need to escalate their care. When we consider escalation, we must think about whether the changes can be maintained in an outpatient setting.

For instance, if a patient is on vancomycin and not showing improvement, we might consider alternatives like linezolid, daptomycin, or ceftaroline. If our goal is to eventually switch the patient to an oral medication, linezolid could be a good option since it has an oral form. However, if the patient is on multiple SSRIs or has other factors making linezolid a poor choice, we might look for other options.

Ceftaroline, for example, translates well to outpatient care, making it a viable alternative. These decisions—whether we're initiating antibiotic therapy or escalating care—are critical. It's important to plan for outpatient parenteral antibiotic therapy (OPAT) early in the hospitalization rather than waiting until just before discharge.

Additionally, institutions are increasingly focused on preventing readmissions, which drives us to choose optimal initial therapies to avoid patients needing to return. Clinical management strategies to avoid readmissions include thorough planning of discharge medications, ensuring appropriate follow-up care, and coordinating with outpatient services to maintain continuity of care.

Contagion: Institutions are focusing on readmission, and this may drive providers to make a more optimal initial therapy decision to avoid patients returning. What are the clinical management strategies to avoid these scenarios of readmission?

Jones: For me, 30-day readmissions are a critical metric that we track closely, whether through research or inpatient quality improvement initiatives. We monitor these readmissions carefully to ensure effective patient care and outcomes.

The primary goal is to discharge patients when they are clinically well, but it’s equally important not to discharge them too early, risking a quick readmission. I believe there are 3 crucial aspects to consider in this context:

  1. Follow-Up Care: It is vital to establish who will handle the follow-up care. In our hospitalist-driven organization, ensuring proper follow-up—whether through primary care or infectious disease specialists—is essential. We need a solid follow-up plan and clear patient expectations. Patients should know what to do if they aren't improving or if they encounter difficulties filling their prescriptions.
  2. Medication Adherence: Before patients leave the hospital, we must ensure they can afford and access their prescribed medications. Many oral agents used in outpatient settings are specialty medications that need to be mailed to the patient’s home. It's crucial to confirm that this process happens smoothly and the patient receives their medication. Recently, we had a patient readmitted because they couldn't afford the co-pay for their medication, so it wasn't delivered. Ensuring medication adherence is a key component in preventing readmissions.
  3. Culture Follow-Up: Cultures often guide our treatment decisions, sometimes based on preliminary data. While this is a common practice, it's important to manage the follow-up when cultures finalize. If a culture shows growth of a pathogen not covered by the initial treatment regimen, or if new information arises while the patient is still hospitalized, it’s critical to have a system in place to notify providers. This ensures there’s no mismatch between the drug prescribed and the pathogen it needs to target.

By focusing on these areas—follow-up care, medication adherence, and culture follow-up—we can significantly reduce the risk of 30-day readmissions and improve patient outcomes.

The conversation was edited for grammar and clarity.

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