It is certainly a good idea to avoid readmissions that are deemed unnecessary. However, from the vantage point of risk and patient safety, the sword of readmissions reduction has another sharp and dangerous edge. Plain and simple, along with sensible system solutions, there will be irrational but powerful pressures exerted on the gatekeepers of inpatient admission to send sick patients home rather than readmit them.
How many emergency physicians have felt the pushback from an admitting physician when a sick patient who clearly needs to be readmitted for the same diagnosis returns to the hospital within 30 days of their last admission? I certainly have, and this is how it goes: “Tom, you have to tune that patient up and send him home! I just discharged him 2 weeks ago for heart failure and I will get dinged if he is readmitted!” I am tempted to respond with something like, “No problem. Do you want to coordinate our malpractice defense strategy now or later?”
I understand that the visiting nurse had to cancel, or the caretaker went on vacation, or the patient did not get his medication, or he ate 2 bags of salted peanuts, or his disease progressed. For whatever reason, the post-discharge transition of care plan did not work, the patient showed up in the ED very sick, and his condition and objective parameters mandate admission. In the future, maybe this patient can go to an observation unit or the system can include more fail-safe measures to avoid readmissions. But this patient returning to the ED today needs to be readmitted to ensure quality of care and patient safety.
As part of the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with excess 30-day readmission rates for patients with the following:
- Acute myocardial infarction (AMI)
- Heart failure (HF)
- Pneumonia (PN)
- Chronic obstructive pulmonary disease (COPD)
- Total hip arthroplasty (THA)
- Total knee arthroplasty (TKA)
In 2017, the program will add coronary artery bypass graft (CABG) surgery. The Readmissions Reduction Program was initiated because it has been determined that many of these return hospitalizations are costly, potentially harmful, and often avoidable. Hospitals are now struggling to design and implement system solutions that will avoid excess readmissions and the resultant financial penalties.
There is a risk of unexpected death when patients with high-risk conditions are discharged from the ED. More than half of these deaths are preventable and due to a medical error! Ironically, some of these conditions are the very same chronic diseases targeted for readmission reduction (HF and COPD). Based on the pathophysiology of these conditions alone, these patients are at high risk for decompensation and adverse outcome. Other categories of patients at risk for unexpected death after discharge include those with:
- Critical test results that were not addressed
- Vital sign abnormalities (tachycardia, hypotension) at the time of discharge
- Bouncebacks – repeated visits to and discharges from the ED
- Atypical presentations – when the workup does not neatly fit a diagnosis
- Mental disability, psychiatric disorders, or substance abuse
Additional factors associated with death after discharge include unexplained acute change in mental status, recent falls in the elderly, and malfunctioning indwelling devices (NG tube, catheter, or shunt).
Back to the double-edged sword. Yes, many readmissions are avoidable and preventable, but so are many of the deaths after discharge from the ED. There has to be a rational balance. Systems for post-discharge care management are imperfect, and some patients get sicker despite our best efforts. Every patient returning to the ED after recent hospital discharge requires careful evaluation that includes consideration of known risk factors for decompensation and death after discharge, and some of these patients will require readmission.
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