Mitigating Liability Risk with Concise Discharge Criteria

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Just because a patient receives the all-clear to be discharged from a healthcare facility doesn’t mean that liability risks do not occur.

From the moment the patient enters a healthcare facility to the moment they leave (and even afterward), the healthcare provider must maintain a specific standard of care throughout their stay. This includes after a patient is discharged until they physically leave the premises.

This month, we discuss two similar incidents that originated during the discharge process after outpatient surgery. Both incidents are awaiting a Medical Review Panel opinion.

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Case #1

A 67-year old male presented to an outpatient cardiac clinic for an angiogram. He received a low dose of the sedative Versed before the procedure and remained awake throughout the 20-minute procedure as intended. The patient was then monitored for two hours after the procedure and was able to ambulate in the facility hallway without difficulty. He met all criteria for discharge and was given post-operative instructions while standing independently at the nursing station.

The nurse instructed the patient to wait while he left to obtain a wheelchair from the clinic waiting area, which is connected to the outpatient facility. The patient was left standing at the nursing station with a second nurse in attendance.

During this brief five-minute period, the second nurse was called away to attend to another patient. The patient’s wife went to pull her vehicle to the discharge area. The patient then walked outside when the vehicle pulled up rather than waiting on the nurse to return with the wheelchair.

As the patient tried to get into the vehicle independently, the car rolled forward slightly and the patient fell, fracturing his hip.

A complaint filed with the Patient’s Compensation Fund alleges the clinic “breached their duty to ensure the patient’s safety by failing to supervise him at all times inside the facility and to ensure that he was safely and properly transported from inside the facility to the inside of his vehicle.”

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Case #2

A 43-year old female underwent a successful outpatient laparoscopic cholecystectomy, or gallbladder removal surgery. She was in recovery for a little less than three hours and then transferred to a room. When it was determined she had met discharge criteria three additional hours later, the patient began to get dressed with the assistance of a family member.

At this time, she began to feel weak and light-headed. Vital signs showed a BP of 81/45. She was placed back in bed. Cold compresses were applied to her neck and forehead. Five minutes later, her BP had improved to 130/50. Twenty minutes later, she had no complaints, was dangling her legs off the bed, and advised that she wanted to proceed with discharge.

She was moved from the bed to a chair. The attending nurse stayed in the room with the patient for another five minutes while the family member went to get the car. The nurse then left briefly to get a wheelchair. When she returned to the room the patient was lying on the floor. She was quickly roused. Vital signs and neuro checks were within normal limits. She did not know if she had hit her head.

The physician was contacted about the incident. He ordered labs and a CT of the head. The patient was kept overnight for observation. All labs and the CT were normal. She was discharged at 3:00 p.m. the next day with no apparent injury.

The healthcare facility received a letter from an attorney criticizing its nursing care for allowing a discharge when the patient in question had a systolic BP reading in the 80s less than a half-hour before the incident and a diastolic reading in the 50s five minutes later.

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What Happens Next

The charting in both of these cases is excellent and we believe they will be successfully defended.

Both cases illustrate the importance of having discharge criteria and discharge policies that meet the appropriate standard of care. To be an effective defense, the charting must document that the facility’s criteria were met and its policy followed. Accurate charting of the timeline of treatments/actions is also paramount.

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Managing the Risk

Thankfully, the charting is very detailed for both cases. However, the circumstances of both incidents also highlight the importance of discharge criteria as well as discharge policies and protocols.

Your healthcare organization must develop and implement specific discharge criteria for patients undergoing a procedure, especially procedures with sedation. Sending the patient home before meeting the discharge criteria increases liability.

Developing criteria for discharging a patient post-procedure from the facility is important for any type of healthcare facility. The criteria should provide specific measures to be met, including:

• The patient has reliable transportation through a family member or friend.
• The patient is awake, alert, and oriented.
• Vital signs are stable and within acceptable limits.
• The patient is tolerating oral fluids.
• The patient has adequate pain control.
• The patient can tolerate mobilization as per physician orders.
• The patient has someone at home to monitor them for potential complications and will not be going home alone.
• The patient and family/friends are educated on post-procedure discharge instructions that include watching for symptoms of complications, medication administration, wound care, who to call in an emergency, and any follow-up appointments to be scheduled.
• Documentation of all the above in the patient’s EMR.

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The next step is to have your organization develop and implement discharge protocols for staff members to follow when discharging a patient, including:

• The patient’s discharge criteria should be met.
• The patient has received and signed discharge paperwork
• The patient and their family/friends are educated on your organization’s discharge policy and process.
• Patients should be escorted out of the facility by a staff member.
• Patients should be transported in a wheelchair unless otherwise indicated.
• Staff should observe the patient getting into the automobile and driving off.
• If during the process of discharging the patient, the staff member is called away, the staff member should ensure the following before leaving:
  • The patient is safely situated on a bed, stretcher, or in a wheelchair.
  • Instruct the patient not to get up without assistance.
  • Provide access to the call bell.
  • Inform the patient and family/friends not to leave without being escorted by a staff member.
  • Notify a co-worker of the need to step away in the middle of a discharge.
  • Ensure someone returns to complete the discharge process.
• Documentation of all the above is done in the EMR.

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The final step regarding discharge criteria and discharge policies and protocols is to make sure:

• All policies/protocols are always readily accessible to all staff members.
• All policies/protocols are communicated with all staff members.
• Any changes in policies/protocols are communicated with all staff members.
• Protocols are standardized throughout your organization.
• Compliance audits are performed on a routine basis to ensure policies and protocols are consistent and being followed.
• Any noted variations between the policy and protocols should be addressed promptly. Any changes should be documented and communicated.

Standardized discharge criteria and consistent discharge policies/protocols are imperative to increasing patient satisfaction, patient safety, and overall quality of care.

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About the Authors

Mike Walsh, AIC, CPCU
Liability Claims Manager, LHA Trust Funds

Mike Walsh is an AIC and CPCU-credentialed professional with more than three decades of experience in insurance claims, primarily in medical malpractice. As Liability Claims Manager for LHA Trust Funds, Mr. Walsh heads a team of senior claims consultants who investigate and assist in the resolution of claims. Mr. Walsh also works closely with hospital administrators, risk managers, safety officers, and clinical staff to help them identify and address potential liability issues

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Caroline Stegeman, RN, BSN, MJ, ONC, CPHRM, CPSO
Director of Patient Safety, LHA Trust Funds

Caroline Stegeman has 28 years of nursing and clinical risk management experience in a variety of healthcare settings. She has extensive experience in the management and handling of patient safety issues/ incidents, clinical and environmental risk assessments, root cause analysis, regulatory and industry best practices (TJC, CMS, DHH), hospital emergency preparedness and disaster management, and quality improvement initiatives.