Who is ultimately responsible for patient discharge

Nursing and physician leadership. Case management. Hospital administration. Hospital IT. Hospital pharmacy leadership. Patients, family members, and other community members. Patient educators. Health plans with whom you can partner in delivering the RED. Discharge planning. Social work. Medical records leadership. Interpreter services. Identify Process Owners and Change Champions Change champions should include leadership from varying professional groups e.

Some questions that are important to think about up front follow: What is the current readmission rate? By specialty? By unit? By diagnosis? What is the readmission rate for those with limited English proficiency? Substance abuse or mental health comorbidities? Have you benchmarked your hospital against peers and local and regional competitors?

What is the target patient population service, unit for implementation? How do you determine success? What data do you need? Patients with diagnoses with day rehospitalization rates higher than the national average or higher than peer hospitals in your community.

Sites of care floor or unit or services within the hospital e. They: Reveal the tasks that need to be completed in order for a patient to be discharged. Give a clearer explanation of a process than words. Impart understanding of potential problems. Allow participants who carry out individual tasks to see the entire process and they help clarify participants' interactions with other providers. Prompt new thinking about how to better prepare patients for discharge. Your map will: List all people involved in a patient's discharge.

Show how it works on weekends and after hours. Reveal how it varies on different services and units. To eliminate redundancy: Compare the elements of the RED to the elements of your current discharge process to identify areas of overlap and eliminate the elements of the old process that duplicate the RED process. Identify regulatory items e. Should You Use Existing Staff?

The staff nurse caring for the patient being discharged Pros: Has clinical expertise, knows the patient and the care plan, may already be responsible for aspects of medicine reconciliation, and often can efficiently organize the discharge plan. Cons: Is busy with routine patient care duties and responsibilities. Modification to current responsibilities is required. Furthermore, many nurses work a 3-day week, which requires systems to be set up to ensure smooth handoffs.

Case managers or nurses from the patient's health plan or insurers Pros: Reduces work burden to existing staff and hospital does not have to pay.

Cons: Hospital has no control over external staff and cannot ensure that work gets performed. Coordination may be difficult, requiring a clear delineation of responsibilities and communication protocols. Discharge summary and the discharge plan would have to be transmitted in real time. Discharge planners or social work staff Pros: Skilled in coordinating postdischarge services.

Cons: Lack clinical skills that are necessary for some components. The resident house staff if you are in a teaching hospital Pros: Has clinical expertise, knows the patient and the care plan, and often can efficiently organize the discharge plan.

Educates new doctors on safe, effective discharge processes. Cons: Turnover requires continual retraining and oversight. Not available in nonteaching hospitals. Pharmacist Pros: Has clinical expertise. Evidence base for the RED process is based on a clinical pharmacist PharmD conducting postdischarge followup call.

Cons: Is busy with pharmacy responsibilities. Table 1. Ascertain need for and obtain language assistance. Make appointments for followup care e. Plan for the followup of results from lab tests or labs that are pending at discharge. Organize postdischarge outpatient services and medical equipment. Identify the correct medicines and a plan for the patient to obtain them. Reconcile the discharge plan with national guidelines.

Teach a written discharge plan the patient can understand. Educate the patient about his or her diagnosis and medicines. Review with the patient what to do if a problem arises. Assess the degree of the patient's understanding of the discharge plan. Expedite transmission of the discharge summary to clinicians accepting care of the patient. Provide telephone reinforcement of the discharge plan.

The DEs and their supervisors could read this toolkit and review its contents in a group session. Training could be accomplished either as a series of inservice sessions or using the "train-the-trainer" technique where a set of key nurses perhaps one or two from each unit or a "master trainer" could be trained at another hospital already using the RED. A 1-day training course. The Sample Training Agenda contains an example of an agenda for a 1-day training that would take place at your hospital.

This course is organized so that the first 2 hours are for senior leaders and the implementation team, and the remainder of the day is for the implementation team only. The course includes various role plays and interactive exercises to help the hospital identify how it will carry out each of the key functions.

This involves using word processing software with a template. This method requires little training and allows the most flexibility in creating an AHCP tailored specifically to each patient. Free text can be added with directions that are specific to that patient. This is the situation in a case that was recently decided by the 5th Court of Appeals in Dallas, Texas. The case is styled Antoinette Dion Decker v. Columbia Medical Center of Plano, subsidiary, L.

You can read the opinion here. The crux of the medical care leading to this medical malpractice lawsuit deal with cardiac issues. The patient collapsed at work and was taken to Medical City Plano.

An electrocardiogram led to a diagnosis of acute cardiac tamponade because of a syncopal episode and ectopic tachycardia. Cardiac tamponade is a dangerous medical condition where excess blood or fluids between the heart muscle and the pericardium the sac that surrounds the heart creates intense pressure on the heart. The excess pressure interferes with normal ventricular contraction and can cause a cascade of problems. A cardiologist was consulted, who used ultrasound guidance to insert a needle into the pericardium and drain the bloody fluid.

The patient was admitted to the intensive care unit, with placement of a pericardial drain to allow additional removal of bloody fluid. After two days, the cardiologist removed the drain and ordered the patient discharged.

Less than two weeks later, the patient died from cardiac tamponade. In this case, the plaintiffs timely produced an expert report from a physician who was a medical school professor, board certified in cardiovascular medicine, and actively practicing a cardiology. The hospital quickly objected, alleging that this expert was not qualified to give opinions as to the hospital and its nursing staff.

The appellate court entered an opinion finding that the trial court abused its discretion by dismissing the case under the tort reform statute. A surgeon who becomes temporarily impaired by illness or injury, chemical dependence, fatigue, or other conditions that affect surgical judgment or performance should arrange for a qualified colleague to assume his or her clinical responsibilities until the impairment has been resolved.

The surgeon should be a member in good standing of the department or service through which privileges are to be recommended. Surgeons are expected to study and evaluate new procedures and to become knowledgeable of and proficient with advances that are appropriate.

Technical skill alone is insufficient to qualify a surgeon to perform new procedures. Procedural skills should be acquired within the context of in-depth knowledge about the disease to be treated. Only qualified surgeons can deliver high-quality surgical care to the sick and injured patient. These qualifications are required for Fellowship in the American College of Surgeons.

Some hospitals permit arrangements through which a staff member can achieve surgical privileges under the tutelage of a qualified surgeon in the operating room without serving in a formal, organized, accredited residency training program. This situation is undesirable, because it frequently results in an inadequately trained physician who may aspire to be a surgeon.

Qualification of a surgeon as a specialist carries the commitment and responsibility to conduct a surgical practice that conforms to his or her defined specialty. Procedures performed are dictated by the guidelines set by a specialty board. Performing procedures outside of the field defined by a specialty board mandates that the surgeon obtain additional education and experience, as well as any appropriate certification.

The College may take disciplinary action against Fellows who engage in surgical procedures outside their scope of practice as previously described or who falsely advertise their training, certification, or experience.

In those instances in which no appropriately trained surgeon is available to perform a necessary procedure, it may be necessary for the surgeon to engage in practice outside of his or her specialty limits. These decisions must be dictated by what is in the best interests of the patient. The medical staff and the governing body of hospitals should periodically review the quality, number, and variety of surgical procedures being performed, as well as the surgical referral policies of the staff, to ensure that the practice pattern of the community does not discourage properly trained and qualified surgeons from applying for staff membership.

Performance of surgical procedures by those individual who are lacking the proper training should not be a frequent or continuing practice. The first assistant in a surgical operation should be a trained individual who is able to participate in and actively assist the surgeon in completing the operation safely and expeditiously by helping to provide exposure, maintain hemostasis, and serve other technical functions.

The qualifications of the person in this role may vary with the nature of the operation, the surgical specialty, and the type of hospital or ambulatory surgical facility. The American College of Surgeons supports the concept that, ideally, the first assistant at the operating table should be a qualified surgeon or a resident in an approved surgical training program. Residents who have appropriate levels of training should be provided with opportunities to assist and participate in operations.

If such assistants are unavailable, other physicians who are experienced in assisting may participate. It may be necessary to have nonphysicians serve as first assistants. Surgeon assistants SAs or physician assistants PAs with additional surgical training should meet national standards and be credentialed by the appropriate local authority.

These individuals are not authorized to operate independently. Formal application for appointment to a hospital as a SA or PA should include the following qualifications and credentials:. Surgeons are encouraged to participate in the training of allied health personnel.

Such individuals perform their duties under the supervision of the surgeon. Informed consent is more than a legal requirement. Surgeons must fully inform every patient about his or her illness and the proposed treatment.

The information must be presented fairly, clearly, accurately, and compassionately. The informed consent discussion conducted by the surgeon should include:. The surgeon should not exaggerate the potential benefits of the proposed operation nor make promises or guarantees. For minors and incompetent adults, parents or legal guardians must participate in the informed consent discussion and provide the signature for elective operations. Any adequately informed, mentally competent adult patient can refuse any treatment, including operation.

When patients agree to an operation conditionally or make demands that are unacceptable to the surgeon, the surgeon may withdraw from the case. Surgical care includes providing preoperative diagnosis and care, educating the patient about the risks and benefits of operation and obtaining informed consent, selecting and performing the operation, and providing postoperative surgical care. Because a team of specialists undertakes much of modern patient care, nonsurgeon physicians often may conduct the initial evaluation of patients.

However, the surgeon bears the ultimate responsibility for determining the need for and the type of operation. In making this decision, the surgeon must give precedence to sound indications for the procedure over pressure by patients or referring physicians or the financial incentive to perform the operation.

There are instances consistent with good patient care that are valid exceptions. The definitions at the end of this Statement provide essential clarification for terms used herein. Concurrent or simultaneous operations occur when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time. The critical or key components of an operation are determined by the primary attending surgeon.

Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances. The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation.

In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation.

In this situation, a qualified practitioner must be physically present in the operating room of the first operation. The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room.

In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.

Contemporary surgical care often involves a multidisciplinary team of surgeons. During such operations, it is appropriate for surgeons to be present only during the part of the operation that requires their surgical expertise. However, an attending surgeon must be immediately available for the entire operation. The surgeon may delegate part of the operation to qualified practitioners including but not limited to residents, fellows, anesthesiologists, nurses, physician assistants, nurse practitioners, surgical assistants, or another attending under his or her personal direction.

The surgeon must be an active participant throughout the key or critical components of the operation. The overriding goal is the assurance of patient safety. The surgeon must be immediately available for recall during such absences. Unanticipated circumstances may arise during procedures that require the surgeon to leave the operating room before completion of the critical portion of the operation. In this situation, a backup attending surgeon must be identified and available to come to the operating room promptly.

If more than one emergency occurs simultaneously, the attending surgeon may oversee more than one operation until additional attending surgeons are available. The surgical team involved in an operation is dependent on the type of facility where the operation is performed and on the complexity of the surgical procedure. At a freestanding outpatient surgery center, many procedures are performed solely by the primary attending surgeon with no assistant.

In contrast, a complex procedure at an academic medical center may involve multiple qualified medical providers in addition to the primary attending surgeon. As part of the preoperative discussion, patients should be informed of the different types of qualified health care professionals who will participate in their operation assistant attending surgeon, fellows, residents and interns, physician assistants, nurse practitioners, and so forth and their respective role should be explained.

If an urgent or emergent situation arises that requires the surgeon to leave the operating room unexpectedly, the patient should be informed subsequently. In an effort to provide some standardization of nomenclature, the following definitions are provided:. The qualified surgical attending who has been designated to provide immediately available coverage for an operation, during a period when the primary surgeon might be unable to fill this role.

Surgical procedures when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time. The critical or key portions of an operation are determined by the primary attending surgeon. Reachable through a paging system or other electronic means, and able to return immediately to the operating room. This term should be defined more completely by the local institution. An example of a multidisciplinary operation is a procedure in which a surgeon of one specialty provides the exposure required by a second surgeon who performs the main surgical intervention such as a general or thoracic surgeon providing exposure for a neurosurgeon or orthopaedist to operate on the spine.

Another example would be an operation that requires the involvement of two or more surgeons of different specialties such as chest wall or head and neck resection followed by plastic surgical reconstruction, face or hand transplantation, and repair of complex craniofacial defects.

The practice of the primary surgeon initiating and participating in another operation when he or she has completed the critical portions of the first procedure and is no longer an essential participant in the final phase of the first operation. These are by definition surgical procedures where key or critical portions of the procedure are occurring at different times. Considered the surgical attending of record or the principal surgeon involved in a specific operation.

In addition to his or her technical and clinical responsibilities, the primary surgeon is responsible for the orchestration and progress of a procedure.

Any licensed practitioner with sufficient training to conduct a delegated portion of a procedure without the need for more experienced supervision and who is approved by the hospital for these operative or patient care responsibilities. The emergence of critical care specialists has provided important support in the management of patients with complicated systemic problems.

It is important, however, that the operating surgeon maintain a critical role in directing the care of the patient. In such cases, the operating surgeon continues to be involved in the care of the patient until surgical issues have been resolved.

Except in unusual circumstances, it is unethical for a surgeon to relinquish responsibility for the postoperative surgical care to any other physician who is unqualified to provide similar surgical care. If the operating surgeon must be absent during a portion of the critical postoperative period, coverage should be provided by another surgeon who is skilled and who can render surgical care—including reoperation, if necessary—equivalent to that provided by the surgeon who performed the operation.

The patient should be informed of this arrangement in advance. When this period has ended, it is appropriate for the surgeon to relinquish the responsibility for management of the patient. The surgeon will ensure that the surgical patient receives appropriate continuity of care.

An ethical surgeon should not perform elective surgery at a distance from the usual location where he or she operates without personal determination of the diagnosis and of the adequacy of preoperative preparation. Postoperative care should be rendered by the operating surgeon unless it is delegated to another physician who is equivalently qualified to continue this essential aspect of total surgical care.

Similar circumstances may apply when patients travel great distances for elective surgery. Emergency surgery performed in locations unusual for the surgeon may be necessary on occasion, but habitual or even frequent performance of operations under these circumstances cannot be condoned.

If the condition of the patient permits and additional skills are required, the patient should be transported to a medical center where adequate resources and appropriately trained health care professionals are available.

Patients usually choose their surgeons, and surgeons, in turn, may accept or refuse patients. In emergencies or when required by law, the surgeon should provide the needed care and arrange for follow-up care.

Certain circumstances for example, the military and health maintenance organizations restrict freedom of choice, and patient and surgeons are assigned. An ethical surgeon should abstain from a system that denies serving the best interests of the patient by refusing referral out of the system. Freedom of choice means that either the patient or the surgeon may terminate the physician-patient relationship. When a patient exercises this right, the surgeon should transfer copies of the medical record to the new surgeon or another appropriate physician.

When a surgeon exercises this right, he or she should notify the patient in writing and provide copies of the medical record to the new surgeon or physician. All parties should cooperate to ensure continuity of care during the transfer. Patient confidentiality is a fundamental tenet of medical care. The information in the medical record belongs to the patient but is shared with those health care professionals responsible for providing care.

However, in most jurisdictions, the records belong to the physician or institution that compiles and maintains them for the caregivers. Access to medical records by caregivers, insurers, government, and other parties places patient privacy in jeopardy.

All surgeons in the U. HIPAA provides for the use of medical information in the public interest—for example, reducing public health risks and accumulating vital statistics. Surgeons should avoid disclosing identifiable health care information to any person without authorization from the patient.

Also, discussion of identifiable patient information in public places is unethical. Modern marketing strategies and tactics place extraordinary pressure on surgeons. No operation should be performed without suitable justification.