During one of my clinical blocks, I was placed at a tertiary government hospital. This hospital is very well-known and it comprises of many highly qualified doctors and health care professionals. The hospital however struggles with the growing number of people seeking medical attention and bed capacity to assist these people.
South Africa’s health care system is under great pressure to provide high quality services but health care facilities simply do not have sufficient resources to care for the high demands of people seeking health care. One of the major inequalities in the health system of South Africa is that the wealthy people (which is the minority of the country) are covered by private insurance, whilst the poor people of South Africa rely on the public health sector, which is extremely under-resourced (Marten, 2014). The poor population is what makes up the majority of the South African population, and this population is continuously growing. Whilst it can be said that the poorest population utilize much fewer health services, the burden of disease is much greater amongst this population (Marten, 2014).
In the Western Cape specifically, there has been an astronomical increase in urbanization, with the majority of people migrating from the Eastern Cape to Cape Town (Jacobs, 2014). This is causing a burden on service delivery in the health sector in the Western Cape (Jacobs, 2014). In the Western Cape, the health department established a patient-centered health service. The focus is to provide a service whereby the patient is the center of health initiatives, resulting in the desired health outcomes as a superior experience of a complete patient journey (Western Cape Department of Health, 2014). Due to the rising demand for healthcare, the Western Cape Department of Health developed the Emergency Case Load Management Policy (ECLMP) which aims to guide hospitals to improve emergency department efficiency, to address the flow of patients through the hospital, whilst still maintaining patient centeredness (ECLM, 2012).
Due to the lack of bed capacity, a hierarchy system is used to determine who is most critically ill. The doctor’s try and stabilize the patient’s as quickly as possible so that the patients can be discharged and make more spaces available. However, the physiotherapists are not always consulted and the patient’s leave before being physically appropriate to be safely discharged.
During my block I experienced this as I was given a referral letter at 1pm which stated that it was urgent that the patient is mobilized as he had had a toectomy 2 days prior. The patient was a 59-year-old male whom had gangrene in his right big toe and thus surgery was done to prevent the spread of the gangrene. The patient was otherwise physically healthy and his only co morbidity was diabetes.
When I attended to the patient that afternoon, the doctors had already discharged him and his transport was on the way to take the patient home. The doctors had assumed that the patient would simply need crutches, however when I assessed the patient he lacked balance when standing and when using the crutches. Even after being demonstrated on how to use the crutches and the patient attempting to use the crutches with physical and verbal cues, it was not safe for him to mobilize independently with the crutches.
The next step would be to give the patient a walking frame, however due to lack of resources, this patient was not a suitable candidate as he had only had a toectomy and walking frames were prioritized for above knee amputee patients. This created an ethical dilemma as the patient was being discharged, but from a physiotherapy point of view it was unsafe for him to be discharged. The patient needed further therapy to assist him in retraining his balance and relying on 3-point crutch walking until he was allowed to weight bear on his affected side. The patient was referred to his local clinic to work on his crutch walking but this appointment would be much later on and the patient could still fall at home before that appointment.
I felt uncomfortable during this situation as I felt that it is my responsibility to ensure my patients are sent home safely. By the time I could report this to my clinician and ask for advice on how to confront the doctors regarding this situation, it was already the end of the day and my clinician was not going to be able to take the matter up with the doctors before the patient leaves.
I also felt conflicted as I understood that the hospital is under great pressures to attend to as many patient’s as possible and that this particular patient was not critically ill and no longer needed medical attention but it was a concern to me that the patient call fall at home and injure himself and then have secondary complications. This situation could have been resolved had the doctors given the physiotherapy department the referral on the day of the amputation so that balance training could begin immediately. The doctor could have also explained to the physiotherapist the need for extra beds and the physiotherapist could have compromised by making an outpatient booking where balance training and crutch walking could have been continued at the hospital. This way there would be better continuation with the patient at this specific hospital and then later the patient could have been referred to his local clinic to complete the entire rehabilitation process to ensure no secondary complications.
A study was done in Ontario, Canada, to examine discharge planning of patients in general internal medicine units in acute-care hospitals from the perspective of physiotherapists. The results of the study showed that mobility status was identified as the key factor in determining discharge readiness; other factors included the availability of social support and community resources (Matmari, 2014). Discharge policies, timely availability of other discharge options, and pressure for early discharge were identified as factors affecting discharge planning (Matmari, 2014). Even though Canada is considered a first-world country, whereas South Africa is considered a third-world country, Ontario still seems to experience the same pressures of early discharges. The difference being that Ontario has an increased demand for health care due to an increase in the aging population, which includes many people with multiple co-morbidities. This rising demand for hospital resources and the need to ensure available capacity, has led to an increased emphasis on formalized discharge planning (Matmari, 2014).
Another study showed that physiotherapists consider a patient’s physical status, goals and wants, ability to participate in care, and life context when making a discharge recommendation (Jette, 2003). This shows that physiotherapists are not only considering how the patient presents now, but how they will also cope at home and participate at a community level. This emphasizes the identification and coordination of support systems needed to allow patients to return to safe community living (Matmari, 2014). Hence why I was uncomfortable with sending my patient home as I did not feel he would mobilize safely at home and within his community, and I had not yet established who his support system was and I had not yet been able to make contact with any family or friends who could assist taking care of him. It has been suggested that when a physiotherapist’s discharge recommendations are not implemented, patients are more likely to be readmitted to acute care within a short period of time (Smith, 2010).
From this situation, I have learnt that I need to be more assertive with regards to my opinion of what should happen with my patients. I will soon no longer be a student and I will have full responsibility for my patients and if I do not fully express my knowledge to the doctors, I will ultimately be doing my patients a disservice. Whilst I do still understand that the doctors are not maliciously discharging patients without consulting physiotherapists, and that it may just be as a result of high pressures to attend to as many patients as possible with little resources, we still need to give the best possible service and this way prevent secondary complications. If this is not done, patients will return to the hospital and worsen the burden of an already full capacity health system.
Resources:
Emergency Case Load Management Policy. 2012. Circular H 145.
Jacobs, W. (2014). Migration patterns and migrant characteristics in the Western Cape through a differential urbanisation lens (Doctoral dissertation, Stellenbosch: Stellenbosch University).
Jette, D. U., Grover, L., & Keck, C. P. (2003). A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Physical Therapy, 83(3), 224-236.
Marten, R., McIntyre, D., Travassos, C., Shishkin, S., Longde, W., Reddy, S., & Vega, J. (2014). An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS). The Lancet, 384(9960), 2164-2171.
Matmari, L., Uyeno, J., & Heck, C. S. (2014). Physiotherapists’ perceptions of and experiences with the discharge planning process in acute-care general internal medicine units in Ontario. Physiotherapy Canada, 66(3), 254-263.
Smith, B. A., Fields, C. J., & Fernandez, N. (2010). Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Physical therapy, 90(5), 693-703.
Western Cape Department of Health. 2014. Healthcare 2030, the road to wellness. Cape Town: Government Printer.
6 thoughts on “Discharge decisions”
Hi Halinka
Thank you for sharing your piece and clinical experience. I could 100% relate to your situation, as I too was placed in a very similar situation quite recently – where a patient was already discharged from medical care when I was given the referral. I understand and know that this is a serious and unwanted situation.
The situation regarding the intense pressure in government facilities is very real and worsening, so I think it is an important topic that you are discussing.
Content: The content of your piece was very good. You researched the topic of discussion well and that was evident in your writing. I like how you explained all the ethical concepts you were talking about and referenced them. I also appreciate that you explained the South African background regarding the health sectors current situation and challenges – as that is most applicable and realistic to us as students in South Africa.
I think perhaps you could add a bit of medical background to your patient – like age, reason for amputation as well as why he was for non-weight bearing post-op (in certain situations patients are often forced to full weight bear post-op), just to give the reader a bit more insight as to how the patient presented and what implications a fall could have had on him (older people tend to be more of a fall risk and it can have detrimental effects on them and potentially be fatal).
Argument: Your argument was clear and it was evident that you believed this patient should not have been discharged, but rather given the time for rehabilitation – even though the South African health sector pressure did not allow for that. Perhaps you could look into possible solutions for this problem, in order to gain knowledge about how to deal with similar situations in future – as I am sure this would not be the first and only time this problem arises. I think it would also strengthen your argument if you maybe researched the impact of physiotherapists’ voices in clinical decisions in South Africa – as I have experienced we are very often not regarded as an important MDT members, when it comes to patient decision making specifically around discharge. How important are physiotherapy inputs in patients’ medical decisions and are we often disregarded due to the high pressures experienced in these tertiary institutions?
References: Your references were very good – you made use of in-text referencing as well as a reference list and your references were recent, which also strengthens your content and argument.
Grammar and Spelling: Overall your piece was very well written and easy to follow. There were a few minor grammar and spelling errors, which I have indicated to you via the side bar (annotations), to make it easier for you to find.
I don’t think your piece needs a lot of changing, but I believe these few minor adjustments will positively impact your writing piece. I hope you find my comment helpful and please let me know if anything was unclear.
Good luck and all the best
Janine
Thanks so much for your comments Janine! I definitely agree that I can add some more information regarding the patient in order to give a better clinical picture of how the patient presented when I arrived to see him.
Thank you for your comment on how to strengthen my argument by explaining the importance of a physiotherapist in assisting with the decision making process. I am busy finding literature that explains the value that physiotherapists contribute to decision making and therefore why doctors should not be the only health professionals making the decisions.
Many thanks
Halinka
Hi Halinka. Thank you for sharing this experience with us. During my first block I’ve found myself in similar situations on a daily. The placement where I was placed are big on discharging patients for the mere fact “we need the beds” and their long waiting lists. I sometimes felt that immense pressure was placed on the physiotherapy department as doctors would sometimes write on the referral “Discharge if physio is happy”. So i had to push patients to mobilize by day 1 and discharge them with the appropriate aids. I addressed the matter with one of the physiotherapists and she instructed me to push my patient to his/ her limit but if the patient struggles you keep them for 1 more day. I could actually see that the doctors understood in some cases.
Content:
I can see that you have done a great deal of research on this topic. I like how you gave us some background of the statistics in South Africa, specifically the Western Cape, as we come across this matter on a daily.
I think you can expand more your case and maybe look at ways this matter could be addressed. I know that in bigger hospitals the health professionals are busy but do you think that it could’ve made a difference if you consulted the clinician before the time?
Arguement:
I think you have a good arguement. Personally I would’ve made the same claim. I think to strengthen your claim a bit more look at specific claims and expand more on it e.g. what you could’ve done in this case that might have been a possible solution? Maybe look at similar experiences and how it was resolved or how you can handle similar situations in future.
References:
Great use of in-text referencing as well as a reference list at the end.
Writing:
Your piece is grammatically correct and well-written with few errors picked-up. Your piece has a logical flow throughout and ideas have been conveyed easily.
Comment:
I hope you find this of some use. I don’t think you have much to change to what you already have but you can add a bit more to further strengthen your arguement.
All the best.
Tammy
Thank you for your comments Tammy!
With regards to your question of whether it would have helped if i had contacted my clinician ahead of time, I think it would have as she would have more authority to disagree with the doctors decision and would have also been able to give me advice on how to challenge the doctors decision but as it was already the end of the day I could only speak to her once the decision had already been made. It was also a learning experience for me to remember that we are going to soon be qualified first line practitioners and so I need to become more assertive that my opinion regarding the patient is of importance and that I can influence what happens with the patient.
With regards to my argument, I am going to strengthen it by adding literature to emphasize the value physiotherapists have with regards to decision making for the patient’s future.
Many thanks
Halinka
Good day Halinka. thank you for sharing your piece with me. This dilemma is really relevant as it is something I have experienced in most my blocks , and therefore I can honestly relate. What makes it worse is that we spend some time in these facilities and we can see that sometimes there truly is the desperate need for the space, however it’s not always fair, or easy to explain that to the patient.
content: your content is very good, it is related to your topic and very relevant in clinical practice. your us of background and literature is very suited to the topic and it enhances the seriousness thereof, it gives the reader a better idea of just how common and serious the problem is. Perhaps you could consider your thought processes and how you weighed it out, what ultimately led you to decide to discharge the patient, perhaps a possible solution or research stating how the state can address these problems.
argument: Your argument was made clearly and well presented. It is evident that you were not comfortable with discharging your patient in that state, however you make a good point in saying that there was not much that you could do at this time. the fact that you made your discomfort clear and then explained how it was out of your control is very relatable as I think we all go through similar circumstances that are just beyond our control. perhaps you could elaborate a bit more with reference to how often something like this happens, especially in south Africa to strengthen the severity thereof.
references : good use of referencing, correct and relevant
writing : your piece has a good flow and is easy to read, it is very relevant and paints a clear picture, however you could possibly work on your conclusion. perhaps make it a bit more powerful and tie your piece together in the end.
I hope that my comments are of some use, remember these are merely suggestions. your piece is already well written and has only a few minor errors. well done, and all the best for the final submission.
Thank you very much for your comments Kaylene!
With regards to your suggestion of how the state could address this problem, I think it is a very large problem with many variables contributing to the problem making it difficult to solve. I think I will rather suggest what could have been done in this specific instance eg. the doctor could have spoken to the physiotherapist first and explained that the patient does need to leave due to lack of beds but what can be done for the interim… and the physiotherapist perhaps could have made an immediate booking with the outpatient department so that there is good continuation with the patient before being sent to another clinic.
I definitely agree that I do not have a strong conclusion and that I need to work on linking my writing together at the end.
Many thanks
Halinka.