Assessing Clinical Instability at Discharge The Clinician's Responsibility

A great deal of attention has been given to what should be hospital policies when a patient is admitted to the hospital. Who should see the patient? At what time after admission? What should constitute an admission history and physical? Very little attention, however, has been paid to determining when it is safe to send a patient home from the hospital. In addition, precious few randomized trials have been performed that use clinical criteria to compare outcomes following discharge for those people who had the customary length of stay vs a medically correct length of stay. 1,2 A little over a year ago, we wrote a series of articles 3-10 about the impact of diagnosis related group (DRG)—based prospective payment on quality of care for Medicare patients hospitalized with one of five conditions: congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. Our data source was a