The Dangers of Premature Psychiatric Patient Discharge

If you or a loved one is admitted to a hospital or medical facility, you would hope that the doctors and health care workers there have your best interest in mind over monetary gain. One would expect to be taken care of and appropriately treated for his or her presenting problem within a reasonable amount of time. One would also expect to get discharged once properly evaluated, treated by a physician, and given the “okay” to safely return home. 

Most patients are prepared and ready to go when they leave the hospital, however, some feel rushed and pushed out too soon. In Georgia, medical providers are to only discharge patients after doing a thorough evaluation to determine when they are clinically stable and ready to be sent home. Physicians and medical facilities have various reasons for prematurely discharging patients. Sometimes it’s because they think the patient is clinically stable when in fact they are not; other times it’s because the hospital is short on staff or doesn’t have enough patient beds. The issue of early discharge is complex. Unfortunately, there are several physicians who make risky decisions about discharge solely based on a patient’s health insurance: either discharging patients as soon as insurance runs out or holding them longer than necessary to collect more money. Discharging a patient too early in particular, can be quite dangerous, especially when he or she is mentally ill or suicidal. 

Standard of Care and Patients with Suicidal Ideation

“Standard of care” is a legal term used to describe the traditional and acknowledged practices of an average physician (i.e. what an average and reasonable doctor would typically do for a patient under similar circumstances). Medical malpractice occurs when a hospital, doctor, or other medical professional causes an injury to a patient by violating the standard of care through an act of negligence. However, not every mistake made by a healthcare worker or hospital will lead to a lawsuit –only those that are grievous.

Misdiagnosis, errors in treatment, aftercare, management, or early discharge may cause harm to a patient resulting in further surgeries, additional medical costs, new or heightened medical conditions, temporary or permanent disability, or even death. Psychiatric treatment in particular is complex and is difficult to diagnose and treat. For example, if a patient is admitted into a facility for suicidal ideation, it is difficult to fully determine when a patient is “healthy” and ready to be sent home. 

According to the American Psychiatric Association Steering Committee on Practice Guidelines,  “a proper psychiatric evaluation is the essential element of the suicide assessment process.” When a patient is admitted into an emergency room or mental health facility for suicidal ideation, a psychiatrist or mental health worker will evaluate his or her medical history and current mental state. Through direct questioning and observation, a healthcare professional is able to identify factors that increase or decrease the patient’s risk for suicide and come up with instant and ongoing interventions to help the at-risk patient. Furthermore, they will address the patient’s immediate safety and determine what environment and context the patient needs to receive treatment. 

Patients who have high degrees of suicidal intent, have made an attempt to take their own life, or have detailed specific plans to inflict self-harm, are typically assigned a higher level of risk. Psychiatrists and mental health professionals are to document these reported behaviors. In addition, they are to note whether a patient has access to a firearm or other weapon to inflict harm on themselves or others. Then they determine whether or not restricting access to, securing or removing weapons is what is best for the patient.

If a patient meets the criteria for high-risk for suicidal ideation, he or she is typically admitted to a hospital or facility for close observation or one-to-one monitoring (one health care worker to patient ratio) which typically includes standard 15 minute checks until the patient is appropriately discharged. However, not all physicians and health care facilities have the patient’s best interest in mind when evaluating their need to extend their stay or discharge early. 

How Insurance Impacts Patient Discharge 

Before being admitted into a hospital or mental health care facility, a patient’s tests and treatments have to be approved for payment by a private health insurance company or public payer (e.g. Medicare, Medicaid, Tricare, etc.). Health insurance companies typically rely on diagnostic codes that describe the patient’s illness/ condition and what treatment or tests may be needed. These codes also provide an average time frame for hospitals to complete such treatments and tasks. While these codes provide hospitals with recommended timelines, they do not provide an accurate estimate of a patient’s physical or mental readiness to leave the facility.  

A patient who requires continued hospitalization typically presents with a critical health condition that necessitates diagnostic or therapeutic intervention, treatment, or monitoring. Prematurely discharging a patient oftentimes leads to hospital readmission. Dr. Oanh Nguyen, a professor of internal medicine and clinical sciences at UT Southwestern Medical Center found that in the U.S., 1 in 5 patients are discharged too soon with one or more vital sign instabilities.

Vital signs are typically measurable such as temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Psychiatric patients specifically require more vigorous observation and evaluation since their symptomologies are mostly cognitive and emotional. According to her research published in the Journal of General Internal Medicine, Nguyen states that “people had higher odds of being readmitted or of death within 30 days that correlated with the number of instabilities” (see Figure 1).

Figure 1: From Dr. Oanh Nguyen’s Study on Vital Signs and Instability on Discharge

Another study on psychiatric rehospitalization conducted in Australia evaluated 135 patients who were discharged prematurely from an acute psychiatric ward. Researchers found that within 6 months, 38% of these patients were hospitalized again due to more psychiatric symptomatology and increased disturbed behavior. In yet another study conducted by Professor Eric Alper of Brown University, his team further found that early discharge does not lead to overall cost-savings for physicians or the medical facility if it eventually results in more subsequent health care utilization. 

“Dr. Oanh Nguyen, a professor of internal medicine and clinical sciences at UT Southwestern Medical Center found that in the U.S., 1 in 5 patients are discharged too soon with one or more vital sign instabilities.”

How Insurance Impacts Patient Discharge 

There are a few skills that suggest you are ready and strong enough to function at home alone both physically and mentally. However, if you feel that you or a loved one is not stable to return home, it is important to inform someone. Do not accept discharge papers from a physician or healthcare worker until they have been explained to you and all your questions and concerns have been answered.

It’s important to share your reasons as to why you think you or your loved one needs to stay longer and why an early discharge would be unsafe. It may be a good idea to put this information with your concerns in writing as to ensure the hospital received the information. If you are still being asked to leave the facility after voicing your concerns, the patient or caregiver should inform another healthcare worker or social worker and contest the discharge plan. 

Medical Malpractice Lawsuits 

There are various reasons as to why hospitals and mental health care facilities decide to discharge patients early. Oftentimes, these facilities face overcrowding and are in a rush to get patients out so they can admit new ones. There are a variety of complex factors that go into the decision-making for hospital discharge. There are other times, however, when discharging an unstable patient too soon could lead to dangerous outcomes.

If you or a loved one suffered harm and was readmitted into a facility shortly after being discharged, you may be able to file a medical malpractice lawsuit. Or if you’ve lost a loved one due to a premature psychiatric discharge, you may be able to make a wrongful death claim. Either way, it is important to ask the right questions and get advice from an experienced medical malpractice and wrongful death attorney if you believe you have been injured or lost someone due to the negligence of a healthcare facility or physician.


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