Hospital patients yearn most of all to shed the label of patient and go home. But the day of discharge carries some special dangers for last-minute testing, according to a new study. The takeaway lesson: Don’t let the joy of new freedom cloud your watchfulness as you’re on the way home.
The study published in the Archives of Internal Medicine showed that tests ordered on the last day of a hospital stay account for nearly half of all test results that are not reviewed. They also represent a larger proportion of abnormal test results.
We’ve written previously about the need to manage a complete transition from hospital to home. (See our post, “Safely Handling the Transition from Hospital to Home.”)
Because patients are deemed ready to go home, most tests ordered on the day of discharge are unlikely to change care and many aren’t even necessary. But, the researchers wrote, “if an important test result is required to guide care at discharge, providers need to figure out a process to ensure follow-up.”
Timing is key: Tests requested early in a hospital stay are more likely to be reviewed than those requested later. “Tests ordered on the day of discharge have a very limited chance of being reviewed,” researchers concluded.
More than 20 in 100 tests ordered on the day of discharge were not followed up, compared with not quite 2 in 100 tests ordered on other days. In addition, day-of-discharge tests were more likely to show abnormal results–nearly 15 in 100 of all unreviewed tests at discharge were abnormal, but of those given on the day of discharge, 65 in 100 were abnormal.
As the researchers noted, 1 in 5 patients experiences an adverse event during the transition from hospital to home, and 6 in 10 of those are preventable. No matter when they were given during a hospital stay, failure to follow up tests once a patient has gone home contributes to the risk of an adverse event. The risk is greater if they’re given on the day of discharge because results aren’t always available the same day a test is given, and if they are, there’s a smaller window for review.
There’s a cynical result here, too. “It appears that at least some late admission tests represent an opportunity to optimize test ordering,” the researchers wrote. “Tests ordered as a result of poor discharge planning may well be unnecessary….”
Their solution to the oversight and possible bill-padding practice is to implement discharge protocols that trigger computer alerts when discharge-day tests are ordered electronically to advise clinicians either that it is unlikely that results will be posted before discharge or that the tests have a high risk of being missed.
Our solution is for hospital patients and their advocates to make sure they know:
- when their doctors plan to discharge them;
- what tests are planned and when;
- when all tests conducted in the hospital can be reviewed; and
- when they have been reviewed.