How to Handle the Patient Who Refuses Discharge

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Dear Director: After some recent events nationally, our hospital administration has told us not to “push” patients out the door by using security or the police. I’m concerned that we’ll end up being a shelter and just have patients who won’t leave after they’re discharged. What can I do?

In a prior life, I worked as a bouncer in a beach bar after college. If you know me now, and didn’t know that fact, you’re probably laughing. Back then, it was an easy job and a chance to live at the beach. The job involved taking out more trash than people, but plenty of people were escorted out of the bar. Usually, it was for fighting, but sometimes the bartender would wave us down and tell us someone had to leave, and our job was to show them out. If you’ve been in emergency medicine long enough, I have no doubt that you’ve also had security or police escort someone out of the ED. But, we work in a hospital, not a bar, and have an obligation to care for our patients. We also have an obligation to make sure our ED is safe, and for violent, aggressive, or dangerous patients, I recommend calling the police. However, for the sake of discussion, this article will focus on the patient who believes they are too sick to leave without being a threat to staff.

I spent most of my career working in urban emergency departments. I often felt that our psych area was a shelter—say you’re suicidal and you could typically get a couple days of ED turkey sandwiches while you waited for a bed and slept before contracting for safety and leaving. On the other hand, occasionally, patients came in for medical issues and then refused to leave once they had been fully evaluated. Security would typically be called. We got into our jobs because we liked emergency medicine and no one wants to think their ED has become a shelter. As I’ve talked to colleagues who still work in this environment, security and police escorting someone off hospital property occurs regularly.

However, a quick Google search will show you that bad outcomes afterwards is not an uncommon occurrence—patients have died or had significant morbidity after being escorted out of the ED after the patient didn’t leave initially because they felt they were too sick and required more care. These are certainly challenging situations and need to be considered on a case by case basis. It’s unrealistic to think that police or security would never be needed to escort patients from the hospital, but below are what I consider to be best-case scenarios for preventing future bad outcomes in this scenario and minimizing the need to have patients physically removed by police or hospital security.

Get the Medicine Right
While this seems inherently obvious, we still make mistakes. For starters, consider the history, the differential diagnosis, how much testing have you done, and how certain are you of your diagnosis. Do you know this patient or not? Are they a super utilizer and never want to leave the ED? I’d be more concerned if this is a dramatic change from their behavior (i.e. they usually leave after some meds, food, or sleeping and now they won’t) or if this is the first presentation of a patient to our ED. I had a great attending when I was a resident. He would say, “Ask another question and order one less test.” That’s great advice that has served me well but for these patients, I would say, ask a few more questions and then consider if you need more testing. These patients are not the ones to take a minimalist approach on and not do labs or a CT. I’m not advocating for needless tests, but if the patient has abdominal pain and you haven’t done any testing and they’re refusing to leave, I might reconsider my work up. Personally, I feel much better having police escort someone out with normal labs and a negative CT than if I simply decided they don’t have a surgical emergency because I didn’t appreciate any rebound or guarding on my exam. We see lots of back pain patients but most get better after some meds and are agreeable to discharge. I feel like I am only allowed so many MRIs a year and I hold on to these chits closely. However, I’ve also been surprised to find significant abnormalities on patients who refused to leave and pressured me into getting an MRI (in my mind, I’m doing it to prove nothing is wrong with them so they will leave).

Vital signs are vital. Part of getting the medicine right means clearly addressing abnormal vital signs. By now, everyone has seen the literature that shows the relationship of unanticipated post ED discharge death to abnormal vital signs. Vitals are the first thing I look at when I review a case from a quality perspective. Experience tells us that abnormal vitals are frequently seen in patients who are discharged and have bad outcomes. Patients can certainly be discharged with abnormal vitals, but these should be explained, or explainable, in the chart.

Phone a Friend
If a patient won’t leave, now’s the chance to get more history or elicit help. Take the opportunity to have them call friends or family to pick them up. If the family is present, ask them to clarify history. Find out what else is going on. If it’s not a medical issue, what is the underlying problem? Get case management involved. Maybe a shelter bed, a cab voucher, or a couple days of a prescription is all they need. However, if it’s not a psychiatric issue or social circumstances, and family is saying the patient appears more ill than usual, then reconsider your diagnosis. Of course, you can also call a colleague. If you have double coverage, take a minute to discuss the case with a colleague for an unofficial consult. We don’t do this too often, but these discussions can provide a fresh perspective on a case. Maybe you need a hospitalist consult. Again, you probably don’t do this very often, but for the handful of times a year where patients won’t leave an ED and require a security escort, this work won’t overwhelm your hospitalists.

Don’t Let Their Personality Impact Your Judgment
This is easier said than done since no one really wants to go out of his or her way to take care of a rude, obnoxious, ungrateful, uncooperative, cursing patient. Certainly, we can quickly be swayed when the nurse comes over and encourages us to discharge someone who’s not pleasant for them to take care of. For these patients, take a few deep breaths, and always make sure you’re making your decisions based on the medicine and not on the patient’s personality.

Document, Document, Document
Now that you’re sure the medicine is right and you’re making the appropriate discharge decision, before you contact security, take the time to do one more review of the chart. Start with the EMS and nursing notes. Is there information that may impact your decision-making and have you addressed all of the issues noted? Now is also the time to document your conversations with the patient, family, patient representatives or nurse supervisors who become involved, and case management.

Be sure to include what has been offered to the patient. Finally, just like you thoroughly document a chart when a patient leaves AMA, now is the time to make sure your medical decision-making is clearly spelled out. Include your differential diagnosis and why you think your diagnosis is correct and hospitalization is not required. Often, these are the cases where the diagnosis is an atypical presentation of an unusual diagnosis; so keep an open mind on your differential diagnosis. Document thoroughly because just like an AMA patient, if there’s a bad outcome, your documentation will be the key to supporting your decision-making.

Conclusion
The ED is not a shelter, and from time to time, patients will refuse to leave the ED. Before calling security or the police, be very confident of your diagnosis. This involves a thorough work up and if available, collaboration with family and case management. Rarely does a patient’s refusal to leave require the police or hospital security to physically remove them. In these cases, take the extra few minutes to thoroughly review the care provided, other social issues that may be impacting the disposition, the documentation in the medical record with a section for your own medical decision making, and consider any other options that may exist prior to the police being involved.

ABOUT THE AUTHOR

EXECUTIVE EDITOR
Dr. Silverman is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virgina Hospital Center. He authors the Director's Corner each month in EPM. Dr. Silverman’s practical wisdom is now available in an easy-to-use reference guide. Order today on Amazon.

4 Comments

  1. This article is worthless. Tell us something we don’t know. You’re avoiding the real question here. We don’t need a refresher course on medicine we need a solution to a social problem that it’s not our problem

  2. James Neuenschwander on

    I remember the “ask one more question do one less test”. Great advice!!

    Well written Michael!

  3. Thanks, Dr. Silverman. All very, very good advice.

    I would also recommend that one always ask the patient directly what he/she is expecting or if there is some other reason for wanting to remain. If you are certain that you have thoroughly and competently executed your responsibility, then discharge the patient. At that point if the patient would not leave I would turn the matter over to the administrator on-call. He/She is now THEIR responsibility. I was never hired as a bouncer for the hospital. I did this on a number of occasions and, after negotiating with the patient, the patient either left voluntarily or the administrator himself had security escort the patient out of the department. And as much as I despise administrators (I can say this now that I’m retired!), I never had an administrator refuse to come down and deal with the patient nor was I ever reprimanded for requesting that they do so.

    Sometimes there are times when a little flexibility on the part of the physician can end the problem. I once had a loud, confrontational young lady register in our urgent care demanding “tests.” Granted, she had no medical complaints – she had simply convinced herself that life would be easier for her if she knew her “tests” were OK (she also had no idea what “tests” she wanted). And she was quite clear that she wasn’t going to leave unless “tests” were done. I ordered a dipstick urine and a finger stick glucose, both normal. She was happy and left without any further confrontation.

    But I DO think it is imperative that the emergency physician seeing the patient has done all the proper things and documented it well. Twenty years ago, I wouldn’t ask this but unfortunately after my own personal experiences in an ED following retirement, I now realize that one must nowadays:

    1) Did you take a directed, pertinent history or did you read off questions from a template like a robot, which the patient may (perhaps rightly) perceive as only marginally related to his/her complaint?

    2) Did you give the patient time to say or add something that is important to him/her?

    3) Did you actually do a physical exam – not the quarter-second “stethoscope tap” or simply putting your hand gently on the patient’s belly without really doing anything – but a REAL physical exam?

    4) Did you discuss the diagnostic possibilities with the patient? Even though you may be sincerely certain that nothing bad is happening, the patient is probably equally sincerely certain that something bad IS happening and needs to be assured that you will rule out those possibilities. Find out what’s frightening them and then address it.

    5) Did you step back in the patients room periodically to update him/her or just to let the patient know he/she hasn’t been forgotten?

    6) And most importantly, during your first encounter with the patient, did you prepare him/her for the disposition home if nothing requiring hospitalization were to be found? Establishing at the very beginning of the visit that if the patient is fortunate enough that nothing bad is occurring, he/she will be discharged to their own doctor’s care, can usually pave the way to a smoother discharge later on.

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