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Dangerous Practice for Hospitals: Releasing Patients with Unstable Vital Signs

October 10th, 2016

DALLAS – Releasing hospitalized patients before all vital signs are stable is associated with an increased risk of death and readmission, yet the practice remains fairly common, according to a new report.

A study published recently in the Journal of General Internal Medicine finds that, at least in one large metropolitan area in the United States, 20% of patients were released from hospitals without fully stable vital signs.

Researchers from the University of Texas Southwestern Medical Center point out that, as hospital stays have contracted over the past 30 years, concerns have been raised that patients are being discharged too early. Noting the dearth of trials on the topic, the study team sought to determine if discharging patients with unstable vital signs actually leads to higher post-discharge mortality and readmission rates.

"We found that nearly 1 in 5 hospitalized adults is discharged with one or more vital sign instabilities such as an elevated heart rate or low blood pressure," said lead author, Oanh Nguyen, MD, Assistant Professor of Internal Medicine and Clinical Sciences. "This finding is an important patient safety issue because patients who had vital sign abnormalities on the day of discharge had higher rates of hospital readmission and death within 30 days even after adjusting for many other risk factors."

To determine that, researchers assessed electronic medical records of 32,835 unique individuals from six Dallas-Fort Worth area hospitals, recording abnormalities in temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation within 24 hours of discharge. They found that nearly 20% had one or more abnormalities, with elevated heart rate — which affected about 10% — the most common. Results also indicate that about 13% of those premature discharges were readmitted or died.

Patients with three or more instabilities had a nearly four-fold increase in the odds of death, study authors reported.

"Our findings, that 'vital signs are still vital,' have important implications for the development of national discharge guidelines to improve patient safety for the 35 million individuals being discharged from hospitals in the U.S. annually," said co-lead author Anil Makam, MD, Assistant Professor of Internal Medicine and Clinical Sciences.

"At a time when people are developing complicated, black box computerized algorithms to identify patients at high risk of readmission, our study highlights that the stability of vital signs, something doctors review with their own eyes every day, is a simple, clinically objective means of assessing readiness and safety for discharge. There's a good reason we call them vital signs," added senior author Ethan A. Halm, MD, general internal medicine chief at UT Southwestern. "It is important for clinicians to look at all of the vital signs in the 24 hours prior to discharge and not just the last set or the best ones in judging a patient's readiness for discharge."

Instead of current practices, study authors recommend that discharge guidelines include objective vital sign criteria for judging stability on discharge, which would improve disposition planning and post-discharge patient safety.

At a minimum, they advise, patients with one instability on discharge should be discharged with caution. Individuals with two or more instabilities should remain in the hospital for continued treatment and observation in the absence of extenuating circumstances, however.

In addition, hospitals are urged to provide close outpatient follow-up and appropriate patient education about warning signs and symptoms that call for urgent medical attention.

Furthermore, what appeared to be appropriate discharge planning wasn’t always good enough, according to study authors. Researchers found that patients sent to post-acute care facilities had still higher rates of readmission and death, suggesting that an alternate site of discharge might have been more appropriate for a significant subset of these individuals.