I've always been fascinated by the seemingly abrupt transition on hospital discharge day to home-the cessation of vital signs, insulin sliding scales, subcutaneous heparin shots, or PRN medications. The decision to discharge someone to the next level of care, including home, is often hard to quantify. We must ask: Has the patient met all the goals relating to why he/she was admitted to the hospital? Has the patient been properly educated about his/her disease process and demonstrated an understanding? Have the patient and family received instruction on the appropriate caregiver roles and responsibilities?
As wound care clinicians, we have the duty to teach not only students and colleagues, but also patients, families, and other caregivers about assuming their role postdischarge. The word "doctor" is derived from the Latin doctus, "having been taught; learned" (from docere, "to teach"). We must embody this definition, especially during and around the critical juncture of "discharge date." In the more unhurried times of yesteryear (pre-electronic medical records), I remember fondly how one of my mentors would alert everyone that we should pay particular attention to the patient's discharge proceedings by his Montblanc fountain-pen entry into the chart: "The patient has reached the penultimate day of hospitalization," indicating to the staff that we should prepare the patient for discharge the next day. The hour of yesterday is the 30 seconds of today. Today, we must prepare the patient for discharge day on the day of admission; lengths of stay are shorter; and there are downward pressures to move patients to the next level of care in a speedier fashion. To compound the transformation from hospital to home, more patients are receiving complex procedures and equipment they must learn to manage in the home environment with fewer resources and training. This has become a recent concern of the Food and Drug Administration (FDA).
Several reports indicate that the FDA is concerned that the proliferation of complex medical devices once used in hospitals by trained personnel is now making its way into the post-acute continuum at home and utilized by potentially untrained caregivers. In April, the United Press International reported that the FDA is starting an initiative to ensure that caregivers and patients safely use these types of devices, such as ventilators and hemodialysis equipment, in their homes. The initiative is expected to develop guidance for manufacturers who market devices intended for home use, provide postmarket surveillance, and implement other measures to promote the safe use of complex medical devices. The FDA guidance will also extend to the use of wound care-related products, devices, and procedures.
Late last year, for example, the FDA issued a notification to healthcare professionals and advice for patients regarding rare, but potentially serious, complications associated with negative-pressure wound therapy (NPWT). The federal agency alerted the public and clinicians that bleeding and infection were among complications that have been reported in some patients using NPWT. These types of complications could occur in any setting, including hospitals, long-term-care facilities, and the home. Most of the critical cases reported occurred in the home or a long-term-care facility. To help address the potential complications, the FDA has issued recommendations for patients using NPWT, including making sure they receive adequate training from a healthcare professional and have the ability to recognize the early warning signs of possible complications.
The use of NPWT was just an example of a wound care-related medical device that can be used in the home postdischarge. Following reports of various concerns, the FDA will be scrutinizing the use of all medical devices for discharged patients. As healthcare practitioners, it is our intrinsic responsibility to ensure that our discharged patients and their caregivers are appropriately educated on the use and safety of all medical devices that will be used in the home. Despite the pressure to move patients faster, we must take the time to validate that the patient and support team demonstrate an understanding of the equipment and the potential complications that may occur.
The patient's discharge day does not discharge us from accountability.
Richard "Sal" Salcido, MD
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