I have written extensively in the past about inappropriate discharge planning from the hospital. Whether the third party reimbursement is based on cost plus (CP) or diagnostic related groupings (DRG), all hospitals have a financial incentive to discharge their patients as early as possible. With the former type, all of the profit is made during the first three days of any hospitalization, so faster turnover leads to a higher bottom line. Likewise, with the DRGs there is a flat rate for an average length of stay for a particular diagnosis so the earlier discharges allows the hospital to keep more of the money. Therefore, discharge planners have the imperative to immediately push the patient out through the front door once the primary care physician declares that the patient no longer needs acute hospital care. This often leads to the hospital dumping your client into an environment that is ill equipped to deal with the catastrophic disability and will fail to prevent the common complications that cause further deterioration and death. When such negligence occurs there is a clear hospital liability. However, it behooves the attorney to protect the disabled client and prevent such complications by hiring a nurse case manager to evaluate the clients needs immediately after arriving from the hospital and present a life care plan. Aside from the humanitarian considerations, a 43 year old otherwise healthy paraplegic male with some upper body weakness (injury at T-6) will incur approximately six million current value dollars in custodial, skilled nursing and medical costs over a life expectancy of 25 years.

Case in Point:

John is a 41 year husband and father of four. Three months ago, he was hit by a dump truck while he was riding his bicycle and sustained multiple compression fractures of the 6th, 7th and 8th thoracic vertebrae. He was airlifted to the nearest trauma center and the neurosurgeons decompressed the cord and stabilized the spine with metal rods. Unfortunately, the cord was completely crushed leaving John with complete flaccid paralysis of the body below his waistline with some upper body weakness. The hospital did a fine job with the acute phase and gave excellent care during his two months on the rehabilitation floor. His skin was intact, he was free of infection and he had a good bladder and bowel regimen with no dumping syndrome (unpredictable loose bowel movements).However, the discharge planning was lacking. John and his wife had a few supplies and an electric hospital bed but no one to help. The HMO denied the authorization request for a home attendant and visiting nurse. The wife, being a mother of four small children, cannot attend to her husbands needs 24 hours a day; its impossible. He also needs a daily visit from a registered nurse to provide respiratory, bladder and bowel care. While John knows how to catheterize himself and can decompress his bladder as needed, he has no way of assuring that his bladder is sufficiently emptied and not chronically retaining too much residual urine. Thus without a daily skilled nursing visit, John is at high risk for hydronephrosis, leading to kidney failure and/or kidney infection which, if untreated, results in septic shock and death.Moreover, Johns upper body weakness causes him top become a shallow breather. This condition prevents coughing up sputum and results in pneumonia, respiratory failure and death. Thus Johns weakened respiratory effort requires a daily nursing visit to evaluate his progress and provide chest percussion with deep breathing and coughing exercises. Upon arriving at home, John had an incentive spirometer but was unaware that he needed to use it every day.Finally, John has to avoid bedsores at all cost. Such a prevention program requires, among other things, meticulous skin care and turning from side to back to side every two hours around the clock. Since John is unable top turn his hips without help, he needs home attendants working in 12 hour shifts around the clock. Any skin breakdown would be devastating because John has no lower body sensation and his bodys healing capability has been altered. He is also lacking the adequate equipment to facilitate transferring and moving in bed without dragging his buttocks on the sheet and transfer board, which is likely to cause friction burns and lead to chronic ulcerations, infection, sepsis and death.In summary, the hospital sent John home without inadequate supplies, equipment and with no professional nursing services. This placed him in a very precarious situation. Once the attorney has been informed he was able to call the HMO's medical review department to task and get approval for the nursing and the additional equipment. Without my evaluation and intervention for prevention, the attorney would likely not have known about the clients danger in time to take any preventive action. The report contains complete information of all of the clients responses to the injury and the cost of care over a life expectancy of 25 years, which amounts to a total of approximately $6 million in current value.

Sample Report (different case demonstrating complications of spinal cord paralysis)

Re: Victor K____

Nursing Assessment of Activities of Daily Living

History of Illness and Trauma

According to the hospital record,

K____ presented to the M________ Hospital Emergency room on 3/27/94 with fever and back pain. He was discovered to have spinal cord compression secondary to epidural abscess on MRI after spending two days in the emergency room. He was taken to the operating room one day following this diagnosis. He has been paralyzed from T-6 since 3/29/94. He was subsequently hospitalized from 12/7/94 to 12/11/94 for orchiditis and prostatitis. He has had repeated episodes of pneumonia and sepsis for which he was hospitalized from 4/23/95 and 5/11/95 and again on 5/13/95.

K____ has also suffered from recurrent complications of the lower urinary tract. On 10/24/97, he underwent a cystoscopy, which revealed chronic urinary tract infection and two urethral fistulas. He was treated with urethral dilatation, catheterization and antibiotics. On 12/19/97 he was readmitted to

Downstate

University

Medical

Center for recurrent urethrocutaneous fistula and underwent another cystoscopy with dilatation and catheterization. A fissure excision procedure was recommended.

Content of Interview

K____'s most pronounced complaint was constant severe pain in the lower back with muscle spasm and twitching of his legs. He spoke calmly of his predicament stating that he was very depressed during the first year of his disability. Now he still gets depressed, but he is learning to live with it.

Social History and Assessment

K____ lives with his elderly father in a two-room apartment on the first floor of a tenement in

Brooklyn. The housing is sub standard. The plumbing and heating are inadequate. The present environment is deleterious to

K____'s health. He is unable to enter or exit the dwelling independently.

Behavioral Assessment

K____ was sociable. He was alert and oriented to time person and place. His affect was flat. He was resigned. He answered questioned appropriately. He apparently did not appreciate the severity of his medical complications such as severe skin breakdown of both feet and the complications associated with chronic urinary stasis.

Physical Assessment

Poorly groomed 43-year-old Caucasian male paraplegic from T6. He is wheelchair-dependent and wears diapers and a condom catheter for urine drainage.

REVIEW OF SYSTEMS

System Complaint Observation

Nursing Diagnosis

Response to injury secondary to untreated spinal abscess:

1. Alterations in comfort

2. Alterations in pulmonary function â€" susceptible to recurrent pneumonia and sepsis

3. Alterations in neuromuscular functioning â€" paraplegia from T6

4. Loss of sensory function from T6 down

5. Loss of sexual function

6. Urinary incontinence

7. Bowel incontinence

8. Alterations in body image

9. Loss of independence with ADL's

10. Sleep deprivation

11. Loss of Self esteem

12. Alterations in skin integrity susceptible to gangrene.

K____ is independent with transfers from the bed to wheelchair and needs total care for all other activities of daily living.

Medical Care Needs

Medical supervision monthly internist, urologist, psychiatrist and podiatrist.

Nursing Care Needs

Home Health Aides for custodial care to live in 7 days per week. Registered nurse visit once per day for wound care, skin care, pulmonary toileting, blood glucose monitoring and supportive counseling.

Medical Equipment and Surgical Supply Needs

1. Electric hospital bed with trapeze

2. Air loss mattress

3. Bedside commode

4. Motorized wheelchair

5. New housing with disability accommodations

6. Shower chair

7. Condom catheters

8. Sterile gloves (4 pairs per day)

9. Sterile gauze with Curlex

10. Non sterile gloves (4 pair per day)

11. Chux

Transportation Needs

Handicap van with hydraulic lift

Cost of Care

Please note that the cost of future hospitalizations and/or medical care for complications arising out of

K____'s injuries and the cost of adequate handicap housing are not included in the above table.