During this first semester I have managed to see patients in both an orthopaedic and neuro based clinical setting and have begun to gain an appreciation of when and why supervising physios make the call regarding whether a patient is appropriate for discharge and to where.
While the patients who are inpatients on an orthopaedic ward will differ significantly in functionality to those in a neuro rehabilitation setting, the criteria for discharge can be similar from a safety perspective, in that the patients need to be able to ambulate and transfer safely and independently ideally. For an orthopaedic patient the main barriers to discharge are being able to ambulate safely given their post op precautions or walking aids (such as being TWB or PWB, or ambulating with Elbow crutches when previously in dependant, or having to be able to fit a Richards splint). In the case of a neurological inpatient the barriers to DC would depend on what level of recovery they have made with regards to impairments of function or balance as well as ambulating with / without aids as needed. I know that when planning for discharge on either ward they have been the criteria that I have roughly assessed patients with. From here the pathways for Ortho patients is ideally home and for neuro patients the same is ideal, although it has not been uncommon for patients from either ward to be sent to a low care facility, or a facility more appropriate to their current needs from my understanding.
However I have noticed over the year that for elderly patients especially they have been discharged home when their status at discharge does not correlate with what I would have called safe. In these cases however it was seen as appropriate by all staff for the patient to go home, and when asking my supervisor why this was the case, it was a decision based on quality of life. For some patients, they would have a much higher quality of life in their home environment then they would in a nursing home, and they had enough support at home to cope. Its worth noting that all of the patients i am referring to were not grossly unsafe, but I would have definitely sought consultation before sending them home. I believe that this sort of decision making is one that comes with experience, which I am only just developing. I can understand and appreciate that for an elderly patient, staying in their home environment would be their desired situation if they thought they were able to continue to care for themselves. I feel more aware that a patients wellbeing involves more then just their physical ability to be independent, but I also believe that being able to make such a decision is something that will come with experience. This is also an example of how patients can be greatly different despite a similar length of hospital stay or diagnosis.
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You are absolutely right this is decision making that comes with experience. On my current placement my supervisor accompanied the other student and myself to visit an 84 year old woman who had just been discharged following a significant car accident (nothing broken but significant pain with lower lobe collapse). The client had 10 years earlier suffered a stroke. On assessment the client had significant mobility and balance issues and was deemed (by us naive students) a very high risk of falling and a long lie if she did fall. We were very reluctant to leave her alone. Yet our supervisor acknowledged our concerns and was happy to walk away. We have continued to treat her at home 1-2 visits per week and on our latest visit she was twirling in the kitchen and walking outdoors 500m++. It has been a great experience to watch the recovery in her own environment and I am sure she has recovered faster than if she had been kept in the hospital. It has been a great learning experience for me and will hopefully assist in future decision making under such circumstances.
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