The first two weeks after a hospital discharge

A discharge feels like the end of the hard part. It is usually the start of the riskiest stretch. Your relative comes home on a medication list that has changed, with instructions given quickly on a busy afternoon, and a follow up appointment weeks away. Nobody is watching in between. Readmissions cluster here, and many begin as small problems that were fixable at home if noticed in time.

Why are the first two weeks after leaving the hospital so risky?

Three things line up badly. The illness that caused the admission is treated but not finished healing. The medication regimen has been rewritten. And day to day care falls to a spouse, an adult child or an aide, not a clinician. Older adults also come home weaker, which is why falls spike after discharge.

Why do medications go wrong after a hospital stay?

This is the most common source of trouble. The discharge list rarely matches what is in the medicine cabinet. Doses change in the hospital while the old bottle at home still says the old dose. A drug stopped during the admission gets restarted at home by accident, because the bottle was there. Two prescribers write for the same drug under different names, so the person takes both. Blood thinners, blood pressure medications, diabetes medications and pain medications do the most damage this way.

The fix is unglamorous and it works:

• Physically gather every bottle in the house, including the nightstand and kitchen drawer.
• Add over the counter items too: pain relievers, antacids, sleep aids, supplements. These interact.
• Put them in one bag and have a clinician reconcile them against the discharge list.
• Discard or clearly separate anything that was stopped.

Do not work from memory or from a printed list. The bottles tell the truth.

What should families watch for in the first two weeks?

You do not need to be a nurse. You need to notice change. If something is clearly different from yesterday, call.

• Breathing: more short of breath, extra pillows to sleep, a new cough.
• Weight and swelling: with heart failure, weigh every morning on the same scale. A few pounds gained over two or three days, or new puffiness in the ankles or belly, matters even if the person feels fine.
• Thinking: new confusion, unusual sleepiness, not knowing the day or place. New confusion in an older adult is a symptom, not a personality change.
• Fever: a temperature over 100.4F, or shaking chills.
• Wounds: spreading redness, warmth, new drainage, or an incision that opens up.
• Eating and drinking: refusing food, barely drinking, vomiting or ongoing diarrhea. Dehydration sends people back.
• Dizziness on standing: often a blood pressure medication now too strong.
• Urine: none for many hours, burning, or urine that suddenly looks dark.
• Pain: pain the plan is not controlling, or pain in a new place.
• Falls: report every one, even a slow slide to the floor.

When to call the doctor and when to call 911

Anything above is a call the doctor today item. Do not wait for the follow up appointment or for Monday. Most are solved with a medication change or a visit.

Call 911 immediately, without calling anyone else first, for:

• Chest pain or chest pressure.
• Stroke symptoms: face drooping, arm weakness, trouble speaking. Note when they started.
• Severe trouble breathing, gasping, or blue lips.
• Heavy bleeding that does not stop with pressure.
• Someone who cannot be woken, or who has a seizure.

What families forget to arrange before the first night home

The clinical plan is usually fine. The logistics fall apart.

• Prescriptions actually filled. Sent to the pharmacy is not the same as in the house. Watch for approval holds and for cost: a copay someone cannot afford will not be taken.
• Home health is real. Confirm the agency and the first visit date. Ordered does not always mean scheduled.
• Follow up appointments booked, with a plan for getting there.
• Equipment delivered: walker, commode, oxygen, and someone shown how to use it.
• Someone stays the first night or two. This is the highest value thing a family does.
• Food in the house that matches any new diet, within reach.

How does a home visit in the first 72 hours help?

A home visit in the first two or three days catches what a phone call cannot. A clinician can reconcile every bottle against the discharge list, then examine the problem that caused the admission: listen to the lungs, check the legs for fluid, look at the incision, take a blood pressure sitting and standing. They also see what never reaches a chart: whether home health arrived, whether the walker is used or parked in a corner.

It also catches a slide early: two pounds gained and tighter breathing on day three is a phone call and a dose change. The same problem on day nine is an ambulance.

Questions to ask before your relative leaves the hospital

Ask the discharge planner or case manager, and write down the answers:

• What changed on the medication list, and what should we stop?
• Which pharmacy got the prescriptions, and will any need approval?
• What symptoms mean we should call, and who do we call after hours?
• Which home health agency was arranged, and when is the first visit?
• What are the diet and activity restrictions?
• When is the follow up, and what if we cannot get in that soon?
• Can we have the discharge summary and medication list today?

Arranging a post discharge home visit in northern New Jersey

Life Primary Care provides primary care in the home across Somerset, Morris, Union, Essex, Passaic and Bergen counties. A post discharge visit brings the exam, the medication reconciliation and the follow up plan to the patient, which matters most when leaving the house is hardest.

Families often call from the hospital room, before discharge, so a visit is booked for the first days home. If a discharge is being planned, or a relative came home this week, call 973-607-4911.