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Doctors 'bullied' and 'harassed' to discharge patients early

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EXCLUSIVE: More than 60 per cent of South Australian hospital doctors surveyed feel pressured to discharge patients before they are medically ready, with one clinician reporting a death soon after.

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More than a quarter say the order to move patients out early comes from middle management, while 38 per cent report the badgering comes from hospital executives.

Half said the discharge direction had negatively impacted on care, with one doctor revealing their patient had died within two weeks of leaving hospital.

The results are based on responses from 250 doctors in a survey conducted by the SA Salaried Medical Officers Association.

It follows claims about such coercion made by the union earlier this year to a parliamentary committee.

More than 80 per cent of the doctors surveyed said they felt pressure to hurry patient care because of the number of people waiting, in some cases resulting in “time consuming” procedures being avoided even if they were in the best interest of the patient.

The survey found that in many instances, patients discharged too early were forced to return to hospital hours later, creating a “revolving door policy” and delayed care.

The pressure was particularly felt and acted on by junior doctors, with more senior clinicians saying they were better placed to ignore it.

SASMOA chief industrial officer Bernadette Mulholland knew it was a problem but said she was “shocked at the results of a widespread practice to pressure doctors on a daily basis to interfere with their medical decision regarding appropriate discharge of patients”.

In the survey responses seen by InDaily, doctors stated feeling “bullied”, “harassed” and “constantly reminded” to discharge patients early.

Many said the practice meant patients had to be re-admitted later.

One doctor described it as a “recipe for disaster”.

“Clinical history taking is rushed, physical examination can be limited due to lack of privacy and space,” the doctor said.

“Sometimes, unnecessary investigations are ordered prior to patients being seen by the doctor in order to speed up the process.”

Have had patient die within 2 weeks of discharge

Another medico said “some patients are discharged too early, without time to get services in place at home to help them”.

“Sometimes patients are moved out of the department to our extended care unit (ED) before they have had their notes written or medication charts written, resulting in errors,” the doctor said.

That concern was echoed in this response: “I have recently seen a patient discharged from hospital while still profoundly confused, without any follow-up plans or safety plans in place, simply because he ‘wanted to go home’. I strongly suspect that bed pressure contributed to the treating team’s decision to allow the patient to leave hospital.”

Yet another doctor said: “It is insulting and unsafe that executive ask teams to discharge patients as if we are keeping them in hospital unnecessarily.”

Nearly 50 per cent reported that the direction to discharge early was against their clinical judgment.

“I work in geriatric medicine and regularly resist enormous pressure from bed managers to discharge frail, vulnerable patients before they are ready,” one doctor stated.

Another said: “Limited available beds in acute mental health wards result in incomplete patient assessments and inappropriate referrals/transfers without adequate medical care.”

There was a report of one patient “transferred to rehab following a direct instruction from executive”.

“I was the medical consultant responsible and became aware after the patient had been transferred,” the doctor said.

“We had to arrange for the patient to return to the hospital for a surgical procedure.”

The direction to discharge early was most commonly given verbally.

“There is constant pressure, but executive is careful to avoid being directly identifiable as the source,” one clinician said.

Another reported: “We have been informed repeatedly by senior medical and senior nursing colleagues that they have received text messages from the hospital executive that the hospital is full.”

“Although I have not been told directly by these colleagues to discharge patients, there is an implied message from them that we have to reduce admissions and to increase discharges,” the doctor said.

I felt bullied and took the matter to SASMOA

Mulholland said the survey was conducted following complaints from doctors.

“SASMOA was approached by a number of doctors, particularly junior doctors, regarding the growing practice of pressuring doctors to discharge patients that the doctors believed was earlier than appropriate because of ramping and bed block,” she said.

“The doctors also raised concerns that this pressure was being initiated from the upper echelons of hospital executives.”

She said doctors’ medical decisions should be respected and she urged authorities to “stop pretending that the failure to invest in our hospitals can be fixed by early discharge of patients who need care”.

“South Australians need to look really carefully at the narrative developed by politicians and bureaucrats that our current resourcing of hospitals is sufficient – it clearly is not,” she said.

SASMOA has issued a reminder to doctors that the Health Care Act makes it clear that hospital administrators “cannot give a direction concerning the medical treatment of a particular person”.

“If this occurs the risk is borne by the doctor and their patient,” Mulholland warned.

“If anyone in administration directs a doctor to discharge or send a patient home you should request the direction in writing and contact SASMOA and/or your medical indemnity insurer.

“This is a particular concern for junior medical officers, who may feel intimidated by administrators.”

Mulholland urged doctors to email hospital executives to advise them when there weren’t enough beds for sick patients who should be admitted.

“Advise the patient or the patient’s family also to contact the hospital executive, or the hospital Board chairperson or both,” she said.

“Sick patients should not be sent home due to a lack of resources.”

SASMOA has given the survey results to Health Minister Stephen Wade.

InDaily has asked him for a response.

When Mulholland first raised initial concerns in the parliamentary committee, Wade called on the union to provide him with specific details of bureaucrats ordering doctors to discharge patients.

“The reality is SA Health is fundamentally predicated on clinicians running healthcare and if there are any reports of that being undermined I would be keen to act,” he said at the time.

“We have made it clear clinicians manage healthcare in our hospitals.”

A spokesperson for SA Health said: “We trust our doctors to make the best possible clinical decisions for the health and wellbeing of each person in their care.”

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