A 35-year-old woman at 38 weeks gestation is admitted to the hospital after premature rupture of membranes at home. The vaginal delivery is uneventful and the patient and newborn are doing well. When the physician informs the patient that she will be discharged tomorrow, the patient says, "I am tired and was hoping I could stay in the hospital a little longer. I have two kids under the age of 5 at home. It will be overwhelming coming home with a new infant. It would be so helpful to have an extra day or two to rest up. Can you come up with a reason to keep me?" Vital signs and physical examination are unremarkable. The patient is not depressed. Her insurance covers only a 2-day hospital admission for an uncomplicated vaginal delivery. Which of the following is the most appropriate response to the patient's concerns?

Question

A 35-year-old woman at 38 weeks gestation is admitted to the hospital after premature rupture of membranes at home.  The vaginal delivery is uneventful and the patient and newborn are doing well.  When the physician informs the patient that she will be discharged tomorrow, the patient says, "I am tired and was hoping I could stay in the hospital a little longer.  I have two kids under the age of 5 at home.  It will be overwhelming coming home with a new infant.  It would be so helpful to have an extra day or two to rest up.  Can you come up with a reason to keep me?"  Vital signs and physical examination are unremarkable.  The patient is not depressed.  Her insurance covers only a 2-day hospital admission for an uncomplicated vaginal delivery.  Which of the following is the most appropriate response to the patient's concerns?

Quizplus · Accepted Answer

Explanation: This physician is in the difficult position of trying to be responsive to the patient's needs while being asked to justify continued hospitalization in the absence of medical necessity. This mother could benefit from another 1-2 hospital days to fully recuperate. However, there are no findings of postpartum depression and she is medically stable and appropriate for discharge. Although the physician should be sensitive to this patient's concerns about feeling overwhelmed, he or she should explain that there is no medical reason to prolong hospitalization and that extra days would not be covered by her insurance. If the patient were to receive an unexpected bill from the hospital for an extended stay, this could cause additional and unnecessary stress. It would be inappropriate for the physician to invent a reason for keeping this patient in the hospital or extend her hospitalization without considering the cost (Choices B and D). Instead, efforts should be made to assist her on an outpatient basis by mobilizing family support and/or having social work arrange for home services that might decrease her sense of being overwhelmed. (Choice A) This statement suggests that the patient has made an inappropriate request, and it may be perceived as judgmental and damaging to rapport. A better approach is to explain why insurance will not cover extra days and arrange for additional outpatient support if necessary. (Choice C) Requesting extra days that will most likely not be covered by insurance is inappropriate and could result in financial hardship for the patient. It is important to acknowledge the mother's concerns, explain that medically unnecessary hospitalization is not covered, and arrange for additional support at home. Educational objective: Insurance rules require that hospital level of care be justified as medically necessary; extended hospitalization for other reasons is unlikely to be covered. The physician should assist the patient in understanding these limitations and arrange for appropriate outpatient care. References: Safe start at home: what parents of newborns need after early discharge from hospital - a focus group study. (http://www.ncbi.nlm.nih.gov/pubmed/26955832)

A 35-Year-Old Woman at 38 Weeks Gestation Is Admitted to the Hospital