Ward round conflict: discharge, mobility, and a booked transport
You are a nurse on an orthopaedic ward. During the morning ward round, the consultant says to the team, “Mrs Bello can go home tomorrow if she’s mobilising.” Later, the physiotherapist tells you, “She’s not safe on the frame yet; she needs a second person and a slide sheet, and her blood pressure dropped to 88/50 when she stood this morning.” The discharge coordinator has already booked hospital transport for 10:00 tomorrow, and the family has taken a day off work. Mrs Bello’s daughter says, “We’ve bought a recliner chair and a commode.” Mrs Bello is 79, day 4 after a total knee replacement, on apixaban, with Hb 92 g/L. She is keen to go home and says she feels “fine.”
1. What is the main conflict, and what information is missing before a safe discharge decision can be made?
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Main conflict: the consultant has given a conditional discharge plan based on mobilising, but the physiotherapist’s assessment contradicts that condition. The discharge coordinator and family have acted as if discharge is confirmed. The patient’s own view (‘fine’) is not the same as a safe functional assessment.
Missing information
- A repeat lying and standing blood pressure, and whether the 88/50 reading was symptomatic.
- The physiotherapist’s formal recommendation: one-person versus two-person assistance, frame versus other aid, and whether a second assessment is planned.
- Haemoglobin trend and any signs of bleeding, especially on apixaban.
- The home layout: steps, toilet, bed height, and whether the recliner and commode are appropriate.
- The patient’s actual transfer and ambulation distance today, not her reported function.
- Who will be at home and whether they can provide the required assistance.
Reasoning: ‘medically stable’ and ‘functionally safe’ are different criteria. A discharge decision needs both, and the nurse should not resolve the conflict by choosing the most convenient version.
2. Who would you contact, in what order, and what would you say?
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Order
- Physiotherapist: confirm the assessment in writing and ask what would need to change for safe discharge. “You documented that she needs two-person assistance and had a symptomatic drop in BP. Can you confirm whether she is safe for discharge tomorrow?”
- Medical team/registrar: report the physiotherapy findings and the Hb 92 g/L, and ask for a medical review of the orthostatic hypotension and bleeding risk. Do not ask the consultant to ‘cancel discharge’ without giving the reason.
- Discharge coordinator: ask them to place the transport on hold pending review, so the family is not told to collect her prematurely.
- Family: give an honest update. “The team is reviewing her mobility and blood pressure today. We have not cancelled the plan, but we are not able to confirm tomorrow until that review is complete.”
Reasoning: clarify the clinical facts before changing logistics. The transport booking is not the decision-maker.
3. What would you document and escalate?
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Documentation
- The consultant’s exact conditional instruction and the time.
- The physiotherapist’s findings: two-person assistance, slide sheet, standing BP 88/50, symptoms.
- The patient’s stated wish to go home and her daughter’s preparations.
- Who was contacted, when, and what they advised.
- That transport was placed on hold and the family was informed.
Escalation: if the medical team does not review the orthostatic drop and the mobility plan before the discharge time, escalate to the nurse in charge and the treating consultant. The risk is a fall at home or during transfer, not just a delayed discharge. Document that the discharge decision remains unresolved until both medical and functional criteria are met.