I have three patients right now that I could discharge.
But I'm not.
See, the system here creates very perverse incentives. Our team is capped at a certain number of patients. You reach that cap, and they can't give you any new ones. So new ones end up with a different team. You discharge patients, and it frees up spots for new ones.
Every new patient you get means at least an hour and a half of work. Taking the history, getting the initial labs, figuring out the plan, seeing if they're stable. You get 4 or 5 new admissions in a day, and that's a full day of work on top of whatever you need to do for your patients that are still around. It means your work gets backed up, it means you can end up staying late, it can really make the day pretty impossible.
There's a point in the day after which you can't get new patients-- depends on the rotation, but usually 5:00 or 5:30-- patients who come in after then get processed by the night teams and then given out in the morning. This saves the day team a ton of time-- you come in, pick up your new patients, and they've already been worked up, you get to skip that hour and a half you'd normally have to spend on them.
So there's a great incentive to hold your discharges as long as you can. If you can wait to get rid of your patients until after the 5:00 admit clock rings, you don't have to do the extra work. The night team gets screwed, but at least you get to go home at a reasonable hour.
Of course, if the night team doesn't get to the new admission, you get them delivered to you first thing in the morning-- a patient who's been sitting in the ER all night, without anything done for them, waiting for a doctor to finally get to them.
But a new admit at 7AM is slightly better than a new one at 5PM, because you're there anyway. I mean, it screws things up for the rest of your patients, who have two extra hours to go downhill before you finally have time to come see them, new admit processed. But at least you can go home for dinner.
Everyone's always trying to push admits to the next team. No one wants to ever admit there's room on their team, or acknowledge they had a discharge. And, I mean, it doesn't really matter because the only people actually hurt are the patients. The patients who have to chill in their rooms for an extra 6 hours because I don't want to discharge them before 5:00, wondering why this is taking so long. And the patients who end up sitting in the ER all night because the night team was too busy with the leftover day admissions to ever get to them.
So if you're wondering why your discharge is taking 7 hours, that's the story.