Locating hospital discharge

Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community or domestic environments. Reflecting this, hospital discharge is not an end point, but rather one of multiple transitions within the patient’s care journey.^14,48 The organisation and provision of this transitional care typically involves multiple health and social care actors, who need to co-ordinate their specialist activities so that patients receive integrated and, importantly, safe care. The inherent complexity of co-ordinating a large number of actors, often based in distinct organisations, leads to the view that hospital discharge can be a vulnerable, time-dependent and high-risk episode in the patient pathway.

A prominent example of this complexity is ‘delayed discharge’, where the patient remains in hospital because of the failure to appropriately co-ordinate care between agencies.^27,48 According to Victor et al.,⁴⁹ nearly 30% of older people experience some delay in their hospital discharge, which is known to expose patients to additional hospital-related risks, create emotional and physical dependency, incur additional hospital costs and restrict the availability of inpatient beds. In parallel, premature discharge or discharge without appropriate arrangements for onward care can also lead to complications for patient recovery. For example, the 28-day readmission rate for older people has doubled from 103,000 in 2001–2 to 201,000 in 2010–11,^50,51 suggesting that more needs to be done to support patient recovery following acute care.

The problems of delayed or poorly planned discharge illustrate the broader challenge of integrating health and social care.²⁷ Analysing the causes of these delays, Tierney et al.³¹ point to a range of common factors, including (a) poor communication between health and social care; (b) lack of assessment and planning for discharge; (c) inadequate notice of discharge; (d) inadequate involvement of patient and family; (e) over-reliance on informal care; and (f) lack of attention to the special needs of vulnerable groups.Indications For Hospitalization Or Discharge Essay.  Reflecting this and other evidence,²⁷ policies have repeatedly sought to improve discharge planning, especially the integration of health and social care agencies. A review of these initiatives is outlined below.

Discharge planning

Improved ‘discharge planning’ has been a consistent recommendation of policy and research.^27,52–54 Over the last two decades, the precise form of discharge planning guidelines has varied to reflect wider health and social care reforms, changing economic imperatives and emerging concerns about care quality.^55–58 Furthermore, they have been developed both locally, by individual care organisations, and nationally, for example by the NHS Institute for Innovation and Improvement, and there is no commonly agreed model. Despite efforts to promote discharge planning, the recent European HANDOVER study found that health-care professions still did not prioritise discharge planning or interagency communication as supporting enhanced discharge.⁵⁹ In 2010, the Department of Health published its new discharge workbook, Ready to Go? Planning the Discharge and Transfer of Patients from Hospital and Intermediate Care,³⁰ which outlined 10 ‘steps’ to ensuring a timely, safe and patient-centred transition from hospital, including:

• effective communication with individuals and across settings
• alignment of services to ensure continuity of care
• efficient systems and processes to support discharge and care transfer
• clear clinical discharge management plans
• early identification of discharge or transfer date
• identified named lead co-ordinators
• organisational review and audit
• 7-days-a-week proactive discharge planning.

Effective discharge planning is usually associated with a number of common activities and procedures along the care pathway:^14,30

• On admission Prepare detailed and accurate patient record; review assessment information and estimate date of discharge with reference to standard care pathway and complexity of patient circumstances.
• During admission Undertake regular multidisciplinary assessment of patient condition to identify and assess opportunity for discharge; discuss with patient and family ongoing and continuing needs. Indications For Hospitalization Or Discharge Essay.
• At least 48 hours prior to discharge Inform MDT about estimated date of discharge and review assessment criteria; initiate referrals to community health-care providers and social care agencies; contact agencies responsible for ordering and/or installing patient equipment or home modification; social work/care assessment and referrals; complete referral for social care; finalise care package; order take-home medicines; arrange transport.
• Day of discharge Contact family and carers to confirm follow-up care arrangements; check documentation completion; issue discharge letter to general practitioner (GP); reinforce patient behaviour recommendations and rehabilitation; confirm and finalise transport.
• Follow-up care Initiate social care package and continuing health-care package, where relevant in consultation with GP.

As these policies suggest, a number of specialist roles and activities are promoted as supporting the integration of different agencies. A longstanding objective has been to promote the use of MDTs in discharge planning.^14,53 These are normally organised as formal, usually weekly, meetings between relevant health and social care specialists with the aim of supporting timely communication, inclusive decision-making and continuity of care. Research often describes MDTs as comprising a core team including the named doctor and nurse, occupational therapists (OTs) and physiotherapists (PTs), and representatives from community and social care agencies, as well as family representatives, GPs and other specialist therapists. According to Bull and Roberts,⁵² MDTs help break down barriers between professional groups and foster a sense of common purpose and trust. Importantly, MDTs provide an opportunity for communication, first between professionals, second with patient and family, and third with community health-care providers. Furthermore, MDTs can help make clear the lines of responsibility for different tasks and create opportunities for individuals to take the lead in co-ordinating the planning process. In practice, however, convening all representatives for individual patients can be challenging in terms of time or resources.²⁷

A further initiative has been the introduction of discharge co-ordinators.^14,30 These are individuals, usually experienced nurses, who take lead responsibility for both strategic planning and co-ordination of discharge at the interorganisational level.⁶⁰ Research suggests that discharge co-ordinators can improve hospital discharge through supporting the integration of different professionals, overseeing and directing planning and addressing emergent problems in a more responsive way.⁶¹ In particular, co-ordinators acquire both deeper understanding of and extended relationships with a wider range of care agencies that help them better navigate and align divergent ways of working that usually delay or undermine discharge.^52,61,62

Integrating care services

In line with the developments in discharge planning, policies have also introduced new or extended statutory powers, financial opportunities and penalties to support more integrated discharge pathways. For example, the Health Act 1999⁶³ enabled health and social care agencies to pool resources to codeliver rehabilitation services. Similarly, in 2005, delayed discharge grants were made available to social service authorities across England to develop reablement services. Indications For Hospitalization Or Discharge Essay. In contrast, the Community Care (Delayed Discharges) Act (CCDDA) 2003⁶⁴ addressed the problems of integration by allowing hospitals to claim financial reimbursements from local authorities where they delayed discharge by not providing timely services. Against this backdrop, a variety of integrated services and new care pathways have emerged to support the transition from hospital to community, but in doing so have extended (and made more complicated) the range of services involved in discharge planning.

One significant development has been the introduction of ESD. ESD is often associated with the care and rehabilitation of mild-to-moderate stroke patients. It enables patients to return home early with a dedicated package of rehabilitation and reablement of a similar intensity to that provided by inpatient care. ESD is shown to reduce the burden on acute providers and support patient recovery.⁶⁵ The funding of ESD through joint commissioning between the acute NHS providers, GPs, social services and central government highlights the role of joint working and resource pooling, but there remain variations across the UK, especially in rural areas, where a lack of funding can limit provision.^66,67

Intermediate services provide transitional, ‘step-down’ care between acute hospital and the domestic environment (usually for 30 days). Patients are typically declared as ‘medically fit’ but requiring ongoing care or rehabilitation, for example those at risk of readmission or with complex care needs. Rather than receiving rehabilitation at home or in hospital, intermediate care offers a form of residential, hospital-like care, but with a focus on rehabilitation. Research suggests that intermediate care services have been effective in both reducing financial costs and improving patient outcomes.⁶⁸ Owing to their close proximity to patients’ homes and relatives, community (NHS) hospitals or nursing homes are often used for intermediate and post-discharge rehabilitation. Stays in such units can be longer than in other intermediate care services, yet research suggests patient outcomes are generally favourable.⁶⁹ The recent Cochrane reviews of long-term rehabilitation in care homes show no evidence of negative health outcomes.^65,70

A similar initiative is the introduction of reablement services. These usually involve a dedicated package of social care to support daily living in the immediate period following discharge (e.g. personal care, cooking and cleaning). They are usually managed and provided by local authority social services, although in some cases they are funded through both health and social care budgets. In 2012, the Department of Health allocated £150M for reablement linked to hospital discharge,³⁰to be allocated through primary care commissioners working in partnership with social care authorities. Significantly, these services are normally arranged and provided by social services to ease transition from hospital for a period of 4–6 weeks, with the expectation that ongoing social care will be reassessed and provided by other agencies. Indications For Hospitalization Or Discharge Essay.

A further example of service innovation, with particular reference to end-of-life care, is the introduction of ‘fast-track’ discharges. This normally relates to supporting early discharges from hospital for those patients wishing to spend the last days of life in the community with palliative support. This end-of-life discharge can exemplify effective joint working and rapid prioritisation, whereby the patient can be discharged within 48 hours with all specialist support and medications in place.⁷¹ For example, funding decisions are established post discharge to remove delays; the needs of the patient and family are met by deliberate use of a continuous dialogue with one specialist co-ordinator; and the emphasis is on timely collaborative working to ensure the patient gets home as requested.⁷²

The threats to ‘safe discharge’

Multiple sources of evidence suggest that care quality can be suboptimal in, or as a consequence of, hospital discharge.²⁸ In a major telephone survey of 400 patients following discharge, Forster et al.¹⁷ found that nearly 20% reported some form of adverse event, of which 6% were preventable and 6% ameliorable. Research highlights a number of common discharge-related risks associated, for example, with the management of medicines, the provision of appropriate health and social care, incomplete tests and scans, the fitting and use of home adaptation, and the risks of falls, infections or sores.^17–28 The underlying sources of these risks can range from factors related to the patient’s condition or comorbidities, to the assessment of patient need, the availability of specialist resources in the community, and wider organisational and cultural factors. Indications For Hospitalization Or Discharge Essay. For example, research shows that the patient’s condition, such as hip fracture, and other comorbidities, especially cognitive function and fragility, can represent a cluster of risks, particularly for older patients, that can complicate the discharge process.^73,74 Research also suggests that time of day, week or year can also have an impact on discharge planning and quality. In particular, discharges during the weekend have been shown to increase the likelihood of death compared with those taking place between Tuesday and Friday, accounting for 34% of all post-discharge deaths.^75,76

Although studies highlight the importance of clinical risk in discharge planning, it is not always clear how ‘risk’ is measured. Moreover, the causal analysis of risk is often implicit or an emergent feature of wider trial research. Reviewing the recent literature (Table 1), a number of risks (direct threats to safety) and identified causes (suggested or inferred) are catalogued.

Although the sources of these risks can be complex and variable, research frequently highlights incomplete, inaccurate and inaccessible information as undermining collaborative workings and contributing to unsafe patient discharge.^{27–29,86,87} A systematic review conducted by Kripalani et al.²⁹ found that communication between hospital and family doctor was often partial or missing, relying primarily upon discharge summaries which were often incomplete, lacking in detail and not provided in a timely manner. Similarly, poor communication between the hospital and social care providers is a long-standing risk factor in adverse events.^27,29,88 There remains little extensive research, however, examining the causes of poor communication and adverse events.^29,89 Less is known about how communication breakdowns and patient safety are experienced by patients and carers.⁵⁴ A number of studies propose, and in some cases evaluate, interventions to support communication and information transfer at discharge, including structured communication tools, discharge planning guides, discharge checklists, medicine reconciliation guides and patient education strategies.^84,90–94 These suggest that effective discharge planning depends upon effective communication and collaboration between health and social care agencies.^28,86,95 In his analysis of the factors that support or hinder such communication and collaboration, Glasby²⁷highlights three dimensions:

• occupational factors related to the particular knowledge, cultures and practices of different professionals
• organisational factors related to the working patterns, capabilities and resources of different agencies
• compatibility and co-ordinating factors related to how occupational and organisational factors are aligned, or differences reconciled.

Attention to these and other factors is needed to better understand and enhance communication and collaboration in discharge planning and care transition. Furthermore, greater appreciation is needed of how communication might undermine not only co-ordination but, in turn, safety. In this sense, communication might be seen as a latent (or active) factor that influences the safety of hospital discharge. The next section develops this idea through relevant theory and research on organisational complexity and safety. Indications For Hospitalization Or Discharge Essay.

The systems approach to patient safety

Current thinking in patient safety is largely informed by theories and research within the fields of ergonomics and human factors. In broad terms, this suggests that performance mistakes are not necessarily brought about by individual negligence, malice or incompetence, but more often by pressures located within the work environment.⁹⁶ This line of reasoning makes the distinction between ‘active’ and ‘latent’ errors. The former refers to individual slips, mistakes or omissions that lead to patient harm; the latter to the unsafe conditions that create, enable or exacerbate the potential for active error or patient harm. This can include poorly designed working arrangements, poor defence and early-warning mechanisms or an over-reliance on automation. This approach suggests that risk reduction should attend, not to individual performance alone, but to the upstream factors that make performance error prone, for example by standardising task design, improving team cohesion and communication, alleviating situational ambiguity and recognising the influence of resource management and culture.⁹⁶

This ‘systems approach’ to patient safety has been articulated through policies such as To Err is Human¹ and An Organisation with a Memory,² and developed through major programmes of applied health research.³ For example, it has been used to highlight how a range of ‘task’, ‘team’, ‘situational’ and ‘organisational’ factors contribute to front-line clinical safety.⁹⁷ Of specific relevance to this study, this conceptualisation of safety draws attention to the way health care is organised and delivered through a system of interdependent elements interacting to achieve a common goal.¹ Based upon these ideas, various strategies have been promoted to better understand and address the threats to patient safety.Indications For Hospitalization Or Discharge Essay. These include, for example, the use of incident reporting procedures to enable clinicians to share their experiences of clinical risk and engender system-wide learning of the root causes;^98,99 the creation of a safety culture that is mindful of danger, blame free and responsive to organisational learning;¹⁰⁰ and a variety of safety-enhancing interventions, such as ICTs or single-use devices which limit unsafe behaviour; checklists, guidelines and the standardisation of practices to reduce variability; and staff training and culture change activities.³The ‘human factors’ approach provides a framework (drawing on Vincent¹⁰¹) for conceptualising and investigating the threats to safe discharge (Table 2). Indications For Hospitalization Or Discharge Essay.