Practice Competent Novice

Planning a patient’s discharge from hospital

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a2694 (Published 12 December 2008) Cite this as: BMJ 2008;337:a2694
  1. Srinivasa Vittal Katikireddi, specialty registrar in public health medicine 1,
  2. Geoffrey Christopher Cloud, consultant physician in geriatric and stroke medicine2
  1. 1NHS Lothian, Edinburgh EH8 9RS
  2. 2Department of Clinical Neuroscience, St George’s Hospital, London SW17 0QT
  1. Correspondence to: S V Katikireddi vkatikireddi{at}yahoo.co.uk

    Junior doctors have an important role to play in planning a patient’s discharge form hospital

    Summary points

    • Discharge planning aims to improve the coordination of services and care after a patient’s discharge from hospital

    • Good planning requires anticipation of potential problems by good information gathering, early resolution of potential barriers to discharge, and timely referral to the multidisciplinary team

    • Planning involves close collaboration between the patient, the family, and the multidisciplinary team; this leads to improved patient and carer satisfaction

    • The junior doctor is often an important coordinating link in the process of discharge

    Discharge planning is a process that aims to improve the coordination of services after discharge from hospital by considering the patient’s needs in the community. It seeks to bridge the gap between hospital and the place to which the patient is discharged, reduce length of stay in hospital, and minimise unplanned readmission to hospital.1

    Discharge planning is an established part of hospital care, but the process varies and is not entirely evidenced based. A Cochrane review analysed 11 randomised controlled trials looking at discharge planning in over 5000 patients and failed to show a reduction in mortality among elderly medical patients, lower readmission rates, or a shorter length of hospital stay.1 However, two trials in the review did report greater satisfaction of patients and carers when discharge planning was used.2 3 The Cochrane review concluded that discharge planning remains important as a small improvement, not detected by the studies performed so far, could still yield highly significant gains in health care with huge resource implications and better use of acute hospital beds.1 Unfortunately, none of the included trials assessed communication with primary care staff about patient transfer of care. This is an important aspect of discharge planning and another potentially important advantage for patients.

    How to do it?

    Preparing for admission

    Currently, little robust evidence exists on which to base recommendations for effective discharge planning. The Department of Health’s guidance for England (based on expert consensus and qualitative studies) says that planning for discharge from hospital “is a process and not an isolated event” and that this process should start at the earliest opportunity.4 For elective patients, it should start during the routine preparation for a patient’s admission—for example, at the preadmission clinic. For unplanned admissions it begins with the decision to admit a patient, and if admission is not necessary, alternatives such as interim care should be considered. See the scenario box (Case study part 1).

    After admission

    The Department of Health recommends (on the basis of expert consensus) that patients admitted in an emergency should have their discharge potential assessed during the clerking.4 Such an assessment requires detailed and systematic clerking in order to:

    • Identify the medical problems (acute, chronic, and inactive)

    • Assess the likely need of in-hospital treatment and its duration

    • Identify factors influencing a safe discharge with a thorough social history, including employment, accommodation, family circumstance, pets, mobility, ability to perform activities of daily living, and reliance on others for aspects of social care.

    Box 1 lists “red flag” warnings of a high risk of readmission. Once these difficulties are identified, a proactive response such as referral to social services, can be made early to minimise delays in hospital discharge. These decisions should be made in partnership with the patient whenever possible.

    Box 1 Red flag warnings for patients at high risk of readmission567

    Medical factors
    • Chronic obstructive pulmonary disease

    • Heart failure

    • Diabetes

    • Coronary artery disease

    • Advanced and disseminated malignancy

    • End stage renal failure

    • Dysphagia

    • More than three comorbid chronic diseases

    Psychosocial factors
    • Poor self rated general health

    • Moderate to severe functional disability (such as impairment of more than four activities of daily living)

    • Living alone

    Use of medical resources
    • More than six visits to a general practitioner in the previous year

    • At least one previous hospital admission in the previous year

    Patient characteristics
    • Age over 80 years

    • Male sex

    The Department of Health’s guidelines recommend that an expected provisional date of discharge should be set, whenever possible, on the day of admission and should be subsequently regularly reviewed.4 This can be difficult to achieve in practice as patients’ clinical situations can alter unpredictably. The expected discharge date is therefore usually set by a senior doctor, with regular review. See the scenario box (Case study part 2).

    Preparing for discharge

    The Department of Health guidelines suggest that preparation for discharge needs to involve health professionals, family members, social services, and the patient.4

    Staff involvement

    Increasingly, the process of discharge is coordinated by the discharge coordinator (a new post in health care), who is often recruited from a nursing or social services background. Discharge coordinators provide a single point of contact for all involved in the discharge planning process.4 In some hospitals, however, this planning role may still lie principally with junior members of the medical team or the ward sister. In either case, the consultant in charge of the patient’s care has responsibility for ensuring an appropriately safe and timely discharge or transfer of care to the community.

    Discharge planning requires effective multidisciplinary team working, and this is usually facilitated by weekly team meetings—which typically include medical, physiotherapy, occupational therapy, nursing, and social services professionals—to discuss each patient’s progress and the current obstacles to discharge.4 To participate fully in these meetings junior doctors need:

    • A good understanding of the medical problems of the patients in their care—including prognosis, ongoing treatments, and investigations that may influence functional outcome

    • An ability to communicate these points clearly

    • To appreciate the clinical roles of other team members, such as anticipating which patients may require a home visit from an occupational therapist.8

    Patient and family involvement

    Admission to hospital is a vulnerable time for patients and their families. As a result of illness patients often experience a loss of functional ability and require either a temporary or more prolonged increase in social support.

    For most patients the ideal situation is to return to their previous level of function (and their usual accommodation). However, the length of stay in an acute hospital bed is usually fairly short and may not be long enough to allow the full potential recovery of a patient. So in such a case, it must be considered whether a patient might benefit from a period of rehabilitation—either as an inpatient or in the community. Intermediate care—for patients not requiring general hospital resources but with needs outside the traditional scope of primary care—has become a popular model for delivering rehabilitation in the NHS and elsewhere.9

    The involvement of patients, carers, and families is crucial to successful and timely discharge planning.4 A survey by the charity Carers UK found that 43% of the 2.3 million carers in the United Kingdom felt inadequately supported when the person returned home.10 11 Topics that carers may want to be discussed before discharge include their role as a carer, the possibility of future respite, finances, and benefits.4

    Discharge destinations

    A patient who has had an irreversible loss of function may require additional support at home. This could be achieved by increased care services (via social services), compensatory aids or adaptations to the home informed by an occupational therapist’s assessment, community nursing input, or through the patient’s informal care network.

    Patients who can no longer manage at home may need long term care in a care home, but this should only be considered after a period of multidisciplinary rehabilitation team assessment and treatment. The process for this is outlined in the national framework for NHS continuing healthcare and NHS-funded nursing care, introduced in 2007.12

    Discussing such a proposition with a patient or their family requires great sensitivity, and the decision to discharge to a new residence is one that requires senior input. However, junior doctors often play an important role in collecting information that helps inform decision making, and box 2 gives some useful questions to ask the patient when making this decision; see also the scenario box (Case study part 3).

    Box 2 Practical tips on assessing function and determining appropriate discharge destination

    Assessing baseline function
    Mobility
    • Do you use any mobility aids?

    • How far can you walk?

    • Do you leave the house? Does someone always go with you?

    • Can you transfer from a bed to the chair by yourself or do you need help?

    • Can you climb stairs?

    • Have you fallen to the ground in the past year?

    Washing and dressing
    • Can you wash and dress yourself? What help do you need?

    • Do you wash in the bath or shower or do you have a strip wash?

    • Do you have any bathroom adaptations?

    Toileting
    • Are you able to take yourself to the toilet or do you need help? Do you use a toilet or commode?

    • Do you have problems with bowel or bladder control?

    Formal or informal care
    • Do you get any help at home? How often does the helper come and what do they help with?

    • Do you have relatives or friends who help you at home?

    • Would you like help at home?

    Household
    • Do you do your own shopping? Does someone help you or does someone do it for you?

    • Do you do the cleaning at home? Do you do your own laundry?

    • Is there anything you find difficult to do? Does anyone else help you and what do they do for you?

    Assessing appropriate discharge destination
    • Where does the patient want to live? (If he or she is unable to make competent decisions, discuss with the next of kin or advocate)

    • What level of mobility does the patient have?

    • What is the patient’s ability to perform activities of daily living such as washing, dressing, feeding, toileting

    • What formal and informal support is available for the patient?

    • What cognitive or behavioural problems does the patient have?

    • How much patient supervision is needed? Is this needed all the time or at specific times of day?

    • What is the patient’s home environment like?

    Discharge documentation and transfer of care

    The patient’s ongoing needs must be considered and provided for before he or she leaves hospital.4 This might entail arranging appropriate follow-up (in primary or secondary care); ensuring appropriate drug treatment (with details of indications, length of course, planned dose changes); noting specific warning signs and symptoms that should prompt immediate medical attention; and ensuring adequate support at home.

    A key aim of discharge planning is to provide good continuity of care to ensure good patient outcomes, hence effective handover to primary care. This is most often achieved through the immediate discharge document.13 Limited data are available on discharge documentation, but recent audits have shown that key facts and data such as follow-up arrangements, new diagnoses, and accurate medication lists are often omitted.14 15 16 The Scottish Intercollegiate Guidelines Network (SIGN) has recommended that senior staff should approve every immediate discharge document.13 Box 3 outlines the recommended minimum content for discharge documentation. In complex or unwell patients, contacting the general practitioner, community matron, or specialist nurse before discharge may be necessary to ensure an effective handover. See also the scenario box (Case study part 4).

    Box 3 Important items for inclusion in discharge documentation13

    • Discharge diagnoses

    • Discharge medications, including their indications, length of course, planned dose changes

    • Therapeutic procedures

    • Complications

    • Outstanding medical or social issues at discharge

    • Consultations during admission

    • Follow-up arrangements

    • Community services arranged

    • Prognosis

    • Functional ability

    What are the challenges?

    On a patient’s initial contact with health services, discharge planning should be started.4 This is often difficult to achieve when acutely unwell patients are admitted as a thorough social history may not be immediately available without a collateral history from a relative or primary healthcare provider (who may be difficult to contact). Taking a comprehensive social history is often thought to be time consuming but can be obtained quickly through the use of systematic open questions (see the four scenario boxes).

    Effective discharge planning requires multidisciplinary team working. This can be difficult to coordinate because of shift work, ward transfers, staff illness, and perhaps poor team communication. To overcome this problem, an adequate handover—oral, written, or electronic—is key. Sometimes disagreements arise in the team about the most appropriate course of action, but this can usually be resolved through the involvement of a more senior member of the medical team.

    Clear sensitive communication with the patient and family is pivotal, especially for the patients who experience a considerable new loss of function. Patient confidentiality cannot be neglected, however, and permission needs to be sought from a competent patient before information is divulged to a family. Relatives will sometimes disagree with the patient’s or team’s views about the most appropriate discharge destination.17 Listening to the relatives’ concerns is especially important in these situations as a compromise is often possible; however, it is the competent patient’s wishes that are paramount. Often asking patients and families for their opinion on the best and safest place to stay and then subsequently considering potential difficulties on discharge can yield the best outcome. Serious disputes should involve the consultant responsible for the care of the patient.

    Handover to primary care is easily neglected as it may be perceived as low priority compared with treating unwell inpatients. Early completion of the immediate discharge document can prevent pharmacy delays, and vigilance is needed to ensure effective follow-up and handover—such as ensuring that follow-up is booked before discharge, oral information is given at handover of patients to primary care, and immediate discharge letters leave with patients.

    Case study: part 1

    Mr Yorke is a 76 year old man with chronic obstructive pulmonary disease who presents to hospital with increasing dyspnoea, sputum production, and reduced exercise tolerance. Mr Yorke’s presentation with an acute exacerbation of chronic obstructive pulmonary disease is deemed too severe for “hospital at home” treatment, and he is therefore admitted to the medical admissions unit for inpatient treatment. You are the junior doctor in the team looking after him. Controlled oxygen, nebulisers, steroids, and antibiotics are started.

    Case study: part 2

    You determine that Mr Yorke’s acute medical problems are an infective exacerbation of chronic obstructive pulmonary disease, and other chronic medical problems include osteoarthritis of both hips. His previous appendicectomy many years ago constitutes an inactive problem.

    After starting some early medical treatment to stabilise Mr Yorke, you ask him, “How are you managing at home?” He admits that things have been “difficult” over the past few months. When asked what’s been most difficult, he replies “I can’t climb stairs any more.” Further questioning (“What makes stairs difficult?” and “What has this stopped you from doing?”) reveals that worsening breathlessness and some hip pain, previously diagnosed as arthritis, means he has had to sleep downstairs for the past two months and hasn’t had a “proper bath” in months.

    You then ask, “How do you manage with cooking and cleaning?” He admits to problems here too, and says that his nephew—who is his only family—visits weekly with shopping and the occasional meal, although he is very busy with his own young children and work.

    As this patient has severe chronic obstructive pulmonary disease, with considerable functional disability, lives alone, and is a male, you believe he will be at high risk of readmission (see box 1). You think that he may benefit from increased support at home as he struggles with household chores.

    The consultant reviews Mr Yorke on the post-admission ward round. He notes the above social history and asks you to speak to the patient and his nephew further to find out where Mr Yorke’s preferred residence would be and if he would be willing to consider accepting help from social services. The consultant sets an expected date of discharge for five days’ time.

    Case study: part 3

    You ask Mr Yorke whether he thinks he can still manage alone at home and whether he would prefer to live elsewhere. He tells you that he would strongly prefer to be at home but would be very keen to receive further help—especially with the cooking and cleaning. Later that day, Mr Yorke’s nephew approaches you to speak to him and his uncle together. After gaining permission from Mr Yorke, you find out that the nephew is very concerned that his uncle (and he) may not be able to cope if he returns home. You then tell them that you will make sure that everything is done to make Mr Yorke as safe as he can be when he leaves hospital. You explain that the team will investigate potential options for extra help at home, such as a home help service for household chores and shopping and meals on wheels, all normally organised through social services. You also inform them that the occupational therapist may be able to help organise a more comfortable and practical downstairs living environment for Mr Yorke, possibly with home adaptations. They are both keen for these referrals to be made.

    At the weekly multidisciplinary team meeting the next day, you explain to the team that Mr Yorke has had a serious exacerbation of his chronic obstructive pulmonary disease but the medical team believes his respiratory function is improving and he will recover further over the next few days as his medications are optimised. You ask the physiotherapist for help to improve mobilisation, especially in view of his osteoarthritis. You also mention his living arrangement, and his nephew’s concerns about managing daily activities—the occupational therapist and social worker agree they need to review him in the next couple of days.

    Case study: part 4

    Before discharge, Mr Yorke’s discharge medication is arranged in a dosette box for ease of administration and his inhaler technique is checked. You complete an electronic discharge summary giving the discharge diagnoses (“infective exacerbation of COPD [chronic obstructive pulmonary disease]” and “bilateral hip osteoarthritis”), a full list of medications (including doses and course lengths), and the interventions in hospital. His outstanding problems are described as “COPD (medically optimised), limited mobility due to COPD and bilateral hip osteoarthritis (optimised with analgesia, physiotherapy, and a walking stick), and the need for support with household tasks (arranged through social services).” It explains that Mr Yorke is being discharged to independent, single level living at home, after modifications, and it details the home support and follow-up that is arranged (including outpatient pulmonary rehabilitation).

    The summary is sent to the general practitioner and community respiratory nurses, who plan to follow him up in the community.

    Notes

    Cite this as: BMJ 2008;337:a2694

    Footnotes

    • This series aims to help junior doctors in their daily tasks and is based on selected topics from the UK core curriculum for foundation years 1 and 2, the first two years after graduation from medical school.

    • Contributors: Both authors were involved in the conception and design. SVK wrote the first draft, and both authors have been responsible for redrafting and revising the article critically for important intellectual content. Both authors have approved the final version to be published. SVK is guarantor of this article.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; externally peer reviewed.

    • Patient consent not required (patient anonymised, dead, or hypothetical).

    References