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Views And Reviews Acute Perspective

David Oliver: Misusing the “criteria to reside” for hospital inpatients

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3747 (Published 29 September 2020) Cite this as: BMJ 2020;370:m3747

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Linked Opinion

Discharge “criteria to reside:” policy lever or blunt instrument?

  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter @mancunianmedic

We now face a potential second wave of the covid-19 pandemic and a backlog of elective work, and it is critical to avoid overcrowding and pressure on beds to prevent cross infection and further cancellation of services. Whose job is it to decide when patients are ready to leave hospital, with their families and community services able to support them? Recent guidance from NHS England on hospital discharge for all NHS trusts and social care staff goes further than ever.1

The government has provided an additional £588m (€640m; $750m) funding, via the NHS, to help cover the cost of recovery and support services, rehabilitation, and care for up to six weeks after patients’ discharge from hospital. In return, it expects action to help keep hospital beds free for patients with the most pressing needs. The new guidance revolves around a “discharge to assess model” that channels patients who leave hospital into four indicative pathways. It also requires eligibility and financial assessments for social and NHS care continuing to take place outside the acute hospital setting, rather than have patients waiting in beds.

The operational guidance also sets out “eligibility to reside” criteria, instructing hospitals to review all patients twice daily against the criteria and to report their organisational data. Presumably this is for NHS England scrutiny of performance pressure and for ministerial assurance on value for emergency funding.

The use of such criteria gets dangerously close to systems where insurers call the shots on how long patients are “allowed” to stay in hospital, although we already use so called trim points in tariffs in England,2 to exert some pressure, and until covid-19 hit we were reporting data on “delayed transfers of care.”3

The model also pushes problems out of hospitals and on to community services and primary care (which is not receiving any of this uplift). Beyond six weeks after discharge, it will create further demand for social care in a system that is already struggling for resources and staff.4 And where does it take account of outcomes after leaving, such as emergency readmissions to hospital, whether patients make it back home, or their experiences of rushed or pressurised discharges? Clearing hospital beds cannot be an end in itself.

Most of all, though, the “criteria” are pretty restrictive. There are some “get-outs” in the form of a NEWS (national early warning score) greater than 2 or 3 for some patients and “acute loss of function beyond the community’s capacity,” which will probably be catch-alls for many patients.

However, NEWS was designed not as a triage tool for fitness to leave hospital but as a way to recognise physiological deterioration for early intervention.5 You could have a NEWS of 1 and still be far from optimised or one of 4, owing to chronic illness, and be fine to leave. We know from national clinical audits that we lack capacity in intermediate care rehabilitation services outside hospital or in home care.6 And loss of physical or cognitive function is not an inevitable feature of ageing but standard in older people with poor physiological reserve and is symptomatic of reversible medical problems aided by rehabilitation and time.7

Other criteria for discharge in the guidance include staying longer than two days after lower limb surgery or three days after major abdominal or thoracic surgery. Demonstrably, not all of these patients are stable enough to leave hospital at that stage, and many have complications and comorbidities. Another criterion is people in the “last hours of life.” So if you are dying, which might take days, you have to leave whether or not you want this? Humanity, compassion, and person centred care surely count?

The criteria ignore many other valid reasons for staying in hospital a little longer. Examples include stress or ill health among carers, severe persistent diarrhoea or vomiting or acute metabolic disturbance, and an infectious disease that could infect others in the care home or community hospital.

Above all, the judgment as to who really is “medically optimised” enough to leave, and whose support arrangements at home are sufficient at that moment to give us confidence, is best made by the clinicians who are with that patient and their family daily and who know the circumstances and concerns.

This is not a matter for bureaucrats several steps from the bedside. The extra burden of data collection may distract local teams from their jobs and, perversely, stop them getting on with the actions that might help patients leave hospital. When things go wrong, any formal complaint or coroner’s verdict, or any negligence claim, will be answered by clinicians, not NHS England officials.

Footnotes

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