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Practice comment

'Policy and practice must align to enable safe discharge at night'

We need national guidance on out-of-hours care to ensure people who are deemed fit for discharge are able to go home, argue Liz Lees and Philip Dyer.

It is going to be difficult to undo the damage to the reputation of hospitals from the recent press coverage of discharging patients in the middle of the night. older people, in particular, will be aghast to imagine patients being uprooted from their beds (while asleep) and sent home. But let’s take a reality check – this does not happen. In fact there are likely to be two distinct categories of patient who are sent home in the middle of the night.

The first group will be those who present to emergency care, later in the day, are acutely unwell, treated and so are medically fit for discharge. At this stage these patients will not have been admitted. They are fit enough for discharge without the need to occupy a bed overnight. A bed is a scarce resource. The second group is those who present to emergency care, are briefly admitted to an assessment bed, are fit enough for discharge and whose admission time and condition will indicate whether they are discharged or not.

Surely a person presenting to hospital with a presumed acute illness that is then excluded should not warrant an overnight stay. You are only a patient if you have an illness that needs treatment. As well as a bed being a scarce resource, the throughput of emergency patients is essential. For every new patient to be accommodated there has to be a patient discharged.

The two examples outlined mainly relate to patients discharged from an acute, emergency setting. Advance planning and communicating discharge decisions with family and relatives mitigates against inappropriate discharge from other areas of the hospital. National policy guidance suggests ten process steps underpin successful, safe, effective discharges from hospital (Department of Health, 2010).

New national guidance is urgently needed to provide clarity regarding the way in which hospitals operate “out of hours”. Current discharge policies may not be specific enough for some clinical areas where the impact of increasing patient throughput and changing working practices across 24 hours impact upon discharge planning. Policy and practice must align. We would suggest guidance could look like the following:

  • Frail older patients living alone should not be discharged home after 8pm;
  • Ensure consent to discharge the patient has been sought and that the family have been told.

Any guidance produced cannot constitute a set of rules and so should not be produced with a view to being rigidly applied. Interpretation of guidance will require an understanding of each case in context, which will include the time of the day – but “time” and “age” of the patient should not be considered in isolation of all other factors.

Patients are only patients when they are in hospital, when out of the hospital they are people, many of whom live and function well at home by themselves with different degrees of frailty. If a person has capacity and is fit enough for discharge, surely they should be able to go home whatever the time? Are we saying a 22-year-old man who has been investigated and found to have no acute medical problem cannot go home after dark?

And finally, it must be remembered that we all sleep much better in our own beds. So, promoting safe discharges in the evening is actually serving to promote a good night of sleep and is better for people.

Liz Lees is consultant nurse and clinical dean; Dr Philip Dyer is consultant (acute medicine and endocrinology); both at Heart of England Foundation Trust, Birmingham

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Readers' comments (4)

  • Thank you. This is a difficult area of practise.
    Just one anecdote:-

    An elderly patient presented to A&E in the early evening.

    The lady had fallen in her own home where she lived alone. She had no relative living in the immediate area and was not in receipt of any community services.

    On examination the lady it was found that the lady had sustained a Colles fracture to her right (dominant) wrist. The lady was otherwise fit had no pre-existing medical problems and did not take any medication.

    By the time this ladies fracture had been reduced (using a Bier's Block) and immobilised in a below elbow plaster cast it was almost midnight.

    Whilst this elderly lady was keen to go back to her home I and the A&E medical staff felt this was unwise.

    Then the argument began !

    We were told by the "bed manager" that requesting a bed for this lady was inappropriate as she "only" had a broken wrist!

    Eventually and after much "debate" the lady was found a bed at 3AM !

    The whole point relating this story is to underline and emphasise the fact that Nurses and Medical Staff are put under great pressure to "review! clinically legitimate decisions to admit.

    Guidelines exist but in the face of intransigent management clinical staff are bullied and in the case of junior staff can easily be forced into making unwise decisions about discharge.

    Unsuitable or offensive?

  • bit late to undo the damage that the media has done again. it's a shame that they are not given the facts before they publish their articles.

    Unsuitable or offensive?

  • I think that this is a superb article, and shows a sensitivity and well thought out approach to the discharge from hospital after hours, in particular from A&E departments during the night.

    My own A&E department has CDU beds we put patients on who require OT in the morning, or whom given the time of night and their age would be an unsafe discharge. But we must also respect a patients choice to go home, and i have discharged an 85 year old home at midnight, after all hospital is not prison, and she was competent to make the decision, and had appropriate family support to go home with at the time.

    Unsuitable or offensive?

  • If a patient is fit enough to be sent home after 8pm would have they not been fit enough at 4pm ? Or does the need for beds determine how fit you are to go home ? Do we care for the patient or the budget ? It must be a strain for any one under 50 but what must it be like for the elderly ? As for sending someone home after 11pm ?

    Unsuitable or offensive?

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