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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Department of Health (2010) Ready to go? Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care. London: DH.