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How can we improve patient experience of early discharge?

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12 August, 2013

A friend of mine recently had very major surgery and will require months of follow-up. Discharged after five days he came home feeling tired, unwell and unable to cope. He had concerns about pain, his wound, how much he should do and how quickly. After three days he was a nervous wreck and began phoning the hospital for support. His wife was equally anxious, bearing the burden of his worries and also her own concerns about his condition. For the first two weeks she felt she had taken on the role of the nurse.

Getting out of hospital quickly has clear gains for the patient and health services – reduced risk of infection, perhaps better sleep and food are all positives, but there is a trade off when things don’t go according to plan.

I felt my friend and his wife had probably been told everything before discharge but in the euphoria of knowing he was well enough to go home didn’t take it in.

When my friend’s wound started to leak they had to go back to the ward. When he felt very weak he was rushed back for blood tests and the burden fell on his wife to keep it all together. Not only did he feel worried each time he was called back in but it was also exhausting to travel to and from the hospital.

So I am left wondering if we send people home too quickly or whether support services are sufficiently developed to help those who do go home early to deal with problems as they arise.

The problems for so many patients are the simple things: When can I have a bath? What should I do if I feel unwell? How far should I walk?

They aren’t questions you take to the GP and I suspect many of us would not want to bother the ward by ringing up.

It seems to me that going home early is great if you feel you are getting better, but those who have major interventions need care to ensure their recovery is as free as possible from stress.

It would be great to hear about your experiences of discharging patients and how early discharge can be improved.

Readers' comments (21)

  • The services in the community to back up early hospital discharge simply do not exist. It is not the fault of the over stretched community staff, but the lack of resources and adequate staffing levels.

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  • all well and good if community services can be reinforced and there is assurance of adequate care.

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  • I work on a ward that has patients following major colorectal surgery, and we also have enhanced recovery, which in essence in the discharging of most patients between 3 & 5 days. I have lost count of the number of our patients who have been readmitted following discharge, and some have even gone on to have further surgery. We find that the majority of our patients if they are going to have complications develop them around about the 5th day, this is when most of them are going home, and yes I think the euphoria of going home makes them feel well enough to do so, but unfortunately it only lasts about as long as the time it takes for them to get home. Yes you are always going to get the odd person who does very well in a short period of time but the majority don't. It's false economy as when they are readmitted it usually takes longer for them to be discharged due to their anxiety levels and fear of events occuring as did on the first discharge. A few more days in hospital at first and they are then truly ready for discharge.

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  • Janet Edwards

    You say that you have "lost count" of the number of patients readmitted.

    The question is have you really been counting and keeping a record of readmissions ?

    Anecdote does no favours for patients!

    If significant numbers of patients are being readmitted the discharge policy needs urgent review !

    To undertake such a review requires reliable data !

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  • Jenny Jones
    Figure of speech really. as I do know that our enhanced recovery patients are being audited, as I questioned about this at the last meeting, and was told that there is somebody who is auditing readmissions, so hopefully this situation will be resolved, and maybe it will involve a review of the discharge policy. I agree with you that anecdote does not do the patients any favours, and can only hope that the audit will give us the reliable data to ensure this happens.

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  • The doctors, nurses and therapists on the ward should be able to tell patients such things as when to have a bath, what to do if they feel unwell and how far to walk post-op.
    When a patient undergoes surgery, or is in hospital for any other reason, isn't it just part of our job to ask them who will look after them at home, will they need extra help from the social services, assess if they need a district nurse etc. etc. Don't all patients get the opportunity to speak to doctors, nurses, therapists, pharmacists prior to discharge and get given post-op information leaflets any more?

    "early" discharge should not really be an option, surely patients should only be discharged when they are fit and ready to go.

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  • Anonymous | 15-Aug-2013 11:23 am

    I agree with you and we used to ensure all of this before discharging a patient when they were fit and well enough. We had weekly meetings with the social worker and OTs to discuss those due for discharge and who would need organised care and support at home.

    Imagine another European country with private insurance. A few years ago I spent Christmas day with a friend and her family keeping her company and taking in a picnic to supplement Christmas lunch. She wanted to be at home and her surgeon wanted her to stay in for more physio and to re-evaluate her at the end of the month. So disappointed though she was we made the most of it for her on Chrismas Day.

    On Boxing Day, during the consultant's absence the junior doctor came and booted her out against his previous advice as the insurance company refused to pay for another day, let alone until the end of the week or until she was fit enough to be discharged! The insurancce companies and not the consultants and GPs now have the final say.

    Her neighbour in the two-bedded room was an elderly lady and was doing well but they came and told her one day she was discharged as the insurance would not continue to pay for her hospitalisation. she lived alone and was still not 100% mobile after her hip or knee op and had not even received suffient warning for the care and support she needed to be organised for her at home! My friend, an HCA, who had got to know her and her limitations during their hospitalisation was very concerned about her.

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  • If there is a high re-admission rate in any speciality then shouldn't we be looking at the reasons why?
    Patients should be discharged home when they are fit to do so, I've had operations in the past and do feel tired afterwards for some weeks, isn't that normal really after an anaesethic and an op. I would expect the staff to have given me advice on post-op care, wound-care and what to do is I was worried about anything, I would also access as much information as I could find prior to having an operation. What to expect afterwards should be part of the pre-op assessment.
    I don't really know what an early discharge is, if staff and patients think they could recover better at home then they need the support available to allow that to happen safely, if it's not available then don't discharge patients.

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  • little sense in carrying invasive and costly procedures and failing to inform patients of the after care they need to do themselves. it happens all the time. perhaps it is just assumed they know or can find out themselves. I just ask and chase after people if necessary until I find out all I need to know. It can be confusing when members of the care team give different advice which can also happen.

    As above it is also good to get as much informaiton as possible before any procedure which can help to allay anxiety.

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  • As a Home Health nurse I believe that it helps to have a discharge planner in the hospital plan your discharge based on the physician's orders; and to be given a personalized discharge letter with specific instructions about what you can and cannot do and for how long.
    It also helps to have Home Health nursing visits for the first few weeks after surgery as they often/sometimes do in the US where I live.

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  • Your friend must be very grateful to have you as a nurse to help them, did you have any advice to offer Eileen and did you have to help your friends a lot?

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  • I am a district nurse and we do see patients in this situation some referred to us by the ward, some self refer. Unfortunately district nursing teams and skills are being cut as work that prevents readmission is not measured and the fragmented way in which the health service is run means each trust looks at its own individual budget and cuts services to save money for themselves without looking at the impact on other areas. I know from talking to DN trams in other parts of the country that they have already been cut and would not offer this service now anyway. We are moving from a can do service to a 'that's not in our criteria service' a qualified DN's are replaced with 'community nurses' and so called skill mix that actually equals skill dilution which is less appropriate in community where at any visit you need to be able to provide holistic care. I would suggest we audit prevention of readmission but we are far too busy ticking boxes these days. Targets now come first.

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  • I recently went in to support my elderly neighbours. The husband the main carer and 85 fell down the stairs and broke his collar bone. It was his second fall that week. His wife has severe Parkinson's and is housebound and walks with a stick. He too mobilises with a stick. They have no family so he went to a+e on his own while I stayed and cared for his wife. When I range the emergency department to tell them about his socialhistory they were not interested. When I voiced my concerns about how was he to care for his wife and himself I was clearly told he was medically fit for discharge and so would be coming home in a taxi in his dressing gown! When I asked if they could organise support for him and his wife at home the matron told me there was no access to support at the weekend, he would have to sleep downstairs in his chair. Being a nurse I was not happy and rang OOH to tell them of my concerns and ask for help. They were brilliant and sent the community nursing team into see us when he got home. They were appalled that he was discharged with no concern for his personal safety of that of his wife. When they gotmtomthe house he was unable to move from his chair and he had not been given any painkillers. If it hadn't been for the rapid response team he would have been readmitted or something more worse may have happened to him or his wife. I am so glad I rang OOH. The community sister told me they often pick up the pieces of poor discharge. I believe A+E was purely focused on 4hr target at the detriment to my elderly neighbour. As an ex A+E nurse i was ashamed and appalled that this had happened.

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  • Anonymous | 17-Aug-2013 12:12 pm

    I have just spent the day with my elderly neighbour who was been sent home this morning with a pneumonia and temp of 39.6 C. I spoke to the sister of the ward he was discharged from, to be curtly told that he was medically fit for discharge. We have just moved into the area and the patient's wife came to our door because they had spoken to my husband last week and he mentioned that I am a nurse. Again the OOH service have been contacted and my neighbour has just been readmitted to hospital, but only after a lengthy wait in A&E, a further wait in an acute admission area and, after 7 hours back to the ward he was discharged from!! The treatment this couple have received form the sullen-faced staff has been atrocious. Whatever the reasons for poor patient experiences, they are not helped by the miserable attitudes of those who exhibited poor judgement in the first instance. Today, I am embarrassed by the behaviour of some of my colleagues towards an 83 year old very ill man and his worried wife.

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  • anon 12.12 and 6.56
    gosh, you do sound busy looking after your neighbours.

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  • Anonymous | 18-Aug-2013 7:15 pm

    a very poor reflection on the NHS..

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  • Anonymous | 18-Aug-2013 7:15 pm
    from
    Anonymous | 17-Aug-2013 6:56 pm

    That's the first time in my career that it's happened. Like I said, we have just moved into the area and the desperate neighbour only came to our door because she knew I was nurse and genuinely didn't know what to do.

    I am an NHS nurse in a busy acute setting and have been for several decades. I am proud of the work I do and of the people I work with, because I know how hard we work day in and day out. So I have every right to be annoyed with those in the minority who cause such unnecessary and avoidable misery to patients. Because it doesn't matter how hard I and my colleagues work, my neighbour and her husband's experiences have been defined by the poor care they received.

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  • Anonymous | 18-Aug-2013 8:55 pm

    that doesn't alter the fact of the very poor care your neighbour received by the NHS for which, as you describe it, there is really no excuse at all and it is not the only incidence. Of course in some areas there probably still exists very good care as well,at least one would hope so, and, if you say so, I have no reason to doubt that you deliver it.

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  • Anonymous | 18-Aug-2013 10:19 pm

    "that doesn't alter the fact of the very poor care your neighbour received by the NHS....."

    That was my point!

    "Of course in some areas there probably still exists very good care as well,at least one would hope so..."

    And that's the trouble, isn't it? You make the assertion that good care is the exception. In which case I disagree with you. Good care is the norm, but doesn't seem to warrant any mention from most people. One incidence of poor care wipes out the many everyday examples of good care which go unremarked upon and unappreciated. That is why I am angry at these particular colleagues.

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  • Anonymous | 19-Aug-2013 7:35 am

    quiite agree with you and don't suggest otherwise. i am not responsible for what 'most people' mention.

    I am just disturbed by the attitude of the sister, and apparent lack of application of nursing knowledge, as you describe it and quite a few with such attitudes are reported in the media, having been bought up in a medical household with a very high sense of duty of care for others - including neighbours and friends often as a first port of call to our house for help or advice as they knew it was an 'open door'.

    I once had a colleague, a highly respected cleaner, on my team when I first started on my ward so I had little chance to get to know her well but saw her contact with patients. She was so professional and kind and one of the best 'nurses' I have ever seen. I wonder whether she was not a registered nurse in her own country but without a licence to practice in the hospital where she was working or maybe had taken this job because of family commitments. she was always the first to see if a patient needed a drink, to be made comfortable or report a change in their condition. she was an excellent communicator and not afraid of speaking to a doctor or the consultant.

    Very shortly after the birth of her second child she presented to A&E in the evening with a fever of 40 degrees and was sent home! The following day she was no better and consulted a doctor and was admitted to our ward and was dead within 40 hours of her admission leaving behind a toddler and a new born baby. That is something one never forgets and especially at the beginning of one's career.

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