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REVIEW

Preventing unsafe discharge from hospital

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Patients and their families can have harrowing experiences after discharge from hospital; a Health Service Ombudsman report is calling for improved post-discharge support

Abstract

A recent report by the Parliamentary and Health Service Ombudsman revealed examples of poor hospital discharge to be considered in light of existing guidance. This article summarises the report’s findings and recommendations for good practice when discharging patients.

Citation: Oxtoby K (2016) Preventing unsafe discharge from hospital. Nursing Times; 112: 25, 14-15.

Author: Kathy Oxtoby is a freelance health writer.

Introduction

After a stay in hospital, it should be a relief for patients to return home but a report from the Parliamentary and Health Service Ombudsman (2016) describes extreme cases in which patients and their families have experienced serious problems while waiting for, or after, discharge.

Complaints about hospital discharge difficulties are rising. Across the NHS in England there were 6,286 complaints on admissions, discharge and transfer arrangements in 2014-15 – up 6.3% on the previous year (Health and Social Care Information Centre, 2015). The PHSO – the independent organisation that makes the final decision on complaints that have not been resolved by the NHS in England – investigated 221 complaints on this issue in 2014-15; this was up by more than a third on the previous year. The PHSO upheld, or partly upheld, over half of these complaints.

The PHSO (2016) report highlights the impact of poorly planned discharge in terms of patient outcomes and experience, and the distress it can cause families and carers. Published in May, it focused on nine cases drawn from recent complaints it believed best illustrated the gap between established good practice and actual experiences of leaving hospital; Box 1 summarises two of these cases.

The report made clear that early discharge without the right support can be as problematic for patients as unnecessary delays, and highlighted the consequences of health and social care organisations failing to manage patients’ discharge from hospital. By sharing these stories, the PHSO aims to shine a light on the failings seen, and help improve patients’ experiences.

Box 1. Cases of poor discharge planning

A woman died after being discharged too soon with severe stomach pain

Mrs T, who was in her late 90s, became ill at home. Her granddaughter called a GP, who diagnosed a bladder infection and also noticed that her stomach was swollen. She deteriorated overnight so her granddaughter called an ambulance, which took her to hospital. The ambulance crew also noticed her stomach was swollen.

At the hospital Mrs T was examined by a doctor who ordered a urine test but did not focus on her severe stomach pain. Mrs T was told she had a bladder infection; she was discharged and the doctor advised her to drink more fluids. Just after being taken home by ambulance, she collapsed and died in her granddaughter’s arms.

A post-mortem showed Mrs T had died from an infection in her large intestine and the tissue that lines the stomach; symptoms of both included abdominal pain. Mrs T was very unwell and had the doctor physically examined her stomach, it is highly unlikely that she would have been sent home.

A man died after a hospital failed to treat sepsis appropriately

Mr L went into hospital with a painful lump on his buttock. Tests showed it was infected and, while doctors tried unsuccessfully to remove fluid from it, they decided there was no need for it to be surgically drained. The hospital discharged Mr L home with antibiotics. He returned three weeks later with intense pain in his foot and was found to have sepsis, which had spread. He died four days later.

Mr L’s daughter complained to the hospital, because she felt more could have been done to treat and care for her father and that he should not have been discharged so soon. The hospital acknowledged the infection probably originated in the lump on Mr L’s buttock but felt this had been treated appropriately and the infection on his second admission was unlikely to have been caused by any treatment during his first.

The ombudsman found Mr L showed signs of sepsis on his first admission, so should have been kept in hospital and his lump surgically drained. Had he been treated appropriately, he may not have developed sepsis and died.

Source: Parliamentary and Health Service Ombudsman (2010)

Serious hospital discharge issues

The report identifies the four most serious issues regarding hospital discharge.

Patients discharged too early

The most fundamental decision clinicians need to make is whether a patient is medically fit to leave hospital. Mistakes made at this point can seriously compromise patient safety, leading to emergency readmissions and potentially avoidable death.

Patients not assessed or consulted properly before discharge

While patients may be “medically fit” to leave hospital, they may not be practically ready to cope at home. If a rounded picture of patients’ needs – including their mental capacity – is not established on admission and regularly monitored, they could be sent home alone, afraid and unable to cope.

Relatives and carers not told their relative has been discharged

Having a relative admitted to hospital can be very worrying. However, it can also be distressing to find out an older, vulnerable relative has been sent home alone, without the family’s or carer’s knowledge. When patients are discharged they may be unable to feed and clean themselves. Many relatives are carers, so failing to notify them can have a direct impact on the care they provide.

Patients discharged with no home care plan, or kept in hospital due to poor coordination across services

Lack of integration and poor joint working between, for example, hospital and community health services can mean patients are discharged without the home support they need. Equally, lack of coordination between health and social care services can lead to lengthy delays in finding suitable care packages for older people with complex needs; this means they can be stuck in hospital wards at the expense of their dignity, human rights and independence.

Improving discharge planning

The report highlights that there is no shortage of clear guidance on effective discharge planning. Examples of such are that from the National Institute for Health and Care Excellence (2015) and Tester (2016). However, the PHSO has dealt with cases it believes show clear examples of trusts and local authorities failing to implement guidance. The problems highlighted in the report reflect findings from other recent reports on hospital discharge and transfers. Healthwatch England (2015) reported that one in 10 trusts do not routinely notify relatives and carers that patients have been discharged, and one in eight patients did not feel able to cope at home post discharge.

Age UK (2015) stated that older patients spent 2.4 million days over the last five years “stuck in hospital beds” due to a lack of appropriate social care placements and support. According to the King’s Fund, “being discharged without proper support is an invitation to relapse, worsening of the condition and re-admission” (Maguire, 2015).

Based on its findings from case studies the PSHO has identified best practice to enable appropriate discharge (Box 2). It also calls for system-wide leadership and shared ownership across health and social care services to improve transfers of care from hospital. This approach would start with understanding the scale and root causes of failures.

The PHSO believes the Department of Health’s recent programme on improving discharge is a chance to address these problems. It brings together key NHS and social care organisations to develop a vision for improvement, to enable all health and social care professionals to put the needs of patients and their carers at the forefront of discharge planning. In developing that vision, the PHSO urges the DH and its partners to assess the scale of the problems highlighted in its report, to identify why they are happening, and to take appropriate action so all patients experience acceptable standards on discharge.

Box 2. Appropriate discharge

  • Start discharge/transfer planning on or before admission to anticipate problems, put appropriate support in place and agree an expected discharge date
  • Involve patients and carers in all stages of the planning, provide information and help them make care planning decisions and choices
  • Health and social care services should collaborate to manage all aspects of the discharge process, including assessments for social care, continuing healthcare and, where necessary, mental capacity
  • Community-based health and social care practitioners should maintain contact with patients after discharge, and ensure they know how to contact services when necessary
  • One health or social care professional should be responsible for coordinating a patient’s discharge (National Institute for Health and Care Excellence, 2015). He/she should be the central point of contact for other health and social care professionals, the patient and family during discharge (Department of Health, 2010)

Key points

  • Complaints about hospital discharge are rising according to the Parliamentary and Healthservice Ombudsman
  • Serious discharge difficulties include patients being discharged too early, and not being assessed or consulted properly beforehand
  • System-wide leadership and shared ownership across health and social care are needed to improve transfers of care from hospital
  • Discharge and transfer planning should be started before or on admission
  • Community health and social care staff should maintain contact with patients after discharge
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