Gathering, right from the time of admission, information that will be key for discharge is one of those ‘small things’ that can improve discharge from hospital, argues Liz Lees-Deutsch
The recent Health Service Ombudsman’s report into unsafe discharge from hospital demonstrates some serious failings into discharge planning from hospital for older patients. The process affects not only patients, but also their carers and family members. I do not think all the problems cited in the report are down to nurses. However, nurses must contribute to improving matters in future.
The four key issues cited in the report are:
- Patients being discharged before they are clinically ready to leave hospital;
- Patients not being assessed or consulted properly before discharge;
- Relatives and carers not being informed;
- Patients being discharged with no home-care plan in place or being kept in hospital due to poor coordination across services.
As part of my research into patient discharge and risk assessment, I have interviewed more than 50 people – patients and carers – who are capable and articulate, and were tenacious in contributing to discharge arrangements. They were keen supporters of nurses, but one overriding theme emerged: “If they had only asked us.”
There is no doubt that the challenges for nurses in discharging patients are increasing at a vast pace, fuelled primarily by “older old” patients, namely those aged over 85 years. These patients are the most complex and challenging to discharge from hospital.
Perhaps the way to view such patients is as “high value”, transforming the notion of the level of difficulty into the “value” of getting it right.
Nurses can make immediate improvements in practice. These need only be small for the overall impact to be large. Examples include gathering information about home circumstances on admission, establishing patient and carer preferences, and contacting relatives. These do not require additional resources; they do however require a change of culture, particularly in acute care.
Nurses in acute care and other admitting areas are responsible for information gathering from the outset of the process. The challenge is to assess patient discharge needs alongside acuity needs. To ensure safe and effective discharge, information and assessments contributing to discharge must be given equal importance as information obtained on admission. This will raise the profile of discharge practice.
The nurse is the patient’s advocate, which means nurses have a pivotal role in patient assessment. Moreover, nurses and other professionals in community settings must also contribute to assessment through the timely transfer of information to hospital. It is a two-way process.
We do not need to redesign the discharge process; we need to rethink the way we work. The discharge process is inextricably linked to the admission process, albeit conducted at different times and places.
Liz Lees-Deutsch is a final-year PhD student and consultant nurse in acute medicine, Birmingham Heart of England NHS Foundation Trust.
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