The key failings that cause delayed discharge and, therefore, contribute to increasing pressures on NHS hospitals have been identified by nursing researchers.
The nurse leading nationally-important research told Nursing Times that poor communication and lack of social care support were among the key problems preventing the timely discharge of hospital patients.
Delays in medication, equipment and transport are also important factors, said Candice Pellett, who is leading the Department of Health-funded study on discharge planning for the Queen’s Nursing Institute.
It was sparked by a QNI report on the future of district nursing, published in 2014, which identified problems with discharge planning as a key concern among community nurses.
Ms Pellett, a district nursing expert and Queen’s Nurse, has reviewed previous research, carried out focus groups with community nurses and surveyed both community and hospital nurses in an attempt to identify barriers to effective discharge planning.
“There is a lot of work to be done around communication”
Having now pulled together her interim findings, she told Nursing Times the number one problem highlighted by nurses was poor communication.
“Communication is up there at the top,” she said. “That is between hospital and community, community and hospital and with social services. There is a lot of work to be done around communication.”
Meanwhile, both hospital and community nurses said lack of social care packages caused delays. It was almost always the cause, according more than a third of both hospital and community practitioners. Lack of appropriate and timely social care arrangements was a particular issue in rural areas, said Ms Pellett.
Other factors causing delays included lack of transport to take people home, medication not being ready and problems with equipment.
Community home district carer hoist elderly
“This is about getting the appropriate equipment into a person’s home in a timely manner, so if they need a hospital bed, pressure relieving mattress, hoist or commode it’s in the house before the patient is discharged home,” said Ms Pellett.
Her findings suggest older patients are more likely to be affected by delayed discharge, with 76% of community nurses and 54% of hospital nurses pinpointing 75- to 84-year-olds as the age group most likely to be affected. In addition, 60% of community nurses and 40% of hospital staff felt those aged 85 and over were more likely to experience a poor discharge process.
Meanwhile, more than half of community nurses said patients were more likely to be discharged on a Friday, making it harder to ensure support services are in place. In contrast, less than a third of hospital nurses said Friday was the most likely day, with 61% reporting discharge days varied.
The research has also uncovered poor understanding of the role of district nursing services and issues with inappropriate referrals. For example, a common theme was district nurses being asked to administer medication that patients were perfectly capable of doing themselves – such as doing home visits to give insulin injections to diabetes patients.
With the right support while in hospital, Ms Pellett said patients could also learn to administer new medication themselves, which helped build their confidence and avoid the disruption of multiple home visits.
Top district nurse to lead ‘nationally important’ discharge planning work
“There’s quite a lot of evidence coming through that people go into hospital that were independent and come out dependent on district nurses, when maybe they could have started to self-administer on whilst on the ward,” she said.
While the focus of the project is on community nurses, Ms Pellett said it was important to include the perspective of hospital colleagues too.
“This project is about how we can make it better for the patient, family and carer, so it is not about what the hospital does wrong and what community do wrong – we’re all in this together,” she said.
“What is clear is hospital colleagues are saying more or less the same as community nurses and appear to be struggling with the same difficulties,” she said. “They are also frustrated their patients have to wait for medicines to take home or sit there waiting for transport.”
“What is clear is hospital colleagues are saying more or less the same as community nurses”
Mr Pellett told Nursing Times she hoped to publish a final report on her findings within the next six weeks, which will also include a series of recommendations and examples of best practice.
She said one model that had stood out was the Discharge to Assess, or D2A, approach advocated by NHS England, which enabled medically fit patients to be discharged and have their ongoing support needs assessed at home.
She added it was vital to share experiences of what really worked when it came to solving some of the problems her study had highlighted.
“District nurses are so caught up with what we do day-to-day that sometimes we don’t step back to consider what other areas are doing, how we can share best practice, learn and benchmark performance,” she said.
“This new research is so important because it creates an evidence base about how services need to change and develop”
Dr Crystal Oldman, chief executive of the QNI, added: ”Our 2020 Vision Five Years On report showed that a large majority of District Nurses were unhappy about current hospital discharge procedures. This new research is so important because it creates an evidence base about how services need to change and develop, in order to meet the needs of patients in future.
“It is vital that we get hospital discharge right, in order to prevent unnecessary readmissions, minimise discomfort and risk, and ensure that patients can be cared for in their own homes wherever it is safe and appropriate to do so,” she said.
Alongside the discharge planning project Ms Pellett has been conducting a separate DH-funded study on the value of the specialist district nurses qualification, which is also due to be published soon.