Discharge assessment for frail older people in acute care is complex and slow. A discharge framework can help nurses integrate discharge guidance into daily practice
This article focuses on discharge planning for frail older patients who have had an unplanned admission to hospital and are subsequently discharged (or transferred) to another setting. It discusses current issues in discharge practice, briefly reviews the background policy to guide the discharge assessment of older people and examines challenges in discharging them from the acute setting. Finally, it uses an assessment framework to integrate current principles from national discharge guidance into practice.
Citation: Lees-Deutsch L (2016) A framework to discharge frail older people. Nursing Times; 112: 37/38, 11-13
Author: Liz Lees-Deutsch is a PhD student, funded by the National Institute for Healthcare Research, and consultant nurse in acute medicine at Heart of England Foundation Trust, Birmingham.
- This article has been double-blind peer reviewed
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This year the Parliamentary and Health Service Ombudsman (2016) published a damning report on problems experienced by older patients discharged from hospital. The case studies contained in the report included patients aged 80-93 years and factors relating to discharge problems included:
- Pressure on bed capacity;
- Failure to respond to patient and carer concerns;
- Inadequate assessment prior to discharge.
The main themes identified in the report were clinical and operational issues (outlined in Box 1).
Box 1. Issues identified by the ombudsman
- Patients discharged before they are clinically ready to leave hospital
- Patients not assessed or consulted properly before their discharge
- Relatives and carers not informed about discharge
- Patients discharged with no home care plan in place or kept in hospital due to poor co-ordination across services
Source: Parliamentary and Health Service Ombudsman, 2016
The National Audit Office (NAO) (2016) highlighted similar issues in its wide-ranging report on patient discharge, which looked at the entire health and social care system.
Most of the key points identified by the NAO (2016) link with the National Institute for Health and Care Excellence (2015) guidance on the transition of older people from hospitals to other settings. The guidance explores overarching principles of discharge practice for patients, carers and staff across the entire care pathway from pre-admission to post-discharge. The pathway is broken down into:
- Before – pre-admission strategies for prevention of admission to hospital;
- During – strategies for actively reducing the length of patients’ hospital stay;
- After – strategies to support care after discharge (NICE, 2015; National Audit of Intermediate Care, 2014).
The assessment for transition of older people from acute care using NICE (2015) principles is inextricably linked to the acute admission and discharge process, and executing this effectively can improve discharge planning (Lees, 2016).
Defining discharge planning
Discharge planning is categorised by the National Library of Medicine (2015) as “Patient discharge: The administrative process of discharging the patient, live or dead from hospitals or other health facilities.”
However, new terms are gradually being used in policy guidance and academic literature that reflect new services and the context in which they are delivered (NICE, 2015; NAIC, 2014). In particular, ‘transfer of care’ is being widely adopted across areas where older people are assessed or admitted. This term generally refers to patients moved from hospital to another care environment (possibly an intermediate stage prior to an end point) (NHS England, 2015; NAIC, 2014). Conversely, ‘discharge’ is usually the final stage before a preferred end point in a care pathway where no further transfers of care are needed.
Goncalves-Bradley et al’s (2016) definition for discharge planning is considered to better represent current practice as they replace the word ‘discharge’ with the word ‘leave’ to describe a discharge from hospital.
“Discharge planning is the development of a personalized plan for each patient who is leaving hospital, with the aim of containing costs and improving patient outcomes. Discharge planning should ensure that patients leave hospital at an appropriate time in their care and that, with adequate notice, the provision of post discharge services will be organized” (Goncalves-Bradley et al, 2016).
Challenge of acute admissions
There has been an 18% increase in emergency admissions of older people between 2010-11 and 2014-15 (NAO, 2016). However, despite continued emphasis on transforming NHS services to transfer more care into the community there is no sign of abatement of emergency admissions. A plethora of recommendations for discharge practice have been developed over recent years, which are often embedded in ‘specialist older persons guidance’, the relevance of which takes time to filter down into clinical practice (Department of Health (DH), 2013; 2011; 2007). Guidance can prove challenging to implement in acute settings where it has to compete with many other guidelines for the care of older people (Cook et al, 2012).
Acute admission and assessment units can be highly pressurised environments for staff to assess frail older patients (Hoyle and Grant, 2015). These challenges are further intensified with pressures to transfer or discharge patients from acute care whose needs can be met outside of a hospital setting, thereby relieving pressure on hospital bed capacity (Groene et al, 2012). The challenges for nurses are:
- Recognising the potential problems that can occur in the transfer and discharge process;
- Incorporating the latest national guidance into practice;
- Achieving this in the time constraints of the acute admission setting.
Reviewing discharge in acute care
It is important to understand your current discharge process and the underlying principles (Lees, 2010). The set of questions in Box 2 will help you to focus on what you need to do to revise your discharge documentation as necessary, and make small changes in practice, briefings or audit mechanisms.
Box 2. Current practice assessment
Questions to ask about your discharge planning process
- How do you routinely gather information regarding patient discharge?
- What type of information do you gather about discharge?
- Where do you document information about the discharge plans?
- Is this information easily accessible to use during the in-patient stay and after discharge (handover documentation/notes)?
- How are carers or relatives involved in the production of information?
- What do you do when information about discharge cannot be gathered?
- Who is responsible for coordinating the patient’s discharge?
- Is discharge information handed over (verbally and in writing) on patient transfer from your area?
- Could this information be incorporated within existing documentation, such as a discharge transfer checklist to provide a written discharge plan?
Sources: Parliamentary and Health Service Ombudsman, 2016; NICE, 2015
Incorporating national guidance
National discharge guidance needs to be adapted to local circumstances if implementation of changes from policy is to be successful. It is impossible to introduce all recommendations for the initial discharge assessment of older people on admission to hospital. An intercollegiate document developed by a range of professional associations and organisations representing older people (Cook et al, 2012) signposts specific considerations as principles for managing the older person’s discharge assessment in acute care. It argues that:
- Planning should begin as soon as possible;
- Comprehensive Geriatric Assessment should be triggered to ensure older people’s needs are considered holistically over time;
- The appropriate multidisciplinary team members who are best placed to assess individual patients should be involved;
- A validated assessment tool should be used;
- Types of services needed out of hours to support discharge should be considered;
- Care management after discharge should be assessed.
The starting point is to explore the appropriate timings of any required assessments for each patient to ensure standards and targets are met; this is crucial to ensure staff are not overburdened with unnecessary workload (Hoyle and Grant, 2015). Box 3 summarises the common features of recent guidance to help you integrate them into all areas where frail older people are assessed.
Box 3. Common features of discharge policies
- Timely patient assessment for discharge – allowing information to be gathered from all available sources
- Comprehensive assessment – triggering full multidisciplinary assessment if required
- Patient and carer involvement – on admission and at the point of all changes/decisions made thereafter
- Communication and documentation – from admission and for every part of discharge practice
- Care and management after discharge – check services to reinstate
- Sharing and the transfer of information – including during transfer into and out of hospital
- Discharge coordination – using discharge coordinators
- Written care plan and checklist for the patient/carers
Addressing time constraints
Time constraints necessitate a pragmatic approach to gathering discharge information about older people in acute care. To address this, I developed a discharge framework, which was piloted, audited and introduced into practice to enable the focused assessment of an older person’s needs using the acronym ‘DISCHARGE’ (Lees, 2005).
The original aim of the DISCHARGE framework was to ensure a consistent, systematic approach to information gathering, to guide the need for admission, transfer to another care setting or discharge of patients to their own homes. The framework proved to be a positive addition to existing documentation and an evaluation of it suggested that doctors’ clerking improved significantly as a result of the organisation and standardisation of assessment (Lees, 2005).
In light of new policy guidance, the framework has been modified and is illustrated in Table 1 (attached). The main intention is that the framework will enable and encourage early discussions about discharge plans and information-seeking/sharing beyond the initial acute assessment. It is not intended to replace comprehensive detailed individual assessments, rather it is intended to promote best practice principles and identify older people’s needs triggering further assessment where appropriate.
The problems with discharge practice cannot be fixed overnight, but using NICE (2015) guidance to identify problems and make small achievable changes to address problems is a good starting point. As with any change it is important to view discharge policies in the context of organisational constraints (Lees, 2016). As their patients’ advocate, nurses have a pivotal role in assessing the needs of older people, and the modified DISCHARGE framework provides a focus based on NICE (2015) best-practice principles. As a minimum standard, discharge planning should incorporate the principles of information gathering, good communication and patient involvement in their discharge.
- Emergency admissions for older people increased by 18% between 2010-11 and 2014-15
- The discharge pathway spans from pre-admission to post-discharge care
- National discharge guidance must be incorporated into local policies
- It is important to recognise local problems that can influence the discharge process
- Accurate and timely discharge assessment is vital in acute admission setting
Cook M et al (2012) Quality care for older people with urgent and emergency care needs (The Silver Book). British Geriatrics Society.
Department of Health (2013) Integrated Care: Our Shared Commitments.
Department of Health (2011) Safeguarding Adults: The Role of Health Service Practitioners.
Department of Health (2010) Ready to Go? Planning the discharge and the transfer of patients from hospital and intermediate care.
Department of Health (2007) Urgent Care Pathways for Older People with Complex needs: Best Practice Guidance.
Goncalves-Bradley DC et al (2016) Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub5.
Groene RA et al (2012) It’s like two worlds apart: an analysis of vulnerable patient handover practices at discharge from hospital. British Medical Journal of Quality and Safety; 21: 67-75.
Hoyle L, Grant A (2015) Treatment targets in emergency departments: nurses’ views of how they affect clinical practice. Journal of Clinical Nursing; 24: 2211-2218.
Lees-Deutsch L (2016) Small changes can have a large impact on hospital discharge. Nursing Times; 112: 21, 11.
Lees L (2010) Exploring the principles of best discharge practice to ensure patient involvement. Nursing Times; 106: 25, 10-12.
Lees L (2005) A framework to promote the holistic assessment of older people in emergency care. Journal of Older Peoples Nursing; 16: 10, 16-21.
National Audit Office (2016) Discharging older patients from hospital.
National Audit of Intermediate Care (2014) Assessing Progress in Services Aimed at Maximising Independence and Reducing Use of Hospitals.
National Institute for Health and Care Excellence (2015) Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
National Library of Medicine (2015) Medical subject heading Index.
NHS England (2015) Quick Guide – Improving hospital discharge into the care sector.
Parliamentary and Health Service Ombudsman (2016) A report of investigations into unsafe discharges from hospital.