Discharge Planning

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Discharge Plannin
Discharge planning is a process that aims to improve the coordination of services after discharge from hospital by considering the patient’s needs in the community. It seeks to bridge the gap between hospital and the place to which the patient is discharged, reduce length of stay in hospital, and minimise unplanned readmission to hospital.1

Discharge planning is an established part of hospital care, but the process varies and is not entirely evidenced based. A Cochrane review analysed 11 randomised controlled trials looking at discharge planning in over 5000 patients and failed to show a reduction in mortality among elderly medical patients, lower readmission rates, or a shorter length of hospital stay.1 However, two trials in the review did report greater satisfaction of patients and carers when discharge planning was used.2 3 The Cochrane review concluded that discharge planning remains important as a small improvement, not detected by the studies performed so far, could still yield highly significant gains in health care with huge resource implications and better use of acute hospital beds.1 Unfortunately, none of the included trials assessed communication with primary care staff about patient transfer of care. This is an important aspect of discharge planning and another potentially important advantage for patients.

On a patient’s initial contact with health services, discharge planning should be started.4 This is often difficult to achieve when acutely unwell patients are admitted as a thorough social history may not be immediately available without a collateral history from a relative or primary healthcare provider (who may be difficult to contact). Taking a comprehensive social history is often thought to be time consuming but can be obtained quickly through the use of systematic open questions (see the four scenario boxes).

Effective discharge planning requires multidisciplinary team working. This can be difficult to coordinate because of shift work, ward transfers, staff illness, and perhaps poor team communication. To overcome this problem, an adequate handover—oral, written, or electronic—is key. Sometimes disagreements arise in the team about the most appropriate course of action, but this can usually be resolved through the involvement of a more senior member of the medical team.

Clear sensitive communication with the patient and family is pivotal, especially for the patients who experience a considerable new loss of function. Patient confidentiality cannot be neglected, however, and permission needs to be sought from a competent patient before information is divulged to a family. Relatives will sometimes disagree with the patient’s or team’s views about the most appropriate discharge destination.17 Listening to the relatives’ concerns is especially important in these situations as a compromise is often possible; however, it is the competent patient’s wishes that are paramount. Often asking patients and families for their opinion on the best and safest place to stay and then subsequently considering potential difficulties on discharge can yield the best outcome. Serious disputes should involve the consultant responsible for the care of the patient.

Handover to primary care is easily neglected as it may be perceived as low priority compared with treating unwell inpatients. Early completion of the immediate discharge document can prevent pharmacy delays, and vigilance is needed to ensure effective follow-up and handover—such as ensuring that follow-up is booked before discharge, oral information is given at handover of patients to primary care, and immediate discharge letters leave with patients

The patient’s ongoing needs must be considered and provided for before he or she leaves hospital.4 This might entail arranging appropriate follow-up (in primary or secondary care); ensuring appropriate drug treatment (with details of indications, length of course, planned dose...
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