Introduction Using the seven key principles of the hospital discharge process devised by the Department of Health (DH, 2003), this case study will critically analyse the process of an elderly patient who was discharged from a local acute trust. It begins by providing a definition of discharge planning, before providing a brief biography of the patient, including a rationale of why this patient was selected, details of her past medical history, reason for current admission, any issues raised and details of any care provided.
Throughout this case study, in accordance with the Nursing and Midwifery Council (NMC, 2008) and the Data Protection Act (1998), the patient shall be referred to as Mrs. Blue to maintain anonymity. Although the case study will largely focus on how the discharge affected and impacted on Mrs. Blues outcomes, it will also include some of the issues highlighted in the current literature surrounding the discharge process. Included will be a summary and any additional points will be raised.
Finally it will draw closure to the case study by concluding the main themes and finishing with a final suggestion to achieve optimal results when discharging patients. Definition According to Wats & Gardner (2005) discharge planning is defined as ‘an on-going process that facilitates the discharge of the patient to the appropriate level of care. It involves a multidisciplinary assessment of patient/family needs and co-ordination of care, services and referrals’ (pg. 176). Biography The rationale for selecting Mrs. Blue was to highlight how easily it is for patients to experience a delay in hospital discharge.
Mrs. Blue was an elderly lady who presented into a local medical assessment unit having sustained a recent fall whilst at home. She lived alone in a bungalow with the support of carers four times a day. She did have a friend who visited daily, but had no other family or friends. Her medical history comprised of short-term memory loss, extrinsic asthma and she currently presented with low grade pyrexia, hypotension and dehydration. Upon admission, assessments were conducted to formulate a plan of care. Whilst conducting the initial assessments, it was identified that Mrs.
Blue had a possible urinary tract infection. Additionally, intravenous sodium chloride was administered to achieve euvolaemia. After the first three days, Mrs. Blue showed signs of improvement and the team began to focus on reinstating her care package and discharging her back home. However, whilst these plans were conducted Mrs. Blues friend approached a student nurse and informed her that she was concerned for Mrs. Blue’s safety as on numerous occasions she had visited her friend and found her on the floor and/or incontinent of urine.
She felt that she had become increasingly unstable on her feet and this prevented her from mobilizing around the bungalow and to the toilet. Principle 1 Providing patient-centred care across the whole of the UK has been a government objective for many years and the DH informs us that when providing a ‘whole systems approach’ a range of health professionals will be involved in patients care (DH 2003). According to Glasby & Martin et al (2008) tackling delayed hospital discharges and preventing unnecessary admissions (O’Brian 2012) has been a vital government focus since the introduction of the NHS plan.
Guidance published by the DH (2000), discusses that it envisions health communities work in partnership to plan and deliver health improvement and services for the benefit of the community as a whole. Miers & Polland (2009) indicate that identifying patients’ needs promptly and utilising the appropriate services will achieve optimum results. Whilst, Underwood & Burnett (2012) discusses that the admission of elderly patients aged over 75 costs the NHS hundreds of millions of pounds each year in hospital admissions. Upon admission, the nurse conducted an initial triage assessment with the involvement of Mrs.
Blue which would identify physical, psycho-social, religious or spiritual needs and potential discharge concerns (Evans & Tippins 2008). However, when the assessment was carried out, Mrs. Blue neglected to disclose that she was not coping at home and this was only discovered when her friend visited the unit. Principle 2 Similar themes as principle 2 are discussed in principle 7 of the DH (2010) principles and in principle 9 of the RCN (2010) principles. These themes largely focus on patient participation, patient choice and promoting independence.
When it comes to organising, decision-making and conducting activities relating to care delivery, Efraimisson & Sandman et al (2004) highlight that both public opinion and the law dictates that patients have the right to be involved. Foss & Askautrud (2010) discuss, that involving elderly patients in this process during a hospital admission is believed to strengthen their ability to cope with everyday life upon discharge. Wells (2007) also informs us that there are varying levels of patient participation which include the providing of information such as leaflets, direct discussions, and patient involvement.
Whilst in hospital care Mrs. Blue was encouraged to be involved in her care. Nurses would regularly provide education and support on how to promote health and well-being. When Mrs. Blue was ready to be discharged home, the nurse provided Mrs. Blue with written information on aftercare and instructions on how to take prescribed medications whilst at home, a contact number for the ward, additional numbers or places that she could contact or attend for advice if she became unwell and clearly documented the process in her notes (Drury & Billings et al 2008). Principle 3
Similar themes that are displayed in principle 3 are discussed in principle 1 in both the DH (2010) and RCN (2010) discharge planning guidance, with the focus leading towards prompt planning of discharge. A broad range of literature and government polices informs us that the discharge planning process should commence upon hospital admission {Case Management Advisor, (2011); Connolly & Deaton & et al (2010); Diaper, (2011); Aston, (2011); Healthcare Benchmarks & Quality Improvement, (2010); Wong & Yam (2011); DH (2003, 2004, 2010); RCN, (2010)}.
Even though Denny (2010) states that the principles of anti-ageist practice include empowerment, involvement, choice, integration and normalization; Social Care Institute of Excellence (2005) and Reed (2011) argues that the elderly often do not adapt well to change, may not wish to be included in the planning and delivery of their care and are happy just too simply follow instructions. Upon admission onto the unit no social issues were identified and Mrs. Blue indicated that she was coping well at home. Correspondingly, when the nurse tried to involve Mrs. Blue, creating autonomy she would often state “It’s lright love I’ll leave it to you. You know best”. When Mrs. Blue’s friend identified that she was not coping at home, there was concern for her safety. The nurse contacted the care providing agency to make some further enquiries and ensure Mrs Blue’s safety was paramount, therefore allowing the nurse to re-evaluate Mrs. Blue’s discharge plan. Principle 4 ‘Principle 4’ of the ready to go principles (DH 2010) and ‘principle 3’ the RCN review of the ready to go principles (2010) display similar topics to principle 4 of (DH 2003), with the focus based on co-ordination of the discharge process.
Lees (2011) informs us there is no clear guidance on the development of the role of a discharge co-ordinator and they are often found in various forms, including staff nurses and administrative staff. Also, Chapman (2007) and Satzinger & Courte-Wienecke et al (2005) states that providing cost-effective care, optimal communication and co-ordination between organisations and promoting efficiency of care services will help to achieve quality of patient care. The DH 2003 discharge guidance, states that pre-admission planning for emergency admissions cannot take place and as Mrs.
Blue was classified as an emergency admission the opportunity to liaise with a pre-admission co-ordinator was unavailable. However, when Mrs. Blue was admitted onto the unit she was assigned a discharge facilitator and when it was established that her needs were more complex, she was referred to the Integrated Community Assessment Bureau who conducted further assessments and facilitated the discharge process to try and prevent a delay in discharge (University Hospital of North Staffordshire 2012).
Principle 5 In reading the guidance, it seems that only principle 5 of the RCN (2010) document describes comparable themes displayed in principle 5 of the DH 2003 guidance, with the attention driving towards multidisciplinary collaboration. RCN (2010, pg. 9) states that ‘multidisciplinary assessment should be co-ordinated effectively to ensure that everyone understands their role and is working to the same time frame and outcome’.
Day (2007) informs us that the NHS has been structured on a traditional hierarchy format and effective collaboration between health and social care professionals can only take place if this is substituted with a more parallel structure. One such method which encourages MDT working is the government initiative ‘single assessment process’ (SAP), designed to ensure that one assessment tool could be used for all health professionals (DH 2001). Yet Masterson (2007) argues that even using the SAP can lead to confusion due to the use of professional jargon.
Whilst in hospital, Mrs. Blue was readily cared for by various members of the MDT, which was largely co-ordinated by her named nurse who made referrals to services she required. One service included occupational therapy; they were involved in assessing Mrs. Blue’s ability to function independently (Wales & Clemson et al 2012). Principle 6 Rout & Ashby et al (2010) state that intermediate care organizations have targeted medically unwell elderly patients. Humphris (2007) informs us that intermediate care service aims at supporting patients in their own home.
Whilst Greene & Caldwell et al (2008) and Age UK (2011) describe the package as a collection of integrated services to avoid hospital admission, promote rapid recovery, support timely discharge and promote independence. Helleso and Fagermoen (2010) point out that community and Hospital nurses have varying opinions on what the term ‘ready to be discharged’ means, saying that community nurses seem more concerned with facilitating and assessing on-going provision of safe care, whilst hospital nurses were greatly focused on ensuring bed availability and discharging patients.
Before being discharged home, Mrs. Blue was referred to the intermediate care team to facilitate her discharge needs, try to promote a timely discharge and avoid an extended stay in hospital, which could lead to loss of confidence, reduced independence and additional infections (Sturdy & Heath 2010). Along with this, the nurse also completed a nurse to nurse form which contained details of Mrs. Blue’s admission and also spoke to a nurse via the telephone to provide a full patient handover. Principle 7
The UK is finding difficulty in providing welfare for patients that is based on their needs, rather than on the services that are available (Fisher & Qureshi 2006). This year the DH has released a new white paper which plans to abolish the PCT’s and run several ‘Clinical Commissioning Groups’, partly run by the GP’s in England. A report published by the Secretary of State (2012) indicates that the aim is to improve post-discharge services and promote joint commissioning of health and social care funding, which will prevent unnecessary delays in hospital discharge.
The DH (2004) guidance on discharge planning informs us that delayed hospital discharges that happen as a result of the local authority, this will incur a ? 100 fee for each day the delay occurs. According to the National Health Service (NHS 2011) the eligibility to receive continued care funded by the NHS is based on patients being assessed as having a ‘primary health need’, substantial on-going care requirements and a complex medical condition.
On the other hand, the DH (2011) states that eligibility to receive social care is means tested by the local authority. This is based on a typical care package for an individual required level of care within the local area and is capped at ? 35,000. The option of Mrs. Blue being admitted into a rehabilitation bed in a local residential home was discussed. However, Mrs. Blue expressed that “She just wanted to go home and indicated that she would be fine once she was back in her own home”.
The decision was made not to continue with any long-term care assessments and to utilise the option of referring Mrs. Blue intermediate care services until she could regain back her confidence and independence. Paramount to this, is that the patient is involved is the assessment process and is allowed to make an independent decision without pressure from staff, family and friends (DH 2008). Summary In summary, this assignment has provided a definition of discharge planning and introduced an elderly patient, admitted as an emergency into hospital.
It has highlighted the current evidence-base surrounding the discharge process and emphasizes any areas where complications arose. Below is some statistics on delayed hospital discharges and emergency hospital readmissions. In 2003 when the DH policy ‘discharge from hospital’ was released, the House of Commons (2002-03) stated that two-thirds of general and acute hospital beds were occupied by the older population and 77% of the patients aged over 75 experience a delay in their hospital discharge. Although no current evidence can be found to show whether these figures have mproved, Nursing Standard (2009) & Nursing Older People (2009) both discuss, in a report by Age Concern in 2006/7, show 150,000 people aged over 75 were readmitted into hospital as an emergency within one month of being discharged, an increase of 2,000 readmissions on the previous year and could be attributed to poor discharge planning. Conclusion In conclusion, this article has introduced an elderly female patient who presented with a simple, treatable infection which should have led to a straight forward discharge from hospital. However, this became a delayed discharge when Mrs.
Blue withheld information about her coping mechanisms whilst at home. Along with this, it has discussed and critically analysed the discharge process following the 7 key principles from the DH (2003) and where applicable has linked the more recent discharge guidance from the DH (2010) and the RCN (2010) to each principle. There has been a consistent link of current evidence-base and how this relates to practice as well as drawing closure with a summary and any further points that needed to be included. Additionally, it presents a conclusion highlighting the key theme of the assignment.
The final point however, is that in order to promote an effective, timely discharge from hospital, there needs to be exceptional planning and effective use of all suitable facilities to achieve optimal results (Miers & Pollard 2009), whilst preventing avoidable expenses incurred from hospital delays and inappropriate use of unsuitable services.
Reference List
Age UK. (2011). Hospital discharge arrangements. Factsheet. London. Age. UK. Accessed: 03. 10. 2012. Available at: http://www. ageuk. org. uk/documents/en-gb/factsheets/fs37_hospital_discharge_arrangements_fcs. pdf? dtrk=true Aston. G. (2011). Is your hospital ready?
THE SILVER STAMPEDE. Hospitals & Health Networks. Vol: 85. Issue: 12. Pgs: 32-36. Case Management Advisor. (2011). 6 ways to prevent hospital readmissions. Journal article. Vol: 04. Pg:40. Chapman. L. (2007). Discharge planning: a family affair. Nursing. Vol: 37. Issue: 05. Pgs: 12-14. Connolly. M, Deaton. C, Dodd. M, Grimshaw. J, Hulme. T, Everitt. S, Tierney. S. (2010). Discharge preparation: Do healthcare professionals differ in their opinions? Journal of Interprofessional Care. Vol: 24. Issue: 06. Pgs: 633-643. Data Protection Act. DPA. (1998). Data Protection Act 1998 Chapter 29. legislation. gov. uk.
Accessed: 04. 10. 2012. available at: http://www. legislation. gov. uk/ukpga/1998/29 Day. J. (2007). Interprofessional Working. An essential guide for health- and social-care professionals. United Kingdom. CENGAGE Learning. Denny. E, Earle. S. (2010). Sociology for Nurses. 2nd Edition. Cambridge. Polity Press. Department of Health. DH. (2004). Achieving timely, ‘simple’ discharge from hospital. A toolkit for the multi-disciplinary team. London. Department of Health. Accessed: 03. 10. 2012. Available at: http://www. dh. gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4088367. df Department of Health. DH. (2012). Caring for our future: reforming care and support. Presented to Parliament by the Secretary of State for Health by Command of Her Majesty. London. Department of Health. accessed: 20. 10. 2012. available at: http://www. dh. gov. uk/health/files/2012/07/White-Paper-Caring-for-our-future-reforming-care-and-support-PDF-1580K. pdf Department of Health. DH. (2008). Common Assessment Framework for Adults: A Consultation on Proposals to Improve Information Sharing Around Multi-disciplinary Assessment and Care Planning. London. Department of Health. accessed: 20. 10. 012. available at: http://www. dh. gov. uk/prod_consum_dh/groups/dh_digitalassets/documents/digital asset/dh_091994. pdf Department of Health. DH. (2012). Commons Health Committee Report on Social Care (Fourteenth Report of Session 2010-12). Presented to Parliament by the Secretary of State for Health by Command of Her Majesty. London. Department of Health. accessed: 20. 10. 2012. available at: http://www. official-documents. gov. uk/document/cm83/8380/8380. pdf Department of Health. DH. (2003). Discharge from hospital: pathway, process and practice. London. Department of Health. Accessed: 03. 0. 2012. Available at: http://www. dh. gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4116525. pdf Department of Health. DH. (2011). Fairer Care Funding. The report of the Commission on Funding of Care and Support. London. Department of Health. Accessed: 04. 11. 2012. Available at: https://www. wp. dh. gov. uk/carecommission/files/2011/07/Fairer-Care-Funding-Report. pdf Department of Health. DH. (2010). Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care. London. Department of Health. Accessed: 03. 10. 2012.
Available at: http://its-services. org. uk/silo/files/ready-to-go–. pdf Department of Health. DH. (2001). National Service Framework for Older People. London. Department of Health. Accessed: 03. 10. 2012. Available at: http://www. dh. gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4071283. pdf Department of Health. DH. (2000). The NHS Plan A plan for investment A plan for reform. London. Department of Health. Accessed: 09. 07. 2012. Available at: http://www. dh. gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118522. df Diaper. M. (2011). Effect discharge and follow-up. Pulse. Vol: 71. Issue: 26. Pg: 20. Drury. L, Billings. D, Kowalski. K. (2008). Transition from hospital to home care: what get lost between the discharge plan and the real world? Journal of Continuing Education in Nursing. Vol: 39. Issue:05. Pgs; 198-199. Efraimisson. E, Sandman. P, Hyden. L, Rasmussen. B. (2004). Discharge planning: ’fooling ourselves? ’ – patient participation in conferences. Journal of Clinical Nursing. Vol: 13. Issue: 05. Pgs: 562-570. Evans. C, Tippins. E. (2008). Foundations of nursing: an integrated approach. New York.
Open University Press. Dawsonera online books. Accessed: 03. 10. 2012. available at: http://www. dawsonera. com/depp/reader/protected/direct/AbstractView,title. $ReaderFunctions. eBookView. sdirect? state:reader/protected/AbstractView=ZH4sIAAAAAAAAAFvzloG1XJiBgYGJkYG1JLMkJ5WBNTWzOCmvhIHX0tzCwNjY1MjYzMjSspyDAYcMAOa4%2F%2F9DAAAA Fisher. M, Qureshi. H, Hardyman. W, Homewood. J. (2006). Using qualitative research in systemic reviews: Older people’s views of hospital discharge. Social Care Institute for Excellence. SCIE. London. Social Institute for Excellence. Accessed: 03. 10. 2012. Available : http://www. cie. org. uk/publications/reports/report09. pdf Foss. C, Askautrud. M. (2010). Measuring the participation of elderly patients in the discharge process from hospital: a critical review of existing instruments C. Foss, M. Askautrud Measuring the participation of the elderly patients in the discharge process. Scandinavian Journal of Caring Sciences. Vol: 24. Pgs: 46-55. Glasby. J, Martin. G, Regen. E. (2008). Older people and the relationship between hospital services and intermediate care: Results from a national evaluation. Journal of Interprofessional Care. Vol: 22. Issue: 06. Pgs: 639- 649.
Greene. J, Caldwell. G, McVeigh. A, Rankin. M, Sheeran. C. (2008). Timely and effective hospital discharge for older people: a person centred approach. International Journal of clinical Leadership. Vol: 16. Issue: 01. Pgs: 49-57. Healthcare Benchmarks & Quality Improvement. (2010). Ways a hospital can improve DP process. Healthcare Benchmarks & Quality Improvement. Vol: 17. Issue: 06. Pgs: 68-70. Helleso. R, Fagermoen. M. (2010). Cultural diversity between hospital and community nurse: implications for continuity of care. International Journal of Integrated Care. Vol: 10. Humphris. D. (2007).
Multiprofessional working, interprofessional learning and primary care: a way forward? A Journal for the Australian Nursing Profession. Vol: 26. Issue: 01. Pgs: 48-55. Lees. L. (2011). A ‘how-to’ guide to discharge Planning. Nursing standard. Vol:26. Issue: 06. Pg:19. Masterson. A. (2007). Community matrons: inter-professional and inter-agency working (part five). Nursing Older People. Vol: 19. Issue: 08. Pgs: 38-40. Miers. M, Pollard. K. (2009). The role of nurses in interprofessional health and social care teams. Nursing Management. RCN publishing. vol:15. issue: 09. National Health Service. NHS. 2011). Practical support. Continuing care. London. National Health Service. Department of health. Accessed: 04. 11. 2012. Available at: http://www. nhs. uk/CarersDirect/guide/practicalsupport/Pages/NHSContinuingCare. aspx Nursing and Midwifery Council. NMC. (2008). Confidentiality. London. Nursing and Midwifery Council. Accessed: 04. 10. 2012. Available at: http://www. nmc-uk. org/Nurses-and-midwives/Advice-by-topic/A/Advice/Confidentiality/ Nursing Older People. (2009). Rise in readmissions blamed on poor discharge planning. Nursing Older People. Vol: 21. Issue: 04. Pg: 05. Nursing Standard. 2009). Hospital readmissions climbing among older patients, says charity. Nursing Standard. Vol: 23. Issue: 31. Pg: 07. O’Brien. L. (2012). District Nursing Manual of Clinical Procedures. West Sussex. Wiley-Blackwell. Parliament UK. (2002-03). Ensuring the effective discharge of older patients from NHS acute hospitals. Thirty-third Report of Session. London. House of Commons. Committee of Public Accounts. Accessed: 05. 10. 2012. Available at: http://www. publications. parliament. uk/pa/cm200203/cmselect/cmpubacc/459/459. pdf Reed. A. (2011). Nursing in Partnership with Patients and Carers. Exeter.
