JANUARY 2 01 4 Hospital discharge: the patient, carer and ... · BMA Patient Liaison Group:...

Hospital discharge:the patient, carer anddoctor perspective

BMA Patient Liaison Group

JANUARY 2014

1BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective

Contents

Foreword by Dr Mark Porter, Chair of Council, BMA ..................................................3Foreword by Catherine Macadam, Chair of the Patient Liaison Group, BMA..........5Background ........................................................................................................................6Introduction ........................................................................................................................7Delayed hospital discharge and premature hospital discharge ...........................................8Patient, carer and family involvement .................................................................................9Leaving hospital ................................................................................................................10Discharge summaries........................................................................................................11A checklist for patients .....................................................................................................12

Patient and doctor perspectives Kim...................................................................................................................................13John..................................................................................................................................14Dr Radhakrishna Shanbhag, Co-Chair of the BMA’s Staff, Associate Specialists and Specialty Doctors Committee ....................................................16Dorothy ............................................................................................................................17Ken...................................................................................................................................18Dr Ben Molyneux, Chair of the BMA’s Junior Doctors Committee (2012-2013)................19Susan................................................................................................................................20Louise ...............................................................................................................................20Julie .................................................................................................................................21Helen ................................................................................................................................22Dr Chaand Nagpaul, Chair of the BMA’s General Practitioners Committee ......................23

Carer/family and doctor perspectivesJacky.................................................................................................................................25Catherine .........................................................................................................................27Dr Helena McKeown, Chair of the BMA’s Committee on Community Care .....................29Barbara .............................................................................................................................30Michael.............................................................................................................................31Pat ....................................................................................................................................31

Further information .........................................................................................................32References ........................................................................................................................33


Dr Mark Porter,

Chair of Council, BMA

Foreword by Dr Mark PorterChair of Council, BMA Going into hospital can be an uncertain, and sometimes distressing, time for patients. The NHS is under considerable pressure to cope with a rising number of hospitaladmissions coupled with a reduction in the number of available beds. Our ageingpopulation places a further strain on NHS resources, with the majority of patientsadmitted to hospital being over the age of 65.

The involvement of patients in decisions that affect them, and the information andsupport available for when they leave hospital, is pivotal in preventing unplannedreadmissions and providing good continuity of care. This will be even more important asthe NHS goes through a period of major change, and is faced with significant pressure to use resources more efficiently.

Personal stories are a critical part of putting a patient face to a policy issue. Therefore, I am pleased to encourage you to read the BMA’s Patient Liaison Group (PLG) booklet on hospital discharge, which documents fascinating true stories, told from the differentperspectives of patients, carers and doctors. It is imperative these views are heard if we are to ensure the NHS is truly responsive to the needs of patients.


Catherine Macadam

Chair of the Patient Liaison Group, BMA

Foreword by Catherine Macadam Chair of the Patient Liaison Group, BMANobody wants to be in hospital longer than they need to. But the process of leavinghospital can be complicated, involving a range of different services, and needs to beplanned and managed well. The consequences of not doing this can have a negativeeffect on patients, their family and carers, the hospital itself and people needing hospitaltreatment. So it is crucial that we get it right.

The PLG is aware of growing concerns among patients about delayed or inappropriatedischarges from hospital. The challenges posed by trying to co-ordinate services betweenhospital staff, transport providers, GPs and social care staff may be exacerbated by thoseinvolved not seeing the whole picture and not being aware of the impact that theircontribution can have on other aspects of the process. This is why we feel it is importantto share patient stories about good and bad experiences to try and illustrate theimportance of sensitive and timely ‘joined-up-working’ to facilitate a smooth andeffective transfer of care for patients leaving hospital.

With increasing pressure on NHS resources, it is very timely for the PLG to engage with this topic, and we hope that this booklet will be a valuable resource for patients,carers, doctors and others involved in the process. We also hope that it will encourageall the key players to reflect on the discharge process and how it can be improved, foreveryone’s benefit.

7BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective6 BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective

At its meeting on 5 February 2013, thePatient Liaison Group (PLG) agreed that itwould develop a checklist to help patientsidentify what they could reasonably expectfrom the hospital discharge process.

In addition to providing a patient checklist,this booklet documents patients’, carers’and doctors’ perspectives of hospitaldischarge. This is with the aim ofidentifying factors that can facilitate asmooth and effective transfer of care forpatients leaving hospital, and to illustratethe consequences of when the process is not properly planned, co-ordinated and carried through.

IntroductionHospital discharge can be a challengingprocess for healthcare professionals,patients, family members and carers.While at least 80 per cent of patientsdischarged from hospital return homewithout any complications or ongoing careneeds, some patients will require inputfrom a number of different healthcareprofessionals, such as social workers,therapists and general practitioners (GPs).1

Patients with complex needs, such asthose with multiple chronic illnesses, mayalso need to be discharged to a care homeor to intermediate care, and their lengthof stay in hospital is more difficult topredict than patients with simple careneeds.1 Intermediate care is made up ofsupport services that help an individual tomake the transition back to their home.

These are delivered by a team that can include nurses, care assistants,occupational therapists and others.Intermediate care can also include a short stay in a local residentialrehabilitation unit, to help patientsrecover and regain their independence.

Despite these differences, the basicprinciples for planning for dischargeapply to every patient including thosewho are admitted to hospital withstraightforward medical investigationsand treatments.

The key focus is achieving ‘timely’discharge, where a patient is transferredhome, or to an appropriate level of care,as soon as they are clinically stable andfit for discharge.

It is vital that patients are not in hospitalfor unnecessary amounts of time, knownas ‘delayed discharge’, but also thatsocial and practical factors are taken intoconsideration before rapid and unsafedischarges occur, known as ‘prematuredischarge’ (see page 8).

Barriers to achieving timely discharge are mainly associated with patients overthe age of 65, not least because they are more likely to have complex medicalneeds, including more after-care needs.The longstanding separation betweenhealth and social care services in the UK, and limited capacity to deal withsome (or many) older patients’ multipleand complex needs, has contributed tothis problem.

These positive and negativestories serve as learning tool fordoctors as well as being a usefulonline resource for patients andmembers of the public.

BMA Patient Liaison Group

Background


What is delayed hospital discharge? Delayed hospital discharge is wherepatients are well enough to leave hospitalbut are not able to because alternativecare arrangements or transport are notavailable or easily accessible.2 Delayeddischarge can also occur when there is, for example, a long wait for a drug to bedispensed at an acute hospital’s pharmacy.

Delayed hospital discharges can occur atany stage of the discharge process andcan affect inpatients of any age, includingchildren. The majority of patients whoexperience delays are over the age of 65.3

Staying in hospital for unnecessaryamounts of time increases the risk of infection, depression, loss ofindependence, and inappropriate use ofNHS resources.4 It can also lead to delaysin patient admissions, inpatient transfers,and cancellations of surgical procedures.

What is premature hospital discharge?Premature hospital discharge is wherepatients are discharged from hospitalbefore they are clinically ready, and before it is clinically safe for them to bedischarged. This can happen for a varietyof reasons, including poor communication,assumptions that family members will look after the patient, bed shortages, or because patients leave against medical advice.

Staff members may feel pressurised tomake beds available, especially as bedoccupancy rates are high. Patients whoare deemed ‘medically fit for discharge’can be given little or no notice to makethe necessary arrangements andadjustments for their return home, or into care.2

Premature discharge is an importantcontributor to unplanned readmission. The likelihood of a patient beingreadmitted to hospital is influenced by the support they receive duringhospitalisation, and at the point of goinghome. There is an increased risk ofreadmission, or using inappropriate ormore costly care services, if patients arenot given appropriate post-dischargeadvice or follow-up arrangements.5

Patient, carer and family involvementPatients should be able to discussarrangements for their discharge withstaff members and receive fullinformation on their diagnosis andhealth and social needs. If patients areunhappy about their discharge ortransfer date, they should be able toraise concerns with the hospital staff.

There can be clear benefits for somepatients with complex medical and socialneeds in involving carers and familymembers. It is important that healthcareprofessionals ensure that the patient hasgiven consent before their confidentialhealth information is shared.

Although it may sometimes appear to be obvious that a patient is happy forinformation to be shared with familymembers/carers, health professionalsshould check this with the patientbeforehand. This is particularly importantwhere there is doubt or a risk ofmisunderstanding as to what informationwill be shared. Care should also be takento share only information which is relevantto the discharge planning process.

It can be beneficial for patients withcomplex needs to share relevantinformation with their carers. This canensure that they are suitably cared forafter leaving hospital and are not at riskof being unable to cope.

10 BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective 11BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective

Discharge Summaries

Dr Helena McKeown, Chair of theBMA’s Committee on CommunityCare, shares her insight into theprovision of Discharge Summaries.

A Discharge Summary is a documentwhich essentially transfers the care of thepatient from the hospital to the GP. Thedocument should be received by the GPon the day of discharge, preferablyelectronically. The document should betyped and all new diagnoses should beidentified, including a brief summary ofwhat has happened to the patient(avoiding abbreviations). Investigationsand why medications have been startedor stopped, or catheters inserted, shouldalso be included.

A list of medications and a supply ofmedicines to complete short courses (or atwenty-eight day supply of on-goingmedication) should be provided ondischarge. If the patient is best treatedusing a Dosette box of medications (aplastic box system for arranging daily /weekly medicines), they should be given asupply of these by the hospital pharmacy.

It should be clear if and when patients areto be followed up. If the patient has beenadvised to remain off work, oradjustments made to their work, theyshould be given a Statement of Fitness forWork or fit note.10,11,12 Investigationsperformed by the hospital need to befollowed up and appropriate action takenby the hospital team.

It is good practice for hospital doctors tophone the GP when consideringdischarge if there are complex problemsor unresolved issues to facilitate a well-planned discharge.

A patient, or a patient’s relative, mayhave access to information regardingwhat happened during the hospitaladmission and the medications thepatient has received sooner than the GP. Patients / carers are often handed apaper ‘flimsy’ and the copy may be sentto the GP by post or perhaps delayed byan internal system, such as scanning. The discharge summary may not havebeen sent to the usual GP looking afterthe patient if there is software at thehospital that sends the dischargeinformation to a GP who has previouslybeen recorded as the patient’s GP.

Leaving hospitalTimely discharge can improve the safetyand appropriateness of discharge fromhospital, and can have a positive impacton length of stay while reducingunplanned readmissions.1 It is part of wideraction needed to reduce the delays at allstages of the patient journey. Effectivelymanaging the patient journey is crucial toimproving patient experience of the NHSand making the best use of beds.1

Each hospital will have its own policy andstandard arrangements for dischargingpatients. The patient, carer and doctorexperiences in this booklet show thateffective discharge planning requiresmultidisciplinary and multi-agency teamworking to manage all aspects of thedischarge process.6

Patients with ongoing needs are also likelyto benefit from a discharge coordinator,who can provide a single point of contactfor all stages of the patient journey.6,7,8

The length of stay in an acute hospitalbed may not be enough time for patientswith complex needs, who may benefitfrom a period of rehabilitation, either as an inpatient or in the community. This could be achieved by increased careservices and, if necessary, long-term carein a care home.9

Intermediate care, or a ‘step-down’ facility,is designed to bridge the gap fromhospital to home (or to residential care).There are a number of national and localservices available that enable people to live in a supported environment withappropriate care. These services can givepatients and their families’ time to makedecisions about their future livingarrangements, facilitate timely dischargeand prevent unplanned-readmissions.2,6

Access to intermediate care services isoften via a joint assessment by a socialworker and a nurse/therapist.

A Discharge Summary is a clinical report prepared by ahealthcare professional that outlines the patient's history,diagnostic findings and treatment administered, as well astheir condition on discharge and recommendations oncontinuing care.

“

”

13BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective12

Patient and doctors perspectivesKIM

I have suffered with depression andpsychosis since childhood, with my firstmajor episode of illness at age 16. Myproblems have required two hospitaladmissions and this discharge experiencerelates to my most recent admission inJune 2010.

I was admitted to hospital afterexpressing suicidal thoughts to the crisisteam staff. My condition had beendeclining steadily and it was agreed thata short stay might be beneficial. As ithappened, the whole experience wasextremely unhelpful – for a variety ofreasons – and my discharge was adifficult aspect of the experience.

I had been placed on a Section, but afterlengthy discussions with myself, mymother and crisis team staff, the hospitalstaff agreed that I should be allowed to

came over to tell me that the taxi waswaiting and that I was free to go. Therewere no discharge papers to sign, I wasgiven no information on my discharge,no medication or advice on follow-upcare, and no-one offered to give me ahand with my bag or escort me down tothe taxi. I left the ward feeling anxiousand confused. I was safely back at homean hour or so later. It must have beenafter three in the afternoon and I hadwaited almost an entire day.

I felt the ward manager had intentionallykept me waiting and relayed this to thesenior crisis team nurse, who notified theward manager of my concern and distress.The experience felt overwhelminglynegative. There seemed to be no clinicalconcern about discharging someone froman acute psychiatric ward and there wasno assistance.

go home. On the morning of mydischarge, I nervously approached theward manager and asked how I shouldgo about arranging to go home. I wastold that he would arrange a taxi andthat I would be notified as soon as it hasarrived. Two hours later, I had to pluckup the courage to ask again. There wasan apology and I was told a member ofstaff would be sent to order a taxistraight away. Another hour or sopassed. I was waiting in the busyreception area.

The ward manager kept walking pastand looking at me, but at no time did hestop to ask whether I was alright orindeed whether anyone had updated meon the arrival of the taxi.

I think I must have asked him three orfour times and finally a female nurse

!

A checklist for patients A checklist can be an important source of information for patients to ensure thereare no unanswered questions when leaving the hospital. Checklists for patientswill vary depending on the severity of their illness and the level of care neededpost discharge. The following checklist can be used for the majority of patientsdischarged from hospital:

n Do I know how I will be getting home?

n Have I provided the correct contact details, including a forwarding address for any post?

n Have I collected my hospital discharge letter for my GP, or is it sent directly to my GP?

n Do I have all the medication I need?

n Do I understand what my medication is for, how to take it, and any associated side effects?

n Do I know how to manage my condition, if I have ongoing care needs?

n Do I need a follow-up appointment?

n Do I have all my belongings, including any cash or valuables?

n Do I have contact names and numbers for organisations and services, if I requirefurther support?

n Do I have any information leaflets about my condition, if needed?

BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective

A ch

ecklist for p

atients


At 8:30pm or so, a suitable wheelchairarrived with two personnel, and westarted the 2.5 mile journey home. With the snow and ice, this was notsimple. When we arrived home, theslope that the OT had assessed asproviding safe access, was sheer sheet-ice and the ambulance crew refused totake me up it (and I would have refusedto go up it anyway), and wanted to takeme back to A&E as being undeliverable.

A neighbour kindly came out and clearedand gritted an alternative path. But, ofcourse, there were insufficient personnelto get me up into the house, and so afurther crew had to be summoned. Withsome difficulty – including at one pointslipping and gently ditching me into thesnow – they got me indoors. There wasthen the problem of how to get meupstairs, which had been designated as the area I was to occupy – the toiletand beds were there. The stairs wereinsufficiently wide for the number ofhelpers needed – so I eventually draggedmyself up the stairs.

We then found out that we didn’t have half the equipment we needed.Although we had the toilet surround,there was no leg hoist for me to get myinjured leg into and out of bed, and at10:30pm there was no prospect ofgetting one.

In summary, a 2.5 mile journey took wellover five hours, involved five ambulancepersonnel and three ambulances, andleft me unable to help myself. Nevermind, the OT had said she would visitthe next day.... I’m still waiting....

JOHN

My experience goes back to 22 December 2010, a very snowy day, and, with hindsight, it seems more like a farce than a true story.

The hospital was anxious to dischargeme before Christmas. I had ruptured apatellar tendon in a fall on the ice on 6 December, and the repair operationhad been conducted on 10 December.

The Occupational Therapist (OT) hadvisited my wife and my house, and hadassessed what was needed for me torecover at home.

My first point of unease was that therewas never any discussion of which of this equipment would be provided by the NHS and which my wife had to find for herself (not easy in the snowyconditions prevailing).

An ambulance was ordered for 4pm totake me home, together with a double-crew (ie four personnel) to get me up the slope into my home, and a specialistwheelchair to take me through thehospital with my fully-plastered leg raised off the ground.

When this hadn’t turned up by 6pm, thenurses rang to enquire its whereaboutsand were told that no ambulance hadbeen booked (despite the fact they had a fax acknowledging the booking). At 7pm a single ambulance driver turnedup with an unsuitable wheelchair, andwas turned away.


DOROTHY

My own personal experience of what Iwould call ‘inappropriate’ discharge waswhen I had undergone major orthopaedicsurgery. This was carried out in a specialisthospital where surgery, nursing care andphysiotherapy were all excellent; howevermy discharge was not. Because thesurgical results had been so good, I wasconsidered fit for discharge even thoughother associated issues had not been fullydealt with, such as the fact that I becamepost-operatively very anaemic and mymedication regime was not sorted out.

I was naturally very keen to go home,and would have full family support whenI got there, but I did not wish to leavethe hospital without a proper medicalassessment of what I could expect tohappen, and how I could be assisted ifthings went wrong.

The house doctor even seemed offendedthat I should have asked and only sawme when I insisted on it! I was left in nodoubt that the hospital wished todischarge me and that was it.

In the event, I did become quite ill after afew days at home and my GP was nonetoo pleased with having to deal with theconsequences.

Drawing on the above experiences, I would say that a really important thingis not to discharge patients, whatevertheir age or circumstances, with thefeeling that they have just been cast onone side as soon as their medicaltreatment is considered to be complete.In addition, there must be betterprovision, and knowledge of, externalsources of care which are properlydiscussed with patients so that they areinvolved in the process, and so thattreatment can be seen eventually as aseamless whole, rather than fragmentary.

16 BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective

DR RADHAKRISHNA SHANBHAG Co-Chair of the BMA’s Staff, Associate Specialists and Specialty Doctors Committee

Discharging patients is a perennial weaklink in the efficient running of hospitals. I believe a larger change of culture andthinking, amongst health professionals, is necessary to overcome the barriers thatnow exist to facilitating timely discharges.

Kim’s experience highlights theimportance of communicating withpatients, keeping them up-to-date, andletting them have realistic expectationsof what to expect from their dischargefrom hospital. Kim should have beenoffered far more emotional and practicalsupport at the point of discharge andonce she arrived home. It is ourresponsibility, as doctors, to negotiatethese difficult hurdles in order to improvethe patient experience and maintain theirdignity and independence.

John’s story, about his experience afterrupturing his patellar tendon, highlightscommon ‘transport’ issues in returningpatients back to their naturalenvironment. The logistical issues werecompounded by the failure to provideappropriate equipment – taking intoconsideration the adverse weatherconditions. Improved liaison and closerworking between hospitals andOccupational Therapists / social serviceswould have enabled a safer arrival backhome with adaptations and appropriatesupport systems in place.

Dr Radhakrishna Shanbhag

Co-Chair of the BMA’s Staff, Associate Specialists

and Specialty Doctors Committee

I believe we need to manage patientexpectations, and integrate acute care,rehabilitation and social services to workas part of a large team towards a sharedgoal. This is vital if we are to facilitatemore patients being able to enjoy timely,much-needed care than is presentlypossible with these ever-shrinking NHS resources.


DR BEN MOLYNEUXChair of the BMA’s Junior Doctors Committee (2012-2013)

Junior doctors play a particularly criticalrole in the discharge process, as they areusually the ones to liaise with the GP andother services. Too often it is viewed asbeing a bureaucratic process, but a goodtransition makes a huge difference to thefollow up of patients and continuity ofcare. It is essential to ensure that this isemphasised in the training of juniordoctors, and that they are well equippedto understand local services and anyspecialty specific discharge processes.

The importance of clear communicationwith patients throughout the hospitaldischarge process cannot be overstated. It is absolutely vital that patients are keptaware of what’s happening, why it ishappening, and what they can expectwith regards to follow up care.

Ken’s experiences highlight theimportance of ensuring that patients areequipped with the knowledge they needto readjust to living independently – notonly information about follow up care,but also the resources and support which exists outwith the health service.Signposting patients to other sources ofinformation is a small step which canmake a huge difference to a patient’sexperience in leaving hospital.

Dr Ben Molyneux

Chair of the BMA’s Junior Doctors

Committee (2012-2013)

Hospital discharge is a vital link betweensecondary and primary care. When donewell, the patient’s journey betweendifferent services is seamless, and the GP is able to co-ordinate the appropriatecare. When done poorly, as Dorothyexperienced, patient care can suffer, with distressing consequences for thepatient and their family.


KEN

My experience began when, after tendays of viral enteritis, I developed severeheadaches and confusion which resultedin an emergency services admission on 19 July 2012. After two days of intensivetreatment I started to recover and I haveno knowledge of the two days fromadmission. On the following Wednesdaymy consultant visited when it wasconfirmed that he felt it was meningitis,although they were waiting for theresults of culture tests. A consultationtook place with the consultant andneurologist on 27 July 2012 and on theMonday the neurologist felt that I couldbe discharged.

I had pointed out that on the dischargenote that my diagnosis wasmeningoencephalitis and was thenadvised that this was a much moreserious condition in adults thanmeningitis. Following the home visit itwas agreed that I ought to contact theEncephalitis Society who had a greaterknowledge of the medical condition. Ispoke to Jon the next day who has beena mine of information and support.

The discharge took place without anyfollow up appointment and without anyinformation where I could receive supportfrom the various societies. The dischargeform also identified the proper medicalcondition which I had not been madeaware of during my stay in hospital.

On my return home, and lacking in advicefrom the hospital, I quickly discoveredwithout hospital staff monitoring that I was far from well as there were issueswith remembering certain functions. After a week, and becoming frustrated bymy inability to appear normal and stillsuffering from headaches, I decided togain further information and contactedthe Meningitis Society. After a very long discussion they agreed it was verynecessary for them to come for a home visit.

http://www.meningitis.org/

http://www.encephalitis.info/


JULIE

I have had four operations over the courseof the past few years and, in general, I have found the discharge procedure tobe quite a slow one. To be told early / midmorning that you can go home yet still beat the hospital late afternoon is highlyfrustrating. The main delay is usuallycaused by having to wait a long time forthe nurses to collect any tablets prescribedfrom the hospital pharmacy. On oneoccasion they couldn't find anyone seniorenough to sign the discharge paperworkso I had to wait for the staff to tracksomeone down before I could eventuallyleave. I understand that staff have otherjobs to attend to but, in my experience ofhospitals, nobody seems to follow any jobthrough from start to finish.

Surely it makes sense for staff to beproperly organised and concentrate ongetting the patient out of the hospital asquickly as possible as this will free upboth their workload and the bed itself.The longer a patient is kept on the wardthe more it costs, as they still have to befed and watered at the hospital’sexpense. Not only that, the patient is leftin the dark as to what the currentposition is, and often wonders if theyhave been forgotten.

As both my parents have also been inhospital during the past year, I can alsocomment on their experiences. My motherhad pretty much the same experience asme; one nurse would promise to fetch a

new drip she needed but then woulddisappear. A few hours later a secondnurse would appear and ask why the driphadn't been replaced. She would then goto get a new one only to disappear aswell! My mother’s discharge was quite alengthy process too. However, in directcontrast to the above, my father was notkept waiting for very long at all when hewas discharged after his operation earlierthis year, so it proves it can be done.

SUSAN*

I had an operation in 2010 and found mystay in hospital to be a surprisinglypleasant experience. The doctors andnurses, although extremely busy, werealways very considerate, polite and kind. I was assigned one nurse to my care, whoexplained everything clearly includingwhat my medicines were for, how andwhen to take them, and the potential sideeffects. She also provided help witharranging transport from the hospital tomy brother’s house. However when thetime came for me to leave, the ambulancewas delayed by four hours. It was a bit ofa nuisance because everything was inplace for me to leave, but the staffmembers were very apologetic.

LOUISE*

I developed Guillain Barre syndrome whichcaused extensive weakness, especially ofmy legs. I was looked after in the localhospital where the multidisciplinary teamprovided a very successful discharge backhome. While awaiting a care package, I was encouraged and enabled to sit outof bed and was allowed to go out onshort trips in a car with my husband whichhelped my recovery enormously.

*a pseudonym.


HELEN*


My brother-in-law had a lower legamputation following an industrialaccident last summer. He was initiallytaken to a specialist skin graft unit wherehe had access to specialist physiotherapyfor amputees and care for the grafts. The difficulty was that he was ‘out ofarea’ and no local social servicesassessments could begin until he movedback ‘into area’. He pushed for this andpulled strings to organise a transfer to alocal hospital after 2-3 weeks so that theprocess regarding assessment of theirhouse could begin.

At this second hospital he was kept for aweek and then transferred to anotherhospital, without notice or consultation,and was put on a ward for strokepatients. This distressed him greatly.

My sister had to take him for the onehour and 30 minute drive back to thespecialist unit for dressings and reviewseach week, as neither of these latterhospitals ordered in the necessarydressings. It would have been muchbetter if he could have stayed in thespecialist unit while the local accessibilityassessments and discussions with socialservices were taking place.

The subsequent social servicesOccupational Therapy assessmentrevealed that their house could not bemade accessible for someone likely tocontinue using a wheelchair on a regularbasis, and that they would have to movehouse – possibly into a suitable HousingAssociation property for which theywould be considered eligible.

He could have been in the hospital formonths and was clearly considered to bea ‘delayed discharge’. Thanks to familysupport, an interim solution has beenfound and somewhere has been rented.The worry is whether or not, once he hasbeen discharged, he will be able toorganise the transport necessary for hisongoing rehabilitation. He is only nowbeing measured for a prosthetic and itwill take time for him to learn to walk.

*a pseudonym

DR CHAAND NAGPAUL Chair of the BMA’s General Practitioners Committee

effect, such as creating delays for otherpatients in A&E waiting for a hospitalbed. The solution is one of better internalorganisation and planning withinhospitals, which would be of benefit notjust to the patient, but equally for thehospital which would be maximising itsbed availability for other patients.

Helen’s story about her brother-in-lawdemonstrates that hospital dischargesare often dependent upon effectivecoordination with social care. In thisexample, a social services assessmentprior to discharge into his homeenvironment could not take placebecause he was being treated in adistant specialist hospital, which was ‘out of area’ to his local authority.Subsequently, on establishing that hishouse was not suitable for wheelchair

access, this would ordinarily haveresulted in him remaining in hospital for possibly months as a ‘delayeddischarge’ while alternative housing was found, was it not for his familyintervening with a private housingarrangement. It is important that suchbarriers in the interface between theNHS and social care are addressed andprevented, since as highlighted in thisexample, it can cause much unnecessarydistress for both the patient and family.

Dr Chaand Nagpaul

Chair of the BMA’s General

Practitioners Committee

Patients often tell GPs about theirdifficulties in being discharged fromhospital. In most cases these are causedby preventable administrative ororganisational factors.

Julie’s story highlights an extremelycommon problem in the protractedprocess that can take place on the day of hospital discharge. In this example, a simple task of being provided withdischarge drugs and a summary tookfrom morning to evening, which meantthat she unnecessarily occupied ahospital bed for several hours, whichcould have been available for anotherpatient. This causes inconvenience notjust to the patient, but also to relatives or carers with a responsibility to take thepatient home. Such administrativeinefficiencies also have a knock-on


JACKY

Mum had a stroke on the 10 August2012. She was taken to an Acute StrokeUnit and my first impression was thateveryone was working to targets; thedeadline in the acute ward was four days.Once the four days were up, she was tobe moved to a rehab stroke unit inanother hospital and there was a delay indischarge on that. I stayed in hospital fortwelve hours waiting for transport, and it caused a huge amount of distress formyself and my mother. Mum was saying ‘I thought we were going, I thought wewere going’ and she became very anxious.At 7.30pm I asked the staff nurse whetherher discharge was going to happen, andshe said ‘no… it will happen in themorning now.’

I was called the next day, and they told meto arrive at the hospital for 11am. Theyeventually moved her at 7.45pm. She’s avery elderly lady, paralysed down one sideof the body, and she was shunted to theother hospital.

We got there at 8.30pm. The stress foreverybody because of the transfer wasunbelievable. They kept saying ‘oh it’stransport; you have to wait your turn.’ The staff members were pressurised tofree the bed because she didn’t requirethis specialist service anymore after four days.

We then got her into the specialist strokerehab unit. Again we were told, becauseof the nature of mum’s stroke, they have a six week target.

Everything was chaotic once the six weekswere up. Everyone got involved, fromsocial services, discharge nurse to wardsister. I met the nurse liaison a couple ofdays after the six weeks were up, whenthey were putting in the motions ofdischarging her.

The delay in discharge was trying to geteveryone together and arrange for her tobe moved out of her borough – to myborough – so she could live with me. My Mum’s borough was paying for thecare but my borough was providing it, andthe lack of coordination was unbelievable.She was sitting in a bed and she didn’tneed to be there anymore. She was therefor two weeks longer than she shouldhave been, purely because of the lack ofcoordination. Eventually on the day shewas discharged, the transport arrivedthree hours late.

Carer / family and doctor perspectives


CATHERINE

Having established that there wasnothing further that could be done formy Mum apart from palliative care, andwith her unconscious and not expectedto regain consciousness, we wereworking with the hospital to transfer herback to the care home. They were verykeen to look after her with help from thecommunity palliative care team anddistrict nurses.

A bed was ordered and dispatched, andan ambulance was booked. While wewere waiting to be told when she wouldbe moved, it transpired that, because myMum’s room was on the first floor andthere was no room available on theground floor at the care home, theambulance service was refusing to takeher beyond the threshold of the carehome. Neither would they allow the carehome staff to take her upstairs usingtheir stretcher. Apparently, if she hadbeen going to a private home, thiswould not have been the case and theambulance crew would have been ableto take her up the stairs.

We were told that unless we wereprepared to pay for a private ambulance,she would have to stay in hospital. In theend the situation was resolved by the“bed manager” who agreed that thehospital would pay for the privateambulance in order to free up the bedthat she would otherwise be ‘blocking’.

The transfer then went ahead and allwas well. Her last days were spentpeacefully at the care home where shecould be kept company by variousmembers of the family.

The day before she was discharged, I wasexpecting a checklist. The staff nurse wassupposed to sit down with me, but shewas run ragged and ended up getting myMum’s drugs mixed up with anotherpatient’s drugs.

The GP was very good, he called on thenight that she arrived back home, andcame to see her the next day to explainthe reality of her situation.

On reflection, someone like the dischargenurse should be the conduit for all this:‘this is what you can expect, this is whatyou need to do and this is what you needto take out of this hospital’. But after youleave the hospital, it is not theirresponsibility. So who do you contact?

The best person who helped once she wasdischarged was the liaison officer at theStroke Association. This role is linkedwith the stroke rehab unit at the hospital.She helped us understand Mum’scondition and outlined the support wecould get such as attendance allowance,carers allowance and other support suchas opticians, hairdressers, chiropodists,physiotherapists, speech therapists, districtnurses, and incontinence support. Withouther, my job as a carer would haveextremely difficult. She helped me put inplace the support my Mum needed andunderstand my rights as a carer. I think thisshould have happened before she wasdischarged into my care..

http://www.stroke.org.uk/


The very distressing story of Catherine’smother’s discharge for her expecteddeath at her place of choice might bestbe considered by a ‘Significant EventAudit’ involving all professionals andagencies. This could identify how afailure of joined up care occurred andprovide the opportunity for jointlearning. In my opinion, this failed the‘was this in the best interest of thepatient?’ test and if I had been there Iwould have tried to inject some commonsense in the ‘best interest’ of Catherine’smother and been prepared to defend myactions if challenged later.

A more senior person should have beencontacted to share the possible risks withthe patient and relative, seek theiragreement for the GP to take theresponsibility, and ask the staff to helpmove Catherine’s mother. A retrospectiveanalysis would identify that this problemshould have been identified before thedischarge and suitable risk sharingexplained and agreed with the patientsand the carer.

DR HELENA MCKEOWNChair of the BMA’s Committee on Community Care

Dr Helena McKeown

Chair of the BMA’s Committee

on Community Care

Targets seem to be having unintendedadverse effects, removing commonsense, care and compassion that areneeded during the days and the hoursthat are not associated with a targetdeadline. In Jacky’s experience, theuncertainty of waiting for ‘transport’ isnot caring and should be managed fromthe top of the hospital and ambulancetransport services as unacceptablyinhumane. We have a duty not to harmour patients; however, making them waitmany hours, without knowing whenthey are going to leave, clearly createsanxiety and may harm our patients.Discharge could be improved by more ofour community staff going into thehospital before discharge takes place,such as a Stroke Liaison Nurse.

BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective30 BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective 31

BARBARA

My father, an 89 year old widower wholived alone and led an independent life,was diagnosed with chronic liver disease.Four years later his condition haddeteriorated and he was admitted to our local community hospital having‘gone off his legs’. Whilst there he had a haematemesis (vomited blood) andwas transferred to a larger acute hospital via A&E.

He was admitted that evening to theEmergency Admission and DischargeUnit – a very busy interim unit forassessing patients. I returned the nextmorning and found him in a comatosestate. No one on this busy unit hadrealised he had slipped intounconsciousness.

Following a neurological examination I was told, in view of his medical historyand his current condition, there was littlemore they could do for him.

I felt very strongly that I didn't want himto die on a busy ward in a big hospital,so I requested that he be dischargedback to our local community hospital. I spoke to his GP who was happy toaccept him back to his care. Theconsultant was initially unhappy, as werethe ambulance crew, because of his verypoorly condition and the prospect thathe may die in the ambulance. I said I waswilling to take that risk, would sign anyforms and would take full responsibilityfor him. I would also travel in theambulance with him.

I was included in a discussion with theward consultant, the nurse practitioner, a member of the ambulance crew and award nurse, and it was agreed that myfather could be discharged out ofhospital back to our local communityhospital to die.

I felt that the hospital staff understoodwhat I was feeling and allowed me (in theabsence of my father unable to make thatdecision himself) to have him transferred.He died a few days later in a comfortablesingle room in our community hospitalwith compassionate nursing staff caringfor him and with his family at his bedside.I felt this was the best possible outcomefor my father and was very grateful to thestaff of the acute hospital to have madethis possible.

MICHAEL*

My wife had terminal cancer and wasadmitted to hospital because of a rapiddecline in mobility and problems withsymptom control. The latter was achievedwith use of a syringe driver but hermobility remained very poor so that shewas unable to climb stairs. She made itvery clear that she wanted to go home todie but our house was very small with nobathroom downstairs. I felt that I wouldn’tbe able to care for her adequately if she was sleeping downstairs. Themultidisciplinary team, which included asocial worker, worked rapidly to ensure anaccelerated discharge; a local healthcharity paid for the installation and rentalfor a stair lift which, with regular carers,enabled my wife to live very comfortablyin the last six weeks of her life at home.

*a pseudonym

PAT*

My uncle, a 75 year old man, had a strokeand was sent the nearest hospital whichwas 28 miles from his home. The hospitalteam was planning to send him to anursing home as they felt he and hispartner, who had severe mental healthproblems (bipolar, although quite stable attimes) wouldn’t manage. My uncle verymuch wanted to go home and so did hispartner, but she was refusing any help. It was difficult because his partner wasrelying on poor public transport to see him as she didn’t drive.

He was transferred to the communityhospital where, because the localmultidisciplinary team knew him and hispartner, they understood the potentialdifficulties but were willing to try to get

him home. His partner was allowed to beinvolved in his care in the communityhospital; she was taught how to transferand care for him, facilitated by thephysiotherapists, Occupational Therapistsand nurses. Successful discharge occurredafter a planning meeting and homeassessment visits, with his bed being ‘kept open’ for two days followingdischarge in case of disaster. He remainedat home for four years with the support ofdistrict nurses, as he had a long-termcatheter and his GP, but no extra carers,until his partner sadly died.

*a pseudonym


Further information NHS Information for patients leaving hospital:www.nhs.uk/NHSEngland/AboutNHSservices/NHShospitals/Pages/leaving-hospital.aspx

The British Red Cross ‘Independent living’ services for people when they face a crisis in their daily lives:www.redcross.org.uk/What-we-do/Health-and-social-care/Independent-living

Age UK ‘going into hospital’ resource:www.ageuk.org.uk/health-wellbeing/doctors-hospitals/hospital-discharge-arrangements/

NHS practical support for carers:www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/hospital-discharge.aspx

Carers UK ‘planning the discharge process’ resource:www.carersuk.org/help-and-advice/practical-help/coming-out-of-hospital/discharge-planning

‘Hospital to Home’ resource pack for all professional sectors that have a role in hospital discharge for older people:housinglin.org.uk/hospital2home_pack/

Please note that all external links are provided for your convenience: the inclusion of any link does not imply the BMA’sendorsement of the website, its operator or its content. The BMA is not responsible for the content of any external website.

BMA Patient Liaison Group: Hospital discharge: the patient, carer and doctor perspective32

References1 Department of Health (2004) Achieving timely ‘simple’ discharge from hospital: A toolkit for the multidisciplinary team. London:

Department of Health.

2 Bryan K (2010) Policies for reducing delayed discharge from hospital. British Medical Bulletin 95:33-46.

3 Royal College of Physicians (2012) Hospitals on the edge? The time for action. London: Royal College of Physicians.

4 Department of Health (2010) Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care.London: Department of Health.

5 Glasby J (2003) Hospital discharge. Oxon: Radcliffe Medical Press.

6 Department of Health (2003) Discharge from hospital: pathway, process and practice. London: Department of Health.

7 Wong E, Yam C, Cheung A et al (2011) Barriers to effective discharge planning: a qualitative study investigating the perspectives offrontline healthcare professionals. BMC Health Services Research. 11:242.

8 Association of Directors of Adult Social Services (2010) Carers as partners in hospital discharge. London: Association of Directors of Adult Social Services.

9 Katikireddi V & Cloud G (2008) Planning a patient’s discharge from hospital. BMJ 337: a2694 doi:10.1136.

10 Department for Work and Pensions (2013) Fit note: guidance for patients and employees. London: Department for Work andPensions.

11 Department for Work and Pensions (2013) Fit note: guidance for GPs. London: Department for Work and Pensions.

12 Department for Work and Pensions (2013) Fit note:guidance for hospital doctors. London: Department for Work and Pensions.

housinglin.org.uk/hospital2home_pack/

www.carersuk.org/help-and-advice/practical-help/coming-out-of-hospital/discharge-planning

www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/hospital-discharge.aspx

www.ageuk.org.uk/health-wellbeing/doctors-hospitals/hospital-discharge-arrangements/

www.redcross.org.uk/What-we-do/Health-and-social-care/Independent-living

www.nhs.uk/NHSEngland/AboutNHSservices/NHShospitals/Pages/leaving-hospital.aspx

BMA Science and Education Department British Medical AssociationBMA HouseTavistock SquareLondonWC1H 9JHT 020 7383 6687E [email protected]

© British Medical Association, 2014

The BMA Patient Liaison Group would like to thank all the doctors, patientsand carers who have taken part in this publication.

CLICK HERE TO RETURN TO THE START

mailto:[email protected]

www.bma.org.uk

JANUARY 2 01 4 Hospital discharge: the patient, carer and ... · BMA Patient Liaison Group:...

Documents

Transcript of JANUARY 2 01 4 Hospital discharge: the patient, carer and ... · BMA Patient Liaison Group:...