Poor quality discharge processes, delayed discharge, being discharged too early or not having the correct support in place prior to discharge from hospital can all have a profoundly negative effect, especially with vulnerable patients. Patients who are discharged too early are more likely to be readmitted, without suitable care in place. Those who are discharged too late are at a higher likelihood of acquiring infections and have poorer recovery rates.
For the purposes of this report, vulnerable groups include:
• Older people
• People with a disability
• People who are homeless
• People with mental health issues
• People who are socially isolated
• People requiring ongoing care and support
• People with dementia
Queen Elizabeth Hospital has a Discharge Policy in place as well as ‘Discharge Lounge Standard Operating Procedure’ guidance.
These documents specify that when admitted to hospital, a treatment plan with details about discharge or transfer, should be developed and discussed with the patient. A discharge assessment should determine whether further care will be needed after leaving the hospital. It is essential the patients are fully involved in the assessment process. Ideally, family or carers should also be kept informed and given the opportunity to contribute, (assuming the patient consents).
If the assessment determines that little or no care is needed after discharge, it is called a ‘minimal discharge’. If more specialised care is needed after leaving hospital, the discharge or transfer procedure is referred to as a ‘complex discharge’. If a complex discharge is identified then a care plan should be developed, detailing the health and social care needs of the patient. This should again be completed with the patient and they should be fully involved in the process.
The Care Quality Commission (CQC) carried out a routine inspection of Queen Elizabeth Hospital from 26th - 28th February 2014 and published the report on 13th May 20144 . The medical care at Queen Elizabeth Hospital was rated as Requires Improvement and the Emergency Department was rated as Inadequate.
CQC did a follow up unannounced inspection on 7 th, 8th and 18th June 2016 to assess if improvements had been made. The report was published on 3rd November 20165 . This report noted that although improvements had been made more work was still needed. Medical care was rated as Requires Improvement and the emergency department was now also rated as Requires Improvement (although better than previously rated). The number of beds available is an ongoing issue throughout the hospital and has an impact on the emergency department. The safe and effective discharge of patients is essential for the smooth running of the hospital.
To consider the issues around hospital discharge in Greenwich we held a focus group to discuss experiences with patients, carers, and residents. We also scheduled Enter and View visits to the discharge lounge at QEH to talk with and gather feedback from patients who are preparing for discharge.
Treatment by healthcare staff
The treatment received by patients admitted to Queen Elizabeth Hospital was highly rated. Individuals said they were treated with respect and compassion throughout their stay. There was some concern from patients that although they may have been clinically fit for discharge they did not feel ready.
• Recommendation 1: Consideration should be given to the patient’s own feelings about whether they consider themselves ready for discharge. If a patient is physically ready to be discharged but they do not feel they are, the Hospital must work with the Royal Borough of Greenwich adult social care team to ensure that not only their physical support needs are catered for, but also their emotional and social needs.
• Recommendation 2: The hospital should produce a discharge checklist, which lists all services that the patient could be referred to with contact details and how to access them. The discharging Nurse can then tick and sign the services recommended for the patient.
Readmission of patients we spoke to was high, with 80% having been previously admitted within the last 18 months. The discharge patients we spoke to were complex discharges and more simple discharge patients may not need to transition through the discharge lounge.
• Recommendation 3: Clear information about the discharge process should be given to all patients when they are first admitted. Their housing and support needs should be identified early to ensure a suitable discharge plan is developed with the patient. Where additional needs are identified, these should be assessed for and put in place well before discharge.
• Recommendation 4: More effective and consistent use of the ‘care card’ well in advance and just prior to discharge will help to ensure patients feel ready to go
Bed usage & delays
We found beds were not always used appropriately, and the discharge lounge was sometimes used as an overflow for other wards. This reduces the effectiveness of the lounge as a place of transition, placing an increased workload on the staff, which may reduce the amount of time they have ensuring the discharge patients receive the support and information they need.
In addition, spreading patients around the hospital increases the amount of time consultants spend ‘on safari’ looking for their patients, reducing the amount of time they can spend with each patient. It also means the patients may not be receiving the specialist nursing care they would receive on the appropriate ward. More effective use of the discharge lounge by the hospital should in theory help to relieve pressure on beds by ensuring people are moved on as efficiently and safely as possible.
• Recommendation 5: Although we recognise the pressure on space across the hospital, the discharge lounge should not be used as an overflow for other wards in the hospital.
Care home bed embargoes following poor Care Quality Commission (CQC) inspections are contributing to delayed discharge from the hospital.
• Recommendation 6: Lewisham and Greenwich NHS Trust, Greenwich CCG and RBG must work together to jointly commission and fund an increase in suitable short and long-term beds to ensure that patients can get the care they need outside of the hospital setting in a timely manner.
• Recommendation 7: The Trust, CCG and RBG could work with the CQC and local care home providers to identify and commission a ‘task force’, made up of improvement specialists to go into services recently rated inadequate and tackle the identified issues, with a view to returning the embargoed beds into full use more rapidly.
Communication/Information about discharge and support services
Communication was probably the single most important issue we picked up throughout this programme. Generally, communication throughout a patients’ admission was found to be good, with patients mostly feeling involved and informed when it came to the discharge process. However, there were several aspects of communication that were felt to be lacking, particularly around the information given to patients about their medication, the support available after discharge and more importantly, how to access that support.
• Recommendation 8: Prior to the discharge process, patients should be asked about their housing situation and the care and support they have in place. If the post-hospital situation is unsuitable, an expedited, jointly commissioned, assessment should be carried out to ensure that a package can be rapidly put in place. This will help prevent prolonged and unnecessary hospital stays and reduce readmission rates.
• Recommendation 9: LGT should have a patient representative sitting on the discharge planning group.
Housing and family/community support after discharge
40% of the people we asked said they were not asked about their housing situation or about their available family/community support when planning their discharge, and 20% said they were ‘Unsure’
Recommendation 10: The hospital, Greenwich CCG and RBG should develop a homelessness discharge pathway and protocol that reflects the multiple needs and complexity of homeless discharge. Feedback from people who are homeless is key to ensuring that this happens effectively. There should be a named person at the hospital with responsibility for identifying people who are homeless on admission, to then work with RBG Housing Options and/or Adult Social Care teams to identify a safe and suitable discharge plan.
Of the people who were prescribed medications after discharge from hospital, 30% said they were not given clear instructions on how and when to take them.
• Recommendation 11: Patients being discharged, who have been prescribed medication by the hospital, must be fully informed of how and when to take the medication. Ideally, this would be written in an easy to understand format that the patient can take with them.
• Recommendation 12: Similarly, if patients are taking prescribed medication prior to admission which is then changed during their hospital stay, the reason and the implications of the change must be clearly explained to the patient, and ideally written down in an easy to understand format.