When I read the newly updated Cochrane review about discharge planning, a memory was stirred about my nursing Finals and answering a question on this aspect of care. I still have the exam papers and, yes, there it is. The question is one of several about an anxious ‘Mr Levin’, who has been told he can go home in four days’ time, and asks us to ‘discuss the nurse’s role in preparing him and his family for his discharge and for leading an active life’. Preparation; care of the patient and his family; concern for what happens beyond freeing up the bed. Of course I’ve no record of my answer, but I’m sure I will have used all the information I was given about Mr Levin and family, along with more general knowledge about his condition, to plan his discharge from hospital.
Does this sound familiar? There is new evidence on how tailoring a discharge plan to the individual compares with a routine process of discharging people from hospital, from a Cochrane review comparing these approaches.
Discharge planning: routine or personalized?
The review broadly defines the aims of discharge planning as these:
- Reduce hospital length of stay
- Reduce unplanned readmission to hospital
- Improve the co-ordination of services following discharge
The Cochrane review has just been updated and includes 30 randomized controlled trials (5 from the UK) with almost 12,000 people. Older patients with a medical condition were recruited in 21 trials and data from these were pooled. The remaining trials involved people with a mix of medical and surgical conditions, patients from psychiatric hospitals and others admitted to hospital following a fall.
Here’s what they found:
- A personalized discharge plan probably brings about a small reduction (just under a day) in the length of hospital stay for older people with a medical condition
- A personalized discharge plan probably reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition (about 3 fewer in every 100 people)
- For elderly patients with a medical condition, there was little or no difference between groups for mortality
- Discharge planning may lead to increased satisfaction for patients and healthcare professionals
- It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall
- It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition
How good is the evidence?
The evidence on hospital stay and readmission for older patients with a medical condition is rated as moderate (GRADE), so we can say that personalized discharge plans probably lead to reduced length of stay and readmission to hospital.
Whilst discharge planning may improve patient and staff satisfaction, the evidence is weaker (rated ‘low’). Only six studies reported this outcome, which they measured in different ways, and findings were not consistent across studies. The impact of discharge planning on costs, and for those admitted to hospital following a fall, remains unclear.
The reviewers note that whilst all the studies included some description of the discharge process, it was not possible to evaluate the relative contribution of the component parts. They are also surprised by the failure to evaluate the effectiveness of communication between discharge planners in hospital and providers of services in the community.
However, the body of evidence is growing. Review author Dr Sasha Shepperd, from the Nuffield Department of Population Health (University of Oxford), commented: “This is a simple service delivery intervention and it is encouraging to see the volume of randomized evidence that can support decision making.”
What does this mean for you and your patients?
So a personalized discharge plan probably means that your patients leave hospital a little sooner and that a few will be spared readmission in the first three months. They may be happier with the process, and so may you, though we have little evidence to go on. It makes sense, doesn’t it? Being able to tailor care to your patient and their family, to their individual needs, preferences and set of circumstances, is always going to be better than processing them to a formula, surely?
That individualized discharge planning doesn’t hold things up is good to know and should gladden the hearts of those responsible for managing bed availability. It’s also good for patients to leave hospital as soon as it ceases to be the best environment for their recovery. Longer hospital stays increase the risk of hospital acquired infections and loss of independence for many elderly patients.
New approaches to transfer of care
In 2015, Queen Elizabeth Hospital Birmingham introduced a Complex Discharge Team as part of a pilot study to tackle delayed transfer of care, with considerable success. You can read more about that here.
Oxford University Hospitals NHS Foundation Trust also recently implemented a new approach to tackling delayed discharge from hospital, with health and social care providers working closely together to enable patients who no longer need acute medical care to move into a care home for the next stage of their recovery. This has immediately reduced the number of patients delayed in acute care and community hospital beds. It will be good to know what other benefits this might bring.
Dr Shepperd reflected, “Adding a formal structure to a discharge planning process can help hospitals deal with the pressure on acute hospital beds by slightly reducing hospital length of stay, and supporting patients to move from an acute hospital to an environment that has been assessed as more appropriate to their care needs. It is possible that this has a longer term benefit by reducing the risk of re-admission to hospital following discharge.”
Putting the ‘I’ into discharge planning by Sarah Chapman is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000313.pub5/abstract.
Permissions beyond the scope of this license may be available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000313.pub5/abstract. The images have been purchased for Cochrane from stock.com and are not available for reproduction.
Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub5.
Plain language summary of this review: http://www.cochrane.org/CD000313/EPOC_discharge-planning-hospital
Oxford University Hospitals NHS Foundation Trust. “Joint action plan helps ‘delayed’ patients to leave hospital sooner.” Oxford University Hospitals NHS Foundation Trust News, 19 November 2015. Web. 15 February 2016. http://www.ouh.nhs.uk/news/article.aspx?id=387
Monitor, on behalf of Department of Health, England. Delivering better integrated care. 27 May 2014. [Last updated 11 March 2015]. Web. 09 February 2016. https://www.gov.uk/guidance/enabling-integrated-care-in-the-nhs
The latest relevant NICE guidance (informed by four Cochrane Reviews) together with its corresponding press release, is the following. It has associated pathways (http://pathways.nice.org.uk/pathways/transition-between-inpatient-hospital-settings-and-community-or-care-home-settings-for-adults-with-social-care-needs) and one of the main recommendations is to make a single person or team responsible for discharging patients
National Institute for Health and Care Excellence. Transition between inpatient hospital settings and community or care home settings for adults with social care needs. London: National Institute for Health and Care Excellence; 2015. (NICE NG27). [Issued December 2015]. Available from: https://www.nice.org.uk/guidance/ng27
National Institute for Health and Care Excellence. “Make a single person responsible for discharging patients to avoid delays”. NICE News, 1 December 2015. Web. 2 December 2015. http://www.nice.org.uk/news/article/hospitals-should-appoint-a-single-point-of-contact-to-avoid-delays-in-discharge