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Before the COVID pandemic, hospital admissions in the UK for the year 2019/2020 were 17,202,558. Of these, 6,509,586 were emergency admissions and 8,842,098 were elective admissions. (Source NHS Digital)
Prior to COVID-19, the average hospital stay was 6.2 days. However, the Nuffield Trust has reported that in the week ending 5 December 2021, on average per day, there were 19,167 patients in English hospitals who met the criteria for leaving hospital but of these, 55% (10,510) on average per day were not discharged, rising to 60% (12,819) in the week ending 23 January 2022.
Among patients who had been in hospital for 21 days or more, the situation was even more stark. Since the week ending 5 December 2021, on average, nine in 10 patients who met the discharge criteria each day were not discharged. One in 10 available general and acute beds per day have been occupied by a patient who, according to the criteria being used, was fit to leave hospital but who was not discharged.
Analysis by Age UK shows that the average excess bed day, that is the cost of a patient remaining in a hospital bed after their treatment has ended, costs £346.
NHS England and NHS Improvement (NHSEI) issued a statement to hospital trusts in England to work with local partners to cut delayed discharges by half by the end of January 2022.
The Department of Health and Social Care issued new hospital discharge and community support guidance applicable from 1 April 2022 setting out how NHS bodies, including commissioning bodies, NHS trusts and NHS foundation trusts, and local authorities, can plan and deliver hospital discharge and recovery services from acute and community hospital settings.
What is hospital discharge?
When someone has been admitted to hospital for a stay of one or more nights, the time will come for them to leave; this is known as being discharged. In general, it is the hospital medical professionals who decide that someone is ready to leave their care. The hospital will have been preparing a discharge plan since the patient’s admission to hospital or at pre-admission clinics the patient may have attended.
A predicted date of discharge should be identified within 24 hours of the hospital admission and will have been agreed with and communicated to each individual patient and, if appropriate, their carers/relatives.
However, there are circumstances where the patient may make the decision themselves to leave; this is called being discharged against medical advice (AMA). To be discharged AMA, the patient has to sign a self-discharge declaration stating they wish to leave even though the healthcare provider thinks it is a bad decision.
What is the hospital discharge process?
For some people, leaving hospital can be just as unsettling as going into hospital, so having a hospital discharge process is not only good practice for the hospital but it can also be reassuring for the patient to know what happens next.
Through the hospital discharge process, hospitals aim to ensure coordinated safe and timely discharge to all in-patients from the hospital to home, to other healthcare organisations, or to social care. The Department of Health and Social Care has stated in its new hospital discharge and community support guidance that “From 1 April 2022, NHS bodies and local authorities should adopt discharge processes that, in their judgement, best meet the choices and needs of the local population”. This could include the Discharge to Assess/Home First approach.
Under this approach it assumes that the vast majority of people are expected to go home to their usual place of residence following a hospital discharge. This may be to return to their own home or, if they are a care setting resident, to return to their residential care setting.
In elective care, planning for hospital discharge can commence before admission, so that the patient and their relatives or carers are prepared for what is going to happen and when.
Planning for a patient’s discharge from hospital is a key aspect of effective care. In emergency, unscheduled care, advance planning is not possible, so robust systems to gather patient information must be in place so that the planning process for hospital discharge can begin as soon as possible.
Minimal discharge and complex discharge
Medical professionals use two terms to describe hospital discharges; these are minimal discharge and complex discharge. A minimal discharge means the patient will need little or no additional care once they leave hospital. A minimal discharge is one that can be carried out at ward level with the multidisciplinary team (MDT).
A complex discharge indicates that the patient will need more complex care post-discharge from hospital. Funding issues, change of residence or increased health and social care needs make the discharge complex.
To establish the help that a patient may require, the assessment of needs includes:
- The complexity of a patient’s needs.
- The intensity or severity of a patient’s needs.
- The extent to which their needs may be unpredictable, and any potential effects on their health.
For the majority of hospital admissions, the discharge will be a minimal discharge. The length of stay and the discharge plan will have been agreed prior to the admission or as soon as possible after admission. The patient and/or carers should agree to the discharge plan and this must be documented in the discharge plan.
The discharge plan could include, for example, care provision by relatives, a restart of a care package or a return to a usual care home setting following assessment by the care home to check that they can still provide the appropriate care needed.
Where a care plan has already been in place, the hospital discharge team will contact the care setting to ensure that the care plan is reinstated following the patient’s hospital discharge.
If a patient’s discharge assessment reveals that they have ongoing care needs, they will need to receive a care needs assessment. This will identify the full scope of health and/or social care needs to be supported, and how to best manage them outside of hospital. Some patients may qualify for NHS Continuing Healthcare.
This NHS funding can be used to pay for ongoing full-time care if care is required for a primary health need. Older patients discharging from hospital should be assessed for NHS Continuing Healthcare before being discharged from hospital. NHS Continuing Healthcare can be provided at a patient’s home or in a care home setting.
It should be noted that there have been changes to hospital discharge policies since the start of the COVID pandemic, which means that patients must be discharged as soon as they no longer need care in hospital.
For most patients leaving hospital this will mean that, where it is needed, the assessment and organising of ongoing care will take place when they are in their own home or residential care setting. These policy changes remain fluid to react to the challenges of the pandemic.
When would you be discharged from hospital?
It is important to note that every hospital will have a different discharge policy, and a request for a copy of a specific hospital’s discharge policy can be made via the Patient Advice and Liaison Service (PALS).
Generally, discharges are planned to take place before midday and the decision to discharge someone from hospital is dependent upon:
- The Consultant declaring the patient medically fit to leave hospital.
- Whether it is safe for the patient to be discharged.
- Whether the patient has been given written information that sets out the support that they will get following their hospital discharge.
What this means is that, whilst a patient should not stay on an acute hospital ward any longer than absolutely necessary, discharge from hospital can only happen when a clinician has decided that the patient is medically fit for discharge. However, this does not mean that the patient is now “well” or now has no medical conditions.
In addition, Health and Social Services must be satisfied that the discharge would be safe, which means that there is an appropriate care and support plan in place for the patient. A Discharge Coordinator should be appointed, who will explain how the discharge will be managed and provide other information needed by the patient, and they should be the point of contact for the patient, their relatives and/or carers throughout the discharge process.
It is the Discharge Coordinator’s role to organise assessments of needs and to coordinate the process, that is to bring the relevant health and social care professionals together, give timescales etc.
As highlighted above, during the COVID pandemic hospitals have been advised to discharge patients as soon as they no longer need care in hospital, so in many cases full support information may not be provided on hospital discharge but should be made available as soon as possible.
How to prepare for hospital discharge
During a hospital stay, the staff on the ward should discuss the patient’s needs on discharge with them, and/or their relatives and carers, and should work with the patient to plan their discharge before they leave hospital.
Before hospital discharge, health and social care assessments should be undertaken to identify the patient’s needs and whether they will require further care and support after discharge. A patient’s consent or that of their relative or carer should be sought before carrying out an assessment of needs.
An assessment of needs will help to identify a patient’s ability to manage on leaving hospital and options should be explored and agreed with the patient or their relative or carer. An assessment of needs should always be completed before Social Services undertake a financial assessment.
This is because a patient has a right to an assessment of their needs regardless of whether Social Services will be funding care or support or the patient will be funding it privately.
A Care Plan should then be drawn up. This should detail the help and support that is needed and confirm how the care will be delivered. All options must be explored, with the objective being to maximise the patient’s independence. The patient’s ability to pay for or contribute to any Social Services care should then be undertaken by means of a financial assessment.
If it is decided that the patient lacks the capacity to make a decision about their needs and if no one has been appointed to act on their behalf, such as by a Lasting Power of Attorney for Health & Welfare, or someone else that they have given their express written permission, Health and Social Services must act in their best interests.
This should involve a Best Interest meeting in which family or close friends are invited to attend, that is the people who have a genuine interest in the patient’s welfare.
During this assessment and preparation for hospital discharge, patients and/or their relatives or carers may have a number of questions that they should explore with the Discharge Coordinator.
- Have the patient’s needs been properly assessed?
- What support is available after discharge from hospital?
- Will the patient have to pay towards the cost of any care/support provided?
- What is respite care, is it available and will the patient have to pay for it themselves?
- What is intermediate care and re-enablement?
- Will the patient require long-term or short-term care?
- Should the patient be getting NHS or Social Services funding?
There are also some very practical things that patients and/or their relatives or carers will need to prepare and do. Some of these things may seem fairly obvious but they can easily be overlooked.
These will include:
- Making sure that the patient has suitable clothes to go home in, including shoes and a coat. Often visitors can help by bringing in what is needed from a patient’s home.
- Making sure that the patient and/or their relatives or carers have a front door key to the patient’s home if they are being discharged to home, and that there is transport arranged; this might be a relative or friend’s car or a taxi service. If it is a taxi, has the patient the means to pay the fare?
- Will the patient need any special equipment to use on their discharge such as a walking frame or wheelchair? Charities such as the British Red Cross hire out small pieces of equipment such as wheelchairs at a low cost.
Other practicalities to consider if the patient is returning to their home might include relatives or friends arranging to:
- Switch the heating on.
- Make the bed up.
- Have a tidy up if needed, to prevent any slips, trips and falls.
- Shop for basic food supplies, such as bread and milk.
- Prepare a meal for the patient’s return.
It is important that a patient’s home is ready for their return. It is the hospital’s responsibility to ensure that a patient doesn’t leave hospital unless adequate arrangements for their support at home have been made.
They and/or their relatives or carers should be given the name and contact details of the person coordinating their discharge. This person is often known as a Discharge Coordinator or Ward Coordinator and they are there to oversee a hospital discharge and can help to sort things out.
What happens during hospital discharge?
Ward staff generally manage the discharge of patients needing only minimal help when they leave hospital; for example, they may need help with transport home or arranging someone to switch on the heating. They can provide information on organisations that can provide additional help, perhaps for a few weeks, with tasks such as shopping, providing meals and housekeeping.
When a patient is ready to leave, they may be asked to wait in the discharge lounge. The lounge usually has a large number of comfortable chairs, and often hot and cold meals can be delivered and hot drinks are available. There is often a television and plenty to read while the patient is waiting for the discharge process to complete.
If a patient has made arrangements for someone to collect them, they should advise them to meet in the discharge lounge at whatever time the hospital has instructed. They should also remind whoever is collecting them to bring clothes for them to go home in and also make sure that they have their house keys if they are being discharged to their own home.
When being admitted to hospital, any valuables or money may have been handed in for safekeeping, so a patient needs to ensure that they ask for these to be returned before they leave.
Discharged patients should ensure that they have any medicine that they need and that their nurse has explained when to take it and what it is for. Medication to take out may have been supplied on the ward or may be delivered to the discharge lounge, and the ward staff will ensure that the discharge lounge staff are aware if a patient needs to wait for medicines.
A qualified nurse and a health care assistant are usually on duty there to care for patients waiting to be discharged. If a patient requires a medical certificate, they or a relative should have informed the doctor or a member of the nursing team of this.
Before being discharged and leaving the hospital, patients should also make sure that they know the date and time of any follow-up outpatient appointment if they need one.
What happens after hospital discharge?
When they are discharged from hospital, some people will only require minimal care arrangements such as outpatient appointments, or they might need assistance including help getting dressed, preparing a meal, or getting up and down stairs.
For others, a team with a mix of people from the NHS and Social Services will help them to do the things they need to do to stay independent.
Hospital staff should have arranged the patient’s care requirements before they leave hospital and this may include visits from or appointments with:
- A nurse.
- An occupational therapist.
- A physiotherapist.
- A social worker.
The patient’s GP will also have been informed of their discharge from hospital and may arrange appointments to monitor the patient’s recovery.
Most people who receive this type of care do so for around 1 or 2 weeks, although it can be free for a maximum of 6 weeks. It will depend on how soon they are able to cope at home. When this aftercare finishes, the team should work with the patient and/or their relatives or carers to agree on what happens next.
This should include:
- Identifying other care that the patient might need, such as home help.
- How the patient can refer themselves again if they need to.
- What they should do if something goes wrong.
- Information about what other types of support or equipment might help.
Every discharged patient will have very individual needs so it is important to work with the aftercare team to identify the best solutions for their particular needs.
Any hospital stay can be stressful irrespective of the reason for it, as can the thought of being discharged after a hospital stay. This is why planning for discharge and putting aftercare in place before the patient is discharged is important for the patient’s peace of mind and to ensure that people are not left vulnerable to a risk of readmission to hospital.
As well as the services that the NHS provide, there are a number of other agencies that can help with patient aftercare services.