Discharge Planning in Hospitals: Why the Delay?

Discharge planning

Discharge planning from hospitals is a critical process that involves coordinating the transfer of a patient from the hospital to their home or another healthcare setting. The goal of discharge planning is to ensure that patients leave hospital in a timely manner and that they receive the appropriate care and support they need after being discharged from the hospital.

Delays in the discharge process are common and can have significant costs for patients, healthcare providers and for health systems more widely.

Failures of effective discharge planning and delays to discharge mean that patients enter a queue for admission to the hospital, often in the emergency department. Evidence shows that the consequent overcrowding causes significant morbidity and mortality.

Delayed admission for unscheduled patients (those that are most unwell) can therefore indirectly cause longer hospital stays, which exacerbates the problem.

In this article, we examine the causes of delays to discharge and problems with discharge planning, consider the costs and effects of this, and what can be done to improve this.

Causes of delayed discharge

Managing the discharge plan for a patient can be fiendishly complicated, especially for patients with complex needs. While admitting a patient is largely a matter of a sequential flow of activity, moving the patient from one place to another, the discharge process, by contrast, is multidisciplinary and requires parallel, coordinated activity from stakeholders both within and without the hospital.

Delayed discharge from hospital can therefore be exacerbated for various reasons, which can broadly be divided in to onsite problems, primarily caused by discharge planning problems, and downstream issues, the causes of which lie outside the remit of the hospital itself:

Discharge planning problems

  1. Lack of dedicated staff dedicated to discharge: discharge planning takes time. If staff are busy admitting patients or dealing with acutely ill patients, then discharge activity will necessarily take second place, and the key activities of discharge will be delayed.
  2. Lack of resources: discharge planning also needs specific resources, other than people, such as discharge lounges (where patients await discharge) or wheelchairs, ambulances or walking aids needed to move patients physically. Just taking discharge drugs from the pharmacy to the patient’s bedside may be a crucial factor and require systems for transporting items around the hospital.
  3. Poor communication: a lack of collaboration between healthcare providers, patients, and their families is a significant cause of delay in the discharge process. If families are not aware that a discharge is going to take place, they may not be ready. Different staff members may not be clear of the pieces of the discharge puzzle that may belong to them.
  4. Lack of good information technology (IT) platforms: the coordination of discharge requires significant collaboration, and many electronic medical record systems or hospital administration systems are not adequate, leaving staff to develop informal systems to compensate.
  5. Legal, insurance or other administrative issues: there are many other hurdles that may prevent timely discharge: lack of insurance (in non-socialised care settings); issues with the legal status of patients or even something as simple as finding the right type of transport for the patient’s needs.

Problems downstream of the discharge process

Even if the internal discharge planning process works seamlessly, there may also be reasons why a patient’s discharge is delayed:

  1. Lack of community or home care services: patients may require ongoing support to aid their recovery, such as social care services, rehabilitation, or step-down facilities. Without the right post-hospital support, the patient will remain in hospital even when ready for discharge.
  2. Lack of tertiary or specialist care services: discharge from hospital is not always to home. Patients with complex medical conditions may require specialised or tertiary care in other hospitals. Most — if not all — of these institutions will be resource constrained and may admit patients from a wide geographical area.
  3. Poor social housing: if the home from which patients were admitted is not a suitable discharge location, then this can cause long delays to discharge (sometimes many weeks), given that the state of their home may have directly or indirectly been the cause of the patient’s admission. This is a particular problem for health systems where health and care services are highly socialised, such as the UK NHS.

The effect of Covid-19 on discharge planning problems

It is worth noting that many of these problems have been exacerbated by the Covid-19 pandemic. Hospital and healthcare settings worldwide are facing increased demand as well as funding problems and staffing shortages. This has led to increased demand on hospitals, as well as delays in the transfer of patients from hospitals to post-acute settings. 

Costs and challenges of delayed discharge

Problems with discharge planning and delayed discharge has significant costs and challenges for healthcare systems, patients and their families. All of these are detrimental to quality of care.

Problems include:

  1. Increased overall healthcare costs: delayed discharge wastes resources by accommodating patients who have recovered in beds that are designed for patients who are unwell. This reduces the productivity and efficiency of health delivery in the acute sector.
  2. Reduced patient satisfaction: even relatively short delays in patient discharge can impact the overall experience of care, which is an important marker of quality. 
  3. Patient backlogs and waiting lists: patients awaiting admission, whether for scheduled or unscheduled care, are inevitably denied access to appropriate and timely interventions. This has a detrimental effect on patients, causing increased morbidity and mortality.
  4. Patient harm: the patients who are themselves delayed in hospital are more likely to suffer harm. Extended hospital stays are associated with increases in falls, hospital-acquired infections (HAIs) and other harms.
  5. Deterioration in mental health and wellbeing: prolonged hospital stays can impact patients’ mental state, which in turn can cause a decline in their overall health.
  6. Staff stress and burnout: hospitals with high levels of delayed discharge put extra strain on staff. Hospitals can experience high levels of over-utilisation – up to 140 or 150% of capacity in some cases. This puts stress and strain on staff who are trying to deal with discharges alongside admissions, unwell patients and routine work such as clinics and theatre lists.
  7. High readmission rates: paradoxically, many of the problems given above are also factors in causing patients to be readmitted. Poor discharge planning can often mean that patients fail to remain at home (a so-called ‘failed discharge’) and are readmitted for the same condition. 

Improving the discharge planning process and reducing delays to discharge

What can be done to improve this situation?  The solutions need to address the causes laid out above and so can be considered in two parts: in-house hospital discharge process improvements and system-wide changes to address issues downstream.

Improving the discharge planning process

Almost all discharge planning improvements come from improved collaboration and communication within the context of a multidisciplinary approach.

  1. Discharge planning leadership: discharge is a complex process that needs high-quality leadership and oversight. Hospitals who have improved the process have done so by appointing senior leaders to develop and improve the processes. Giving leaders the authority to change processes and direct improvements is a key element.
  2. Multidisciplinary discharge teams: Since discharge is a multidisciplinary effort, dedicated multidisciplinary teams with a focus on discharge must be put in place with clear responsibilities and accountabilities. 
  3. Criterial-led or nurse-led discharge: one of the consequences of approaching discharge planning in a multidisciplinary fashion can be the appointment of discharge coordinators that allow nurses, in particular, to authorise discharge, according to established criteria. 
  4. Including families and carers: ensuring that families and carers are fully involved in the discharge process will ensure that their concerns or objections will not delay the patient’s discharge. If the patient is to go home, then the family and carers will need to be confident they can look after the patient.
  5. Improving IT systems: the dire levels of information technology in most hospitals – even those with advanced HIS or EPR systems – means that staff collaborate using informal systems such as spreadsheets, clipboards and telephone conversations. Improved IT systems such as the CAREFUL platform (www.careful.online) are useful adjuncts to discharge planning. 
  6. Improvements to administration: many delays are caused by delays to insurance payments and other administrative and bureaucratic hurdles. Addressing ways to improve coordination and collaboration between clinical and non-clinical staff will improve the efficiency of the discharge process.

Improving problems downstream of the discharge process

As discussed above, many of the problems of discharge stem from issues downstream of the hospital. This means that solutions must be addressed by the wider healthcare system. This is more easily done in socialised systems such as the NHS, which attempts to coordinate health and social care.

  1. Expanding community or home care services: having enough downstream care facilities is clearly a crucial factor. This can include community hospitals, step-down facilities, nursing homes, rehabilitation services and so forth. Planning such services at the level of the population depends on the structure of the healthcare service involved.
  2. Managing specialist care services: where discharge is delayed by the lack of tertiary care services, this can be addressed by service reconfiguration (e.g. visiting specialists) and other innovations such as telehealth.
  3. Improvements to housing: at the population level, this is clearly a significant issue with political ramifications. However, on the individual level, there are ways to improve the housing situation of individuals – including through simple interventions such as the addition of bath-holds, guard-rails, anti-slip matting or stair lifts. Although cheap and simple, they can improve the chances of a successful discharge in, for instance, a frail or elderly population.

The discharge process: measures of success

There are several ways to measure the effectiveness of discharge:

  1. Turnaround time: this is the time between the patient being flagged for discharge and the time they leave the hospital. This measures the efficiency of the processes that need to be completed.
  2. Median hour of discharge: a more relevant measure may be the time at which 50% of patients have left the hospital. This is useful because it correlates with available bed capacity in the middle of the day.
  3. Patient satisfaction: patient satisfaction with discharge is well correlated with the efficiency of the process and is inversely related to delays. However, it also captures the fashion in which discharges are carried out (including satisfaction with information-giving and staff attitudes).

It is our view that median hour of discharge is considered the most sensitive all-round measure.

The NHS and discharge planning in the UK

The UK National Health Service (NHS) faces specific challenges when it comes to discharge planning. One of the primary challenges is the shortage of both community facilities (nursing homes) and the recent reduction in hospital bed stock. The rebound from the Covid-19 pandemic has put strain on the bed stock. 

The  NHS also faces a dramatic shortage of medical and nursing staff and of relevant care workers in the community.

To address these challenges, the NHS has implemented a number of initiatives aimed at improving discharge planning and reducing delays. For example, the NHS Long Term Plan, published in 2019, includes a commitment to improve the coordination of care between hospitals and community-based healthcare providers, as well as increased funding for social care and community health services.

The ideal discharge process

It is clear from the discussion above that the ideal discharge process involves high levels of multidisciplinary coordination both within and between hospitals and community services. 

It also requires continuous and high quality communication between healthcare providers, the patients and their families.

The process should be supported by strong leadership, a multidisciplinary team and good IT systems.

These, the use of a multidisciplinary team approach, and the timely coordination of the necessary resources and support for a patient’s care after leaving the hospital means starting the discharge planning early in a patient’s hospital stay, identifying any potential challenges or barriers to a timely discharge, and working collaboratively to address them.

Conclusion

Delayed discharge is a complex issue that affects healthcare systems worldwide. It is caused by a range of factors, including lack of community support, complex medical needs, poor communication, and legal and administrative issues. The costs and challenges of delayed discharge include increased healthcare costs, reduced quality of care, negative impact on patient wellbeing, and increased caregiver burden. To improve the delayed discharge process, healthcare systems can implement several solutions, including community-based care, multidisciplinary care teams, early discharge planning, technology solutions, and reducing administrative barriers.

The short- and long-term benefits of improving hospital discharge processes are significant and far reaching. Done well, we can ensure that patients receive the care they need and reduce the burden on hospitals and healthcare systems.

REFERENCES

https://www.england.nhs.uk/wp-content/uploads/2021/10/B0928-criteria-led-discharge-guidance-v2.pdf

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