Delayed discharge from acute hospitals – how to improve patient safety and experience
By Dr Barry Henley, former Chair of Birmingham Community Healthcare Trust
Delayed discharge from hospital of medically fit patients slows their recovery, makes it harder to admit new patients, leads to ambulance queues outside A&E departments, and puts additional pressure on staff. However, improving the discharge process is complex because of the need to establish a safe destination providing the appropriate and necessary levels of care.
I have worked in the NHS for 14 years as a director of a primary care trust and a mental health trust.
Until my recent retirement I was chair of a large community healthcare trust with 5,000 staff. My longstanding concern has been with accelerating the discharge of frail elderly patients admitted to acute hospitals.
Why we need to speed up hospital discharge
There are two reasons why we need to speed up hospital discharge: the first relates to the current situation of NHS bed shortages and lengthy ambulance queues forming because there are not enough empty beds to admit patients attending A&E. One solution to the bed shortage would be to discharge medically fit patients more quickly than we do now. The second reason is that admitting frail older people can lead to a decline in their physical and mental health, including hospital-associated delirium, functional decline, incontinence, infections, falls and pressure injuries.
The question therefore arises as to why medically fit for discharge (MFFD) patients may languish in hospital for a considerable time. They need appropriate and safe care in a rehabilitation hospital, a nursing/care home or at home. Hospitals have discharge teams whose role is to locate a suitable care setting and coordinate a transfer with the new provider. The new provider may be in the NHS and provide free medical care or be funded on a means-tested basis by a local authority responsible for social care.
Discharge to Assess
During the pandemic, the review of care provision was changed through a scheme known as Discharge to Assess (D2A). Most MFFD patients were discharged under this scheme to make space for COVID-19 patients. The NHS paid for all care over six weeks until a formal assessment was made to decide on the responsibility for further provision. This scheme ended in March 2022. NHS England data shows that in acute hospitals during January 2023, approximately 25,000 patients per day ‘no longer met the criteria to reside in hospital’. D2A ended because of the cost burden shifting from own-funding and local authority funding onto the NHS.
Since the problem of speeding up discharge relates both to the procedures in the hospital and the availability of appropriate care elsewhere, the most common solution is to move community clinicians into the hospital’s own discharge team. The aim is to improve communication between the two care settings and link the two systems which have separate manual and IT systems. This is sometimes enhanced by placing all MFFD patients together on one ward in the hospital with nursing care and constant attendance by the discharge team. Both techniques are credited with reducing average length of stay by several days, typically from 14 down to 11.
Impact of task management
When a patient is due to be discharged, the process of discharge falls partly on the ward and partly in the community. Task management is essential to communicate on a smartphone the tasks that are required, provide acknowledgement that the responsible person has accepted the task, and give instant indication to the multidisciplinary team when the task has been completed.
These tasks can include arranging a district nurse or physiotherapy appointment; organising delivery of a wheelchair, commode, or hospital bed; or confirming social care has been arranged for morning, lunchtime, and evening visits. Faxes, emails, telephone calls, and messaging apps cannot manage the workflow necessary to progress tasks which should be completed in parallel. These conventional methods are adequate for steps which are sequential, but unfortunately still have built-in delays between request, acknowledgement, and notification of fulfilment.
“In an era of vast investment in EPR systems that do not increase clinical productivity, task management software is a low-cost solution to many problems where good communications are required across internal and external boundaries. ”
Bringing together multidisciplinary teams
The various teams in community care, social care and acute hospital discharge can be united in prompt action by the software, which is independent of their IT system. It connects to medical records in a hospital, GP surgery, or community trust if there is an available application programming interface (API). The crucial information is gathered and retained despite the fact that care is being transferred from one setting to another with different electronic patient records (EPR).
Handheld devices can also be provided to local authority social workers who have key roles in social care, Deprivation of Liberty Safeguarding (DoLS), and Mental Health Act (MHA) assessments. DoLS and MHA delays are another proven reason for patients waiting excessive times in A&E and on hospital wards. Task management can be used to minimise these.
NHS England’s Discharge Delays Acute Weekly Situation reports show that on a typical January day this year, a trust with a task management solution had only a third of the number of MFFD patients that a similar sized trust using other methods of reducing numbers had. This benefit extends to far fewer lengthy ambulance waits outside A&E.
A low-cost solution
If every acute trust adopted workflow management through task management software there would be a huge reduction in the time taken to discharge MFFD patients, an equivalent increase in capacity for patients with greater acuity, and concomitant improvements in patient safety and experience resulting from shorter stays on the wards. In an era of vast investment in EPR systems that do not increase clinical productivity, task management software is a low-cost solution to many problems where good communications are required across internal and external boundaries.
Dr Barry Henley BSc MSc DBA is a consultant to Infinity Health and former Chair of Birmingham Community Healthcare Trust.
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