Improving the process of discharge (1)
Editor – Dainty and Elizabeth's excellent review (Clin Med August 2009 pp 311–4) should be read by all professionals dealing with discharge; I shall certainly give it to medical students in our small group tutorials dealing with teamwork. But, while better education is certainly needed, most physicians will recognise organisational problems that thwart the best plans even of those who know what to do.
Discharge planning is a good general marker for the integrity and performance of teams. Before recent retirement from clinical practice I spent a great deal of time trying to improve the ways in which ward teams could work. What gets in the way of good practice? The first problem is, very simply, a lack of proper teams. The word ‘teamwork’ is on everyone's lips and ‘good team player’ included in person specifications for jobs but too few understand what it takes to form and maintain an effective team. Even then working and staffing conditions are such that successful teams are difficult to achieve. Disintegration of teams and continuity of care are key problems for discharge but there is often also a problem of engaging with outside agencies. Some still regard hospitals as ‘places of safety’ for patients and lack incentives to accept patients quickly back into the community when medically appropriate.
Two problems deserve particular mention. The authors rightly state that discharge planning starts at admission. Unfortunately this first step is problematic unless the admitting doctor and nurse sit down together for a few minutes to agree (and document) the nature of the patient's problems and the initial plan. Anyone who has not compared medical and nursing plans for the same patient might be surprised by the amount of incongruity. The excuse is usually that they lack time to work together in this way although a little time spent together initially saves much more time and trouble later. Many hospitals also still lack a reliable way of documenting one agreed discharge plan that follows the patient in time and place and which is used by everyone involved in care and discharge. The resulting confusion increases risk and wastes time.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
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