Barriers to hospital discharges: a mixed-method audit
Introduction
Delayed discharges have been recognised to be a source of additional cost to the NHS as well as leading to reduced functional mobility to the elderly. In the current economic climate with hospital trusts in financial deficits, ways to reduce cost without harming patient care or the quality of care are being sought. Transferring patients efficiently to the appropriate care setting once the acute illness has been treated is one potential way hospitals can realise cost savings. This study aims to establish what the barriers are to achieve this.
Materials and methods
This is a mixed-methods study. A literature search was performed to identify interventions that may enable or inhibit effective transitions of care and patients’ experience of prolonged hospital admissions. A quantitative study included a cross-sectional survey of hospital inpatients to identify those not in the correct care setting. Hospital data of these patients were analysed to describe them. A sample of the patients in the incorrect care setting had their notes reviewed and further data was collected and analysed to identify variables that may be used in a predictive model. The qualitative study used semi-structured interviews with patients whose hospital admission had been prolonged. Thematic analysis was used to classify themes from the interviews.
Results and discussion
There was a significant difference in length of stay (mean difference 12.6 days; 27.35 vs 14.70; 95% confidence interval (CI) 8.96–16.6; p <0.01) and age (mean difference 11.35 years; 95% CI 7.92–14.77; p <0.01) between those who were in the incorrect care setting compared with those in the correct care setting. Those patients who were in the incorrect care setting had independent mobility prior to admission, required informal help with activities of daily living, lived in their own accommodation and mobilised using a stick or ‘Zimmer frame’. They had no previous contact with health or social care services. They suffered an illness (infection, stroke, fracture) that meant that they were unable to return to their previous social and community arrangements. The issues involved in delays in transfer of care included organising a placement or rehabilitation, care packages, funding for the health and social care services or resolving family issues which rely on multiple health and social care providers. The prolonged hospital admissions made patients feel they were imprisoned and isolated. Poor communication was found between patients and health and social care teams. These feelings of abandonment led patients to change their behaviour as they appeared to feel that becoming aggressive was the only way to get attention for the difficulties they were going through.
Conclusion
Delayed transfer of care is a complex issue reliant on multiple health and social care organisations. The patients identified in this study with significant delays were due to organisation and coordination of all these services to enable the patient to be discharged from hospital. Further complexity is added as patients may improve or get worse during their assessments changing the health and social care requirements in a dynamic fashion.
Conflicts of interest
None declared.
- © Royal College of Physicians 2020. All rights reserved.
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