Whose responsibility is it anyway? Hospital admission and discharge of older people in an inner-London District Health Authority

Readmissions - can they be predicted on admission?

This paper looks at the development of logistic regression models to predict readmissions for medical patients on their initial admission to hospital. The design of our study was a retrospective analysis of a large dataset drawn from a range of secondary sources - medical, nursing, therapy and social care records. Three northern hospitals and related community health districts and social care organizations in the UK participated. Records of 1,192 patients discharged from medical wards during the period April 1992-March 1995 were analysed. Readmission within six weeks of discharge was the main outcome measure.Four logistic regression equations were produced. Three individual site equations were calculated and classification levels for readmission of 17-22 per cent were achieved. Component factors that differed in importance were age, GP contact, social services contact, marital status and living status. The weakest equation was the equation that encompassed patients from all three sites, which classified 7 per cent of readmissions. It is possible to develop equations that will explain readmission for a fifth of medical patients on admission to individual hospitals. Further exploratory work needs to be undertaken to explore reasons for differences between districts and develop more generalizable predictive equations.

Provider-to-Provider Communication during Transitions of Care from Outpatient to Acute Care: A Systematic Review

BACKGROUND

Most research on transitions of care has focused on the transition from acute to outpatient care. Little is known about the transition from outpatient to acute care. We conducted a systematic review of the literature on the transition from outpatient to acute care, focusing on provider-to-provider communication and its impact on quality of care.

METHODS

We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane databases for English-language articles describing direct communication between outpatient providers and acute care providers around patients presenting to the emergency department or admitted to the hospital. We conducted double, independent review of titles, abstracts, and full text articles. Conflicts were resolved by consensus. Included articles were abstracted using standardized forms. We maintained search results via Refworks (ProQuest, Bethesda, MD). Risk of bias was assessed using a modified version of the Downs' and Black's tool.

RESULTS

Of 4009 citations, twenty articles evaluated direct provider-to-provider communication around the outpatient to acute care transition. Most studies were cross-sectional (65%), conducted in the US (55%), and studied communication between primary care and inpatient providers (62%). Of three studies reporting on the association between communication and 30-day readmissions, none found a significant association; of these studies, only one reported a measure of association (adjusted OR for communication vs. no communication, 1.08; 95% CI 0.92-1.26).

DISCUSSION

The literature on provider-to-provider communication at the transition from outpatient to acute care is sparse and heterogeneous. Given the known importance of communication for other transitions of care, future studies are needed on provider-to-provider communication during this transition. Studies evaluating ideal methods for communication to reduce medical errors, utilization, and optimize patient satisfaction at this transition are especially needed.

Potential role of the community liaison pharmacist: stakeholder views

Objective

To determine the views of stakeholders regarding a community liaison pharmacy (CLP) service and to obtain their opinion about the risk of medication misadventure for patients in the immediate post-discharge period.

Setting

The study was conducted with medical practitioners, community nurses, community pharmacy, hospital pharmacy, consumers and hospital administration from a division of general practice in Victoria, Australia.

Method

Semi-structured interviews were conducted to address areas of: the discharge process, liaison between primary and secondary healthcare sectors and views of a CLP. A focus group was conducted with key informants from the interviews to explore the emergent themes.

Key findings

Themes from 23 interviews and the focus group explored the difficulties experienced with the discharge process and communication at the primary and secondary interface. Participants discussed the types of problems that patients face after hospital discharge and those potentially at risk of medication misadventure. The role of a liaison pharmacist was defined and logistics of implementation of a CLP service and ameliorable barriers were identified. Information from the focus group was utilised to develop a medication misadventure risk assessment tool for patients returning to community care from hospital.

Conclusion

Problems with the discharge process and communication at the primary and secondary interface often result in deficiencies in the continuum of care between hospital and the community. Most participants recognised the potential benefits of a CLP service that may bridge the gap in communications between the healthcare settings as well as educating and supporting some patients regarding their medications shortly following discharge from hospital.

Organisational silos: affecting the discharge of elderly patients

PURPOSE

This paper aims to explore the unintentional formation of internal functional barriers, (organisational silos) during moves towards departmental efficiency, within an acute trust, and the subsequent effects on the discharge process in elderly patients.

DESIGN/METHODOLOGY/APPROACH

This paper presents some of the findings from a qualitative study examining the role of the nurse in the discharge process. Semi-structured interviews were conducted with a purposively selected cohesive sample of 28 registered nurses, from the medical and elderly care wards in an NHS Acute Trust. The interviews were taped, transcribed and their content analysed.

FINDINGS

The problems associated with patient discharge were frequently operational. Each part of the process was hindered, often inadvertently, by attempts on the part of individuals, departments and services to make themselves efficient, without regard for the resulting organisational consequences. This left the ward nurses attempting to overcome the obstacles in an attempt to effectively discharge patients, within a required period of time.

RESEARCH LIMITATIONS/IMPLICATIONS

It is recognised that, the perceptions of those not participating in the study may have been different to those who did participate. As a small study in one trust the results may not be generalisable.

PRACTICAL IMPLICATIONS

It is imperative that evaluation of operational changes is undertaken, with particular regard to the consequences of change, for other services, patients and clients.

ORIGINALITY/VALUE

This type of study can provide a method of diagnosing organisational problems, especially in areas that are reliant on inter-professional and departmental collaboration.

The process of hospital discharge for medical patients: a model

BACKGROUND

The 1990 NHS Community Care Act established a requirement for hospital discharge policies and procedures in the United Kingdom to be developed in collaboration with local government authorities in order to ensure supported discharge for those in need.

AIMS

The aim of the study reported in this paper was to track decisions about hospital discharge in relation to outcomes for a sample of medical patients and their carers, identified as at risk of experiencing unsuccessful discharge processes.

METHODS

Themed unstructured interviews were conducted in three different hospitals with 30 patients identified as at risk of unsuccessful discharge and their carers pre- and postdischarge. Hospital, community and social care staff involved in the care of the patient were also interviewed.

FINDINGS

Patients and carers were constantly negotiating their social roles, seeking to juggle appropriate identities and limited resources to maintain their own and each others' dignity and quality of life. When the negotiation process was destabilized (for example, by exacerbation of chronic disease, withdrawal of some resource, or the experience of additional stressors - not necessarily health-related), then either or both parties sought a way out. In all the cases examined the result was admission to hospital - usually, but not always, mediated by community professionals.

CONCLUSIONS

The effective discharge of patients from hospital needs to move from a functional focus on symptom management to a negotiation of quality of life that seeks to promote health for all parties involved.

Enhancing older people's concordance with taking their medication

It has been shown that older people are more likely than younger people to be prescribed a variety and number of medications (Lindley and Tulley, 1992). Older people are especially vulnerable to the effects of medication, particularly because of the possibility of medication mismanagement and non-concordance with prescribed medication regiment. People become increasingly sensitive to the actions of drugs with increasing age and, added to the problems of memory deterioration and physiological changes, medication-taking behaviour can alter quite dramatically (National Prescribing Centre, 2000). Reductions in the quantity of prescribed medication and the use of prescribing indicators aim to improve concordance with medication in older people. Patient education should be an inclusive component of patient care, not a concern before patient discharge. Education can take numerous forms, both written and verbal, and it needs to be patient-centred and specific to the medication being discussed. As healthcare professionals, nurses, pharmacists and medical colleagues should work collaboratively to reduce the frequency of medication mismanagement in older people.

Discharge planning and transitional care: issues in Thai nursing

Discharge planning is part of the care process that places nurses in a pivotal position in facilitating continuity of care for clients. This ethnographic study explored the current discharge practices of Thai nurses and examined how transitions from hospital to home were incorporated into Thai nursing practice. The study was conducted with registered nurses in an acute hospital in central Thailand. Results indicated that the discharge process in this community was highly informal with several factors affecting the effectiveness of nurses' discharge functions. Consequently, strategies to improve this care process were proposed for further implementation.

Discharging older people from hospital to care homes: implications for nursing

This paper summarizes a research study which explored the experiences of older people being discharged from hospital to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes. While this may reflect an assumption that this form of discharge is less problematic, it is arguable that this is only the case for staff - there is a body of literature on re-location which suggests that the move to a care home is a major life event for older people. Taking a qualitative approach, this study interviewed 20 older people and 17 of their family members after discharge from hospital to a care home. We found that few people had been offered opportunities to discuss their move with nurses, and that older people tended to adopt a stoical attitude. In focus groups, interviews and written responses from 23 members of staff in the hospital and in care homes, we found that there was a lack of clarity over whose role it was to initiate such discussions. The paper concludes with some discussion of the implications for nursing practice of changing care interfaces.

Successful patient discharge. A comprehensive model of facilitators and barriers

The need for effective discharge planning by nurses has become more urgent and complex in light of recent healthcare initiatives. In response to better understanding discharge planning, four focus groups were held to describe a comprehensive framework of factors needed for effective discharge that are relevant to multiple nursing specialties across practice sites. Through content analysis, four themes--common across sites and specialties--were identified as important to discharge.

Continuity of care on admission to hospital: an audit of Airedale NHS Trust's transfer policy

Describes an audit of interprofession communications among hospital, community health and social services concerning hospital admission. Information from 150 patient admissions (50 from each of three general practices after a target date) was gathered from both community and hospital sources. The results were used to audit the transfer policy operated by Airedale NHS Trust. The audit design incorporated an element of research, the results of which were used to inform the interpretation of the audit results and to suggest appropriate recommendations for change. Recommendations included the introduction of a pre-admissions checklist, specific changes to the nursing documentation, measures to improve the speed of information transfer, and the clarification of responsibilities for initiating contact across the hospital-community interface when patients with existing contacts in community services are admitted to hospital. Concludes that the introduction of supplementary research to an otherwise traditional audit cycle strengthened the resulting recommendations.