Hospital discharge of the elderly--an observational case study of functions, variability and performance-shaping factors

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views

BACKGROUND

Hospital discharge of older patients is a high-risk situation in terms of patient safety. Due to the fragmentation of the healthcare system, communication and coordination between stakeholders are required at discharge. The aim of this study was to explore communication in general and medication information transfer in particular at hospital discharge of older patients from the perspective of healthcare professionals (HCPs) across different organisations within the healthcare system.

METHODS

We conducted a qualitative study using focus group and individual or group interviews with HCPs (physicians, nurses and pharmacists) across different healthcare organisations in Sweden. Data were collected from September to October 2021. A semi-structured interview guide including questions on current medication communication practices, possible improvements and feedback on suggestions for alternative processes was used. The data were analysed thematically, guided by the systematic text condensation method.

RESULTS

In total, four focus group and three semi-structured interviews were conducted with 23 HCPs. Three main themes were identified: 1) Support systems that help and hinder describes the use of support systems in the discharge process to compensate for the fragmentation of the healthcare system and the impact of these systems on HCPs' communication; 2) Communication between two separate worlds depicts the difficulties in communication experienced by HCPs in different healthcare organisations and how they cope with them; and 3) The large number of medically complex patients disrupts the communication reveals how the highly pressurised healthcare system impacts on HCPs' communication at hospital discharge.

CONCLUSIONS

Communication at hospital discharge is hindered by the fragmented, highly pressurised healthcare system. HCPs are at risk of moral distress when coping with communication difficulties. Improved communication methods at hospital discharge are needed for the benefit of both patients and HCPs.

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

BACKGROUND

Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.

METHODS

Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.

RESULTS

Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals' performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.

CONCLUSIONS

Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

Actions taken to safeguard the intended health care chain of older people with multiple diagnoses - a critical incident study

Background

Older people with multiple diagnoses often have problems coping with their daily lives at home because of lack of coordination between various parts of the healthcare chain during the transit from hospital care to the home. To provide good care to those persons who have the most complex needs, regions and municipalities must work together. It is of importance to develop further empirical knowledge in relation to older persons with multiple diagnoses to illuminate possible obstacles to person-centred care during the transition between healthcare institutions and the persons livelihood. The aim of the present study was to describe nurses’ experienced critical incidents in different parts of the intended healthcare chain of older people with multiple diagnoses.

Methods

The sample consisted of 18 RNs in different parts of the healthcare system involved in the care of older people with multiple diagnoses. Data were collected by semi structured interviews and analysed according to Critical Incident Technique (CIT). A total of 169 critical incidents were identified describing experiences in recently experienced situations.

Results

The result showed that organizational restrictions in providing care and limitations in collaboration were the main areas of experienced critical incidents. Actions took place due to the lack of preventive actions for care, difficulties in upholding patients’ legal rights to participation in care, deficiencies in cooperation between organizations as well as ambiguous responsibilities and roles. The RNs experienced critical incidents that required moral actions to ensure continued person-centred nursing and provide evidence-based care. Both types of critical incidents required sole responsibility from the nurse. The RNs acted due to ethics, ‘walking the extra mile’, searching for person-centred information, and finding out own knowledge barriers.

Conclusions

In conclusion and based on this critical incident study, home-based healthcare of older people with multiple diagnoses requires a nurse that is prepared to take personal and moral responsibility to ensure person-centred home-based healthcare. Furthermore, the development of in-between adjustments of organizations to secure cooperation, and transference of person-centred knowledge is needed.

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home

BACKGROUND

The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention.

METHODS

This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi-structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims.

RESULTS

Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness.

CONCLUSION

The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing.

PATIENT OR PUBLIC CONTRIBUTION

This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation.

Successful Outcomes for Whom and for What? Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

The coronavirus disease 2019 (COVID-19) pandemic is the case of a complex global crisis that requires resilient performance across all levels of healthcare systems worldwide. The analysis of government actions during the COVID-19 pandemic in Australia and Canada by Smaggus et al raises the possibility for a much needed and essential debate on the notion of outcomes in the resilience in healthcare literature. Government actions have downstream effects on stakeholders' capacity for resilience throughout the healthcare system. Yet, outcomes are fluent, multi-faceted and dependant on time, space, and stakeholder perspectives. It is appropriate and timely for the resilience in healthcare field to better grasp the nuances of successful outcomes in complex adaptive systems.

Evaluation and perceptions of a nursing discharge plan among nurses from different healthcare settings in Spain

Purpose

The exchange of information between different healthcare settings through a nursing discharge plan is essential for safe care. However, the factors contributing to achieving the most efficient exchange have not been well studied. This study aimed to evaluate and explore the perceptions of a nursing discharge plan from the perspective of nurses in different healthcare settings.

Methods

A mixed methods approach comprising a specifically designed ad hoc questionnaire (n = 437) and a focus group session (n = 8).

Findings

Overall, 66.1% out of 437 nurses, and especially those working in nursing homes, were satisfied with the nursing discharge plan.

Lack of time to complete the report and poor information about both nursing diagnoses and patients’ social assessment were identified as problem areas. Some proposals emerged from the focus group: providing sufficient time for its completion, giving the nursing discharge plan a more flexible structure permitting more open-ended responses, requiring more information to be provided about the social and psychological situation of the patients, training nurses to use standardized language to avoid possible misinterpretations, and getting nurses from the different health care settings to work together in designing continuity of care plans. Elderly and low-income patients are found to need greater attention when filling out nursing discharge plans.

Conclusions

The study has revealed key aspects that need to be improved and some recommendations in implementing the nursing discharge plan in our health area. These include that there should be more time provided to complete the NDP, and also specific details regarding the format, structure, content of the information that is communicated, and the prioritization of the patient profile.

Hospital physicians' experiences and reflections on their work and role in relation to older patients' pathways - a qualitative study in two Norwegian hospitals

Background

Older patients are the most frequent users of initial hospital admissions and readmissions. Both hospital admission and discharge require communication and coordination between healthcare professionals within the hospital, and between professionals in hospitals and primary healthcare. We have identified few studies exploring hospital physicians’ perspectives on older patients’ pathways in the interface between hospital and primary healthcare services. The aim of this study was to explore hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways between hospital and primary healthcare. Specifically, we focused on the challenges they faced and how they dealt with these in relation to admission and discharge, and their suggestions for service improvements that could facilitate older patients’ pathway.

Methods

We used a qualitative approach, conducting individual in-depth interviews with 18 hospital physicians from two hospitals in eastern Norway. Data were analyzed using systematic text condensation, in line with a four-step prosedure developed by Malterud.

Results

The participants emphasized challenges in the communication about patients across the two service levels. Moreover, they described being in a squeeze between prioritizing patients and trying to ensure a proper flow of patients through the hospital wards, but with restricted possibilities to influence on the admissions. They also described a frustration regarding the lack of influence on the healthcare delivery after discharge. The participants had various suggestions for service improvements which might be beneficial to older patients.

Conclusions

The results demonstrate that the hospital physicians perceived being squeezed between professional autonomy and limited capacity at the hospital, and between their medical judgement as a specialist and their power to decide on hospital admissions for old patients and also on the delivery of health care services to patients after discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07846-1.

Do financial aspects affect care transitions in long-term care systems? A systematic review

Background

Suboptimal care transitions of older adults may ultimately lead to worse quality of care and increased costs for the health and social care systems. Currently, policies and financing often focus on care in specific settings only, and neglect quality of care during transitions between these settings. Therefore, appropriate financing mechanisms and improved care coordination are necessary for effective care transitions. This study aims to review all available evidence on financial aspects that may have an impact on care transitions in LTC among older adults.

Methods

This systematic review was performed as part of the European TRANS-SENIOR project. The databases Medline, EMBASE (Excerpta Medica Database) and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they reported on organizational and financial aspects that affect care transitions in long-term care systems.

Results

All publications included in this review (19 studies) focused specifically on financial incentives. We identified three types of financial incentives that may play a significant role in care transition, namely: reimbursement mechanism, reward, and penalty. The majority of the studies discussed the role of rewards, specifically pay for performance programs and their impact on care coordination. Furthermore, we found that the highest interest in financial incentives was in primary care settings.

Conclusions

Overall, our results suggest that financial incentives are potentially powerful tools to improve care transition among older adults in long-term care systems and should be taken into consideration by policy-makers.

Trial registration

A review protocol was developed and registered in the International Prospective Register of Systematic Reviews (PROSPERO) under identification number CRD42020162566.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00829-y.

The Functional Resonance Analysis Method as a health care research methodology: a scoping review

OBJECTIVE

The objective of this review was to examine and map the literature on the use of the Functional Resonance Analysis Method (FRAM) in health care research.

INTRODUCTION

The FRAM is a resilient health care tool that offers an approach to deconstruct complex systems by mapping health care processes to identify essential activities, how they are interrelated, and the variability that emerges, which can strengthen or compromise outcomes. Insight into how the FRAM has been operationalized in health care can help researchers and policy-makers understand how this method can be used to strengthen health care systems.

INCLUSION CRITERIA

This scoping review included research and narrative reports on the application of the FRAM in any health care setting. The focus was to identify the key concepts and definitions used to describe the FRAM, the research questions, aims, and objectives used to study the FRAM, the methods used to operationalize the FRAM, the health care processes examined, and the key findings.

METHODS

A three-step search strategy was used to find published and unpublished research and narrative reports conducted in any country. Only papers published in English were considered. No limits were placed on the year of publication. CINAHL, MEDLINE, Embase, PsycINFO, Inspec Engineering Village, ProQuest Nursing & Allied Health were searched originally in June 2020 and again in March 2021. A search of the gray literature was also completed in March 2021. Data were extracted from papers by two independent reviewers using a data extraction tool developed by the reviewers. Search results are summarized in a flow diagram, and the extracted data are presented in tabular format.

RESULTS

Thirty-one papers were included in the final review, and most (n = 25; 80.6%) provided a description or definition of the FRAM. Only two (n = 2; 6.5%) identified a specific research question. The remaining papers each identified an overall aim or objective in applying the FRAM, the most common being to understand a health care process (n = 20; 64.5%). Eleven different methods of data collection were identified, with interviews being the most common (n = 21; 67.7%). Ten different health care processes were explored, with safety and risk identification (n = 8; 25.8%) being the most examined process. Key findings identified the FRAM as a mapping tool that can identify essential activities or functions of a process (n = 20; 64.5%), how functions are interdependent or coupled (n = 18 58.1%), the variability that can emerge within a process (n = 20; 64.5%), discrepancies between work as done and work as imagined (n = 20; 64.5%), the resiliency that exists within a process (n = 12; 38.7%), and the points of risk within a process (n = 10, 32.3%). Most papers (n = 27; 87.1%) developed models representing the complexity of a process.

CONCLUSIONS

The FRAM aims to use a systems approach to examine complex processes and as evidenced by this review, is suited for use within the health care domain. Interest in the FRAM is growing, with most of the included literature being published since 2017 (n = 24; 77.4%). The FRAM has the potential to provide comprehensive insight into how health care work is done and how that work can become more efficient, safer, and better supported.

Using the Functional Resonance Analysis Method to explore how elastic compression therapy is organised and could be improved from a multistakeholder perspective

OBJECTIVES

Elastic compression stocking (ECS) therapy is an important treatment for patients with deep venous thrombosis (DVT) and chronic venous insufficiency (CVI). This study aimed to provide insight into the structure and variability of the ECS therapy process, its effects on outcomes, and to elicit improvement themes from a multiple stakeholder perspective.

DESIGN

Thirty semi-structured interviews with professionals and patients were performed. The essential functions for the process of ECS therapy were extracted to create two work-as-done models using the Functional Resonance Analysis Method (FRAM). These findings were used to guide discussion between stakeholders to identify improvement themes.

SETTING

Two regions in the Netherlands, region Limburg and region North-Holland, including an academic hospital and a general hospital and their catchment region.

PARTICIPANTS

The interviewees were purposely recruited and included 25 healthcare professionals (ie, general practitioners, internists, dermatologists, nurses, doctor's assistants, occupational therapists, home care nurses and medical stocking suppliers) and 5 patients with DVT or CVI.

RESULTS

Two FRAM models were created (one for each region). The variability of the functions and their effect on outcomes, as well as interdependencies between functions, were identified. These were presented in stakeholder meetings to identify the structure of the process and designated variable and uniform parts of the process and its outcomes. Ultimately, six improvement themes were identified: dissemination of knowledge of the entire process; optimising and standardising initial compression therapy; optimising timing to contact the medical stocking supplier (when oedema has disappeared); improving the implementation of assistive devices; harmonising follow-up duration for patients with CVI; personalising follow-up and treatment duration in patients with DVT.

CONCLUSIONS

This study provided a detailed understanding of how ECS therapy is delivered in daily practice by describing major functions and variability in performances and elicited six improvement themes from a multistakeholder perspective.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

Modeling and analyzing hospital to home transition processes of frail older adults using the functional resonance analysis method (FRAM)

The main purpose of this study was to model and analyze hospital to home transition processes of frail older adults in order to identify the challenges within this process. A multi-phase, multi-sited and mixed methods design was utilized, in which, Phase 1 included collecting semi-structured interviews and focus group data, and Phase 2 consisted of six patient/caregiver dyad prospective case studies. This study was conducted in three hospitals in three cities in a single province in Canada. The Functional Resonance Analysis Method (FRAM) was employed to model daily operations of the transition process. The perspectives of both healthcare providers and patients/caregivers were used to build the FRAM model. The transition model was then tested using a customized version of the FRAM. The six patient/caregiver cases were used in the process of testing the FRAM model. The results of building the FRAM model showed that five categories of functions contributed to the transition model, including admission, assessment, synthesis, decision-making, and readmission. The outcomes of using the customized version of the FRAM revealed challenges affecting the transition process including waitlists for geriatric units, team-based care, lack of a discharge planner, financial concerns, and follow-up plans. The findings of this study could assist managers and other decision makers to improve the transition processes of frail older adults by addressing these challenges. The FRAM method employed in this study can be applied widely to identify work practices that are more or less successful, so that procedures and practices can be adapted to nudge healthcare processes towards paths that will yield better outcomes.

Crossing knowledge boundaries: health care providers' perceptions and experiences of what is important to achieve more person-centered patient pathways for older people

BACKGROUND

Improving the transitional care of older people, especially hospital-to-home transitions, is a salient concern worldwide. Current research in the field highlights person-centered care as crucial; however, how to implement and enact this ideal in practice and thus achieve more person-centered patient pathways remains unclear. The aim of this study was to explore health care providers' (HCPs') perceptions and experiences of what is important to achieve more person-centered patient pathways for older people.

METHODS

This was a qualitative study. We performed individual semistructured interviews with 20 HCPs who participated in a Norwegian quality improvement collaborative. In addition, participant observation of 22 meetings in the quality improvement collaborative was performed.

RESULTS

A thematic analysis resulted in five themes which outline central elements of the HCPs' perceptions and experiences relevant to achieving more person-centered patient pathways: 1) Finding common ground through the mapping of the patient journey; 2) the importance of understanding the whole patient pathway; 3) the significance of getting to know the older patient; 4) the key role of home care providers in the patient pathway; and 5) ambiguity toward checklists and practice implementation.

CONCLUSIONS

The findings can assist stakeholders in understanding factors important to practicing person-centered transitional care for older people. Through collaborative knowledge sharing the participants developed a more shared understanding of how to achieve person-centered patient pathways. The importance of assuming a shared responsibility and a more holistic understanding of the patient pathway by merging different ways of knowing was highlighted. Checklists incorporating the What matters to you? question and the mapping of the patient journey were important tools enabling the crossing of knowledge boundaries both between HCPs and between HCPs and the older patients. Home care providers were perceived to have important knowledge relevant to providing more person-centered patient pathways implying a central role for them as knowledge brokers during the patient's journey. The study draws attention to the benefits of focusing on the older patients' way of knowing the patient pathway as well as to placing what matters to the older patient at the heart of transitional care.

Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway

BACKGROUND

Patients are expected to participate in the hospital discharge process, assume self-management after discharge and communicate relevant information to their general practitioner; however, patients report that they are not being sufficiently empowered to take on these responsibilities. The aim of this study was to explore and understand the discharge process with a focus on medicines communication, from the patient perspective.

METHODS

Patients were included at a hospital ward, observed during health-care personnel encounters on the day of discharge and interviewed 1-2 weeks after discharge. A process analysis was performed, and a content analysis combined data from observations and data from patient interviews focusing on medicines communication in the discharge process.

RESULTS

A total of 9 patients were observed on the day of discharge, equalling 67.5 hours of observations. The analysis resulted in the following themes: (a) the observed discharge process; (b) patient initiatives; and (c) the patient role. The medicines communication in the discharge process appeared unstructured. Various patient preferences and needs were revealed. The elements of the best practice structured discharge conversation were observed; however, some patients did not have a discharge conversation at all.

CONCLUSIONS

The study contributes to a broader understanding of the discharge process, how patients experience it, including their role. It is evident that the discharge process is not always tailored to meet the patients' needs. More focus on early patient involvement and communication, in order to better prepare patients for self-management of their medications, is important for their health outcomes.

"The light at the end of the tunnel". Discharge experience of older patients with chronic diseases: A multi-centre qualitative study

AIM

To explore the experiences of being discharged from hospital of older patients with chronic diseases at time of discharge.

DESIGN

Multi-centre descriptive qualitative study.

METHODS

Semi-structured interviews were conducted with older patients with chronic diseases discharged from two Italian university hospitals, between March 2017 and October 2019. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis. Several strategies were used to ensure the credibility, dependability, confirmability, authenticity and transferability of the findings. The study was reported in accordance with Standards for Reporting Qualitative Research and Consolidated criteria for reporting qualitative research.

RESULTS

Sixty-five patients participated in the study. Six main categories emerged: feelings, need for information, time of fragility, need for support, need for trusting relationships, and home as a caring place.

CONCLUSION

Older patients with chronic diseases are patients who require quality discharge planning with a patient-centred care vision. Healthcare professionals should intervene more extensively and deeply in the discharge process, balancing the patients' perception of their needs against organizational priorities and the wish to return home with that of not being abandoned.

IMPACT

Discharge from hospital remains an area of concern as older people have varying degrees of met and unmet needs during and following hospital discharge. Discharge is characterized by conflicting feelings of patients, who need information and support of healthcare professionals through trusting and continuous relationships. Understanding the experience of discharge is essential to support older patients with chronic diseases, considering that discharge from hospital is not an end point of care but a stage of the process involving care transition. The reframing of discharge as another transition point is crucial for healthcare professionals, who will be responsible for making their patients fit for discharge by preparing them to manage their chronic condition at home.

Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall: a realist synthesis

BACKGROUND

Older adults hospitalized following a fall often encounter preventable adverse events when transitioning from hospital to home. Discharge planning interventions developed to prevent these events do not all produce the expected effects to the same extent. This realist synthesis aimed to better understand when, where, for whom, why and how the components of these interventions produce positive outcomes.

METHODS

Nine indexed databases were searched to identify scientific papers and grey literature on discharge planning interventions for older adults (65+) hospitalized following a fall. Manual searches were also conducted. Documents were selected based on relevance and rigor. Two reviewers extracted and compiled data regarding intervention components, contextual factors, underlying mechanisms and positive outcomes. Preliminary theories were then formulated based on an iterative synthesis process.

RESULTS

Twenty-one documents were included in the synthesis. Four Intervention-Context-Mechanism-Outcome configurations were developed as preliminary theories, based on the following intervention components: 1) Increase two-way communication between healthcare providers and patients/caregivers using a family-centered approach; 2) Foster interprofessional communication within and across healthcare settings through both standardized and unofficial information exchange; 3) Provide patients/caregivers with individually tailored fall prevention education; and 4) Designate a coordinator to manage discharge planning. These components should be implemented from patient admission to return home and be supported at the organizational level (contexts) to trigger knowledge, understanding and trust of patients/caregivers, adjusted expectations, reduced family stress, and sustained engagement of families and professionals (mechanisms). These optimal conditions improve patient satisfaction, recovery, functional status and continuity of care, and reduce hospital readmissions and fall risk (outcomes).

CONCLUSIONS

Since transitions are critical points with potential communication gaps, coordinated interventions are vital to support a safe return home for older adults hospitalized following a fall. Considering the organizational challenges, simple tools such as pictograms and drawings, combined with computer-based communication channels, may optimize discharge interventions based on frail patients' needs, habits and values. Empirically testing our preliminary theories will help to develop effective interventions throughout the continuum of transitional care to enhance patients' health and reduce the economic burden of avoidable care.

Protocol for a non-randomised feasibility study evaluating a codesigned patient safety guide in primary care

INTRODUCTION

Patients and carers should be active partners in patient safety with healthcare professionals and be empowered to use personalised approaches to identify safety concerns and work together to prevent them. This protocol paper details a study to examine the feasibility of a multicomponent intervention to involve patients and/or carers in patient safety in primary care in the UK.

METHODS AND ANALYSIS

This is a two-phase, non-randomised feasibility mixed methods pragmatic study of a patient safety guide for primary care (PSG-PC). 8 general practices will recruit 120 patient and/or carer participants. All patient and/or carer participants will receive the PSG-PC. It will examine the feasibility and acceptability of the PSG-PC in primary care settings in patients aged 18 years or older who attend appointments at general practice with health professionals four or more times per year as either patients or carers. It will identify secondary outcomes for improving patient safety, health status and patient empowerment, and reducing health service utilisation over 6 months between baseline and 6-month follow-ups. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients and practices will be needed. The study will be undertaken between January 2020 and September 2021.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the National Health Service London-West London and Gene Therapy Advisory Committee Research Ethics Committee (reference: 19/LO/1289). Research findings will be disseminated with participating general practices and shared in a range of different ways to engage different audiences, including presenting at international and national conferences, publishing in open-access, peer-reviewed journals and facilitating dissemination workshops within local communities with patients, carers and healthcare professionals.

TRIAL REGISTRATION NUMBER

ISRCTN90222092.

Crossing boundaries: Establishing a framework for researching quality and safety in care transitions

BACKGROUND

Despite the breadth and diversity of research and policies on care transitions, research studies often report similar components that affect the quality and safety of care, including communication across professional groups and care settings, transfer of information, coordination of resources or training of healthcare personnel. In this article, we aim to deepen our understanding of care transitions by proposing a heuristic research framework that takes into account the components and factors influencing the quality and safety of care transitions in diverse settings.

METHODOLOGY

Using a pragmatic qualitative narrative meta-synthesis of empirically grounded research studies (N = 13) involving 31 researchers from seven countries (Australia, Canada, Denmark, Germany, the Netherlands, Norway and the UK), we conducted a thematic analysis to identify the components analysed in the included studies. We then used these components to create a framework for researching care transitions.

RESULTS

Our narrative synthesis found that the quality and safety of care transitions are influenced by a range of patient-centred, communicative, collaborative, cultural, competency-based, accountability-based and spatial components. These components are encompassed within a broader set of dimensions that require careful consideration: (1) the conceptualising of the care transition notion, (2) the methodology for researching care transitions, (3) the role of patients and carers in care transitions, (4) the complexity surrounding care transitions, (5) the boundaries intertwined in care transitions and (6) care transition improvement interventions. These six dimensions constitute an analytical framework for planning and conducting research on care transitions in diverse settings.

CONCLUSION

The proposed six-dimensional framework for researching quality and safety in care transitions offers a roadmap for future practice and policy interventions and provides a starting point for planning and designing future research.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

BACKGROUND

Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home.

METHODS

We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semi-structured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles.

RESULTS

Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs.

CONCLUSIONS

It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients.

TRIAL REGISTRATION

The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174 ).

Using Safety-II and resilient healthcare principles to learn from Never Events

OBJECTIVES

Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events.

DESIGN

Qualitative and quantitative retrospective analysis of RCA reports.

SETTING

A large acute healthcare Trust in London.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Quality of RCA reports, robustness of actions proposed.

RESULTS

RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events.

CONCLUSION

Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.

'Handing over to the patient': A FRAM analysis of transitional care combining multiple stakeholder perspectives

INTRODUCTION

The period following discharge can present risks for older adults. Most research has focused on hospital discharge with less attention paid to on-going care needs. Despite evidence that patients undertake 'invisible work' to improve care safety, their reported willingness to be involved in care, and the consensus that successful transitions interventions include patient involvement, in reality, this is variable. Further, little research has viewed transitional care as a 'system', with gaps, interdependencies and variability across settings, nor the role of patients and families in supporting the system resilience.

RESEARCH OBJECTIVES

1) model transitional care from multiple perspectives using the Functional Resonance Analysis Method (FRAM); 2) use the model to develop a theory of change to support intervention development.

METHOD

We drew data from two studies: i) exploring the perspective of older adults across transitional care, and ii) exploring how health services experience transitional care. We employed the FRAM to develop a model of transitional care, with a system boundary spanning an older patient's admission to hospital, through to thirty days post-discharge.

FINDINGS

Modelling transitional care from multiple perspectives was challenging. 27 functions were identified with interdependencies between hospital-based functions and patient-led functions once home, the success of which may impact on transitions 'outcomes' (e.g. safety events, readmissions). The model supported development of a theory of change, to guide future intervention development.

CONCLUSIONS

Supporting certain patient-facing upstream hospital functions (e.g. encouraging mobility, supporting a better understanding of medication and condition), may lead to improved outcomes for patients following hospital discharge.

Consequences of 'conversations not had': insights into failures in communication affecting delays in hospital discharge for older people living with frailty

OBJECTIVES

Older people living with frailty (OPLWF) are often unable to leave hospital even if they no longer need acute care. The aim of this study was to elicit the views of health care professionals in England on the barriers to effective discharge of OPLWF.

METHODS

We conducted semi-structured interviews with hospital-based doctors and nurses with responsibility for discharging OPLWF from one large urban acute care hospital in England. The data were analysed using the constant comparative method.

RESULTS

We conducted interviews with 17 doctors (12 senior doctors or consultants and 5 doctors in training) and six senior nurses. Some of our findings reflect well-known barriers to hospital discharge including service fragmentation, requiring skilled coordination that was often not available due to high volumes of work, and poor communication between staff from different organizations. Participants' accounts also referred to less frequently documented factors that affect decision making and the organization of patient discharges. These raised uncomfortable emotions and tensions that were often ignored or avoided. One participant referred to 'conversations not had', or failures in communication, because difficult topics about resuscitation, escalation of treatment and end-of-life care for OPLWF were not addressed.

CONCLUSIONS

The consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients' quality of life and care. As the population of older people is rising, this becomes a key priority for all practitioners in health and social care. Evidence to support practitioners, OPLWF and their families is needed to ensure that these vital conversations take place so that care at the end of life is humane and compassionate.

The Discharge Process-From a Patient's Perspective

Inadequacy in discharge planning, preparation of readiness, and unplanned readmissions are closely linked and could cause misutilization of hospital services, creating higher costs to the health-care system. The information given before discharge is vital and of great importance for the well-being of the patient. The study’s objective was to describe the patient’s experience of their discharge process. A descriptive study was designed. Fifteen (n = 15) interviews with patients at one University Swedish hospital were held, and a qualitative content analysis was made from the collected data. The results show that accessibility, information, communication, confidence, and participation are pivotal in future development in the discharge process. The findings of this study indicate that in affirmation with the patient’s experiences and desires, there is a great urgency for improvement in the discharge process. There is a need to focus on information and communication at discharge by initiating interaction from the nurses together with the doctors at a specific time in the discharge process. The discharge process needs to be more individualized and person-centered which could lead to better patient governance. Both accessibility and continuity need to be improved. The information given needs to be met with the patient’s level of understanding.

Health States of Exception: unsafe non-care and the (inadvertent) production of 'bare life' in complex care transitions

This paper draws on the work of Giorgio Agamben to understand how the social organisation of care transitions can reduce people to their 'bare' life thereby making harmful and degrading treatment seemingly legitimate. The findings of a 2-year ethnographic study show how some people experience hospital discharge as undignified, inhumane and unsafe process, expressed through their lack of involvement in care planning, delayed discharge from hospital and poorly coordinated care. Our analysis explores how these experiences stem from the way patients are constituted as 'unknown' and 'ineligible' subjects and, in turn, how professionals become 'not responsible' for their care. The result being that the person is reduced to their 'bare' life with limited value within the care system. We suggest that the social production of 'bare life' is an inadvertent consequence of reconciling and aligning multiple disciplines within a complex care system.

Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary

BACKGROUND

Ageing patients are discharged from the hospital 'quicker and sicker' than before, and hospital discharge is a critical step in patient care. Older patients form a particularly vulnerable group due to multimorbidity and frailty. Patient participation in healthcare is influenced by government policy and an important part of quality improvement of care. There is need for greater insights into the complexity of patient participation for older patients in discharge processes based on aggregated knowledge.

OBJECTIVE

The aim of this study was to review reported evidence concerning the experiences of older patients aged 65 years and above regarding their participation in the hospital discharge process.

METHODS

We conducted a qualitative metasummary. Systematic searches of Medline, Embase, Cinahl, PsycINFO and SocINDEX were conducted. Data from 18 studies were included, based on specific selection criteria. All studies explored older patients' experience of participation during the discharge process in hospital, but varied when it came to type of discharge and diagnosis. The data were categorised into themes by using thematic analysis.

RESULTS

Our analysis indicated that participation in the discharge process varied among elderly patients. Five themes were identified: (1) complexity of the patients state of health, (2) management and hospital routines, (3) the norm and preference of returning home, (4) challenges of mutual communication and asymmetric relationships and (5) the significance of networks.

CONCLUSIONS

Collaboration between different levels in the health systems and user-friendly information between staff, patient and families are crucial. The complexity of patient participation for this patient group should be recognised to enhance user involvement during discharge from hospital. Interventions or follow-up studies of how healthcare professionals can improve their communication skills and address the tension between client-centred goals and organisational priorities are requested. Organisational structure may need to be restructured to ensure the participation of elderly patients.

Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway

OBJECTIVES

To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities.

DESIGN

Qualitative case study.

SETTING

The Norwegian healthcare system.

PARTICIPANTS

Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients.

RESULTS

The results of this study showed that patients were being discharged earlier, with more complex medical conditions, than they had been previously, and that discharges sometimes were perceived as premature. Insufficient capacity at the hospital resulted in pressure to discharge patients, but the primary healthcare service of the area was not always able to assume care of these patients. Communication between levels of the healthcare service was limited. The hospital stay summary was the most important, and sometimes only, form of communication between levels. The discharge process was described as complicated and was affected by healthcare personnel, by patients themselves and by aspects of the primary healthcare service. Early hospital discharges, poor communication between healthcare services and inadequacies in the discharge process were perceived to affect hospital readmissions.

CONCLUSION

The results of this study provide a better understanding of hospital physicians' views on the discharge and hospital readmission processes in the interface between the hospital and the primary healthcare service. The study also identifies discrepancies in governmental requirements, reform regulations and current practices in municipalities and hospitals.

The continuity of hospital nursing care for Primary Health Care in Spain

OBJECTIVE

To learn the profile and activities carried out by the Hospital Nurse Liaison for the continuity of care in Primary Health Care in Spain.

METHOD

An exploratory study with a qualitative approach developed in five University Hospitals in Madrid and three in Barcelona, with Hospital Nurse Liaisons who work in Hospitals in Madrid (8) and Barcelona (11). An online questionnaire was applied with open and closed questions for data collection. The data were analyzed by the content analysis technique in the thematic modality.

RESULTS

Nineteen (19) Hospital Nurse Liaisons participated in the study. The liaisons' ages ranged from 26 to 64 years old, the majority were women (94.73%) with experience between 21 and 30 years (52.63%), and had worked in this job between 6 months and 26 years. The Nurse Liasion is required to perform a clinical assessment of the patient prior to discharge and to contact the Nurse in the patient's area of origin by telephone or e-mail. It is necessary to have experience as an educator, to work in a team and have motivation.

CONCLUSION

Nurses in Spain perform care continuity for Primary Health Care, in which their activities encompass the availability of resources and experience in managing the care of complex patients and their families.

Characterization of Chronic Obstructive Pulmonary Disease Patients with a Long Length of Stay: A Retrospective Observational Cohort Study

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) exacerbation is one of the most common reasons for hospital admission. Patients with COPD with a long length of stay (LoS) occupy a disproportionately high fraction of hospital bed-days. The objective of this study was to identify associations of long LoS in patients admitted with COPD exacerbation.

MATERIAL AND METHODS

From December 2012 until June 2013, 499 patients were admitted to Queens Hospital, Romford, UK, with COPD exacerbation. Mean LoS was 7 days, with a median of 5 days, and a 90th percentile of 14 days. In this retrospective observational cohort study, 64 patients with a short LoS were compared with 62 patients with a long LoS.

RESULTS

Relative to the short LoS, patients with long LoS had significantly lower arterial blood pH, higher arterial PaCO2 and HCO3, higher white cell count, higher globulin and more frequent chest X-ray changes, lower albumin levels, and lower Barthel and Braden scores. They were less likely to have seen the hospital COPD specialist nurse, more likely to require escalation of social care on discharge, and more likely to die during admission. Nearly 66% of the long LoS patients remained in hospital beyond the time of being medically fit for discharge. Commonly cited reasons for delayed discharge were the wait for therapy and social services assessments and the wait for commencement of community social care.

CONCLUSION

Meticulous targeting of features peculiar to long LoS patients has the potential to reduce future hospital bed-days for patients with COPD in our and other hospitals.

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres

BACKGROUND

Challenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences.

METHODS

A qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach.

RESULTS

Twenty-four interviews included 19 patients and 7 family members. Participants' experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities' ability to care for injured patients.

CONCLUSIONS

The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient-centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention.

A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service

Background

Hospital discharge is a vulnerable transitional stage in patient care. This qualitative study investigated the views of healthcare professionals and patients about the threats to safe hospital discharge with aim of identifying contributory and latent factors. The study was undertaken in two regional health and social care systems in the English National Health Service, each comprising three acute hospitals, community and primary care providers and municipal social care services. The study focused on the threats to safe discharge for hip fracture and stroke patients as exemplars of complex care transitions.

Methods

A qualitative study involving narrative interviews with 213 representative stakeholders and professionals involved in discharge planning and care transition activities. Narratives were analysed in line with ‘systems’ thinking to identify proximal (active) and distal (latent) factors, and the relationships between them.

Results

Three linked categories of commonly and consistently identified threat to safe discharge were identified: (1) ‘direct’ patient harms comprising falls, infection, sores and ulceration, medicines-related issues, and relapse; (2) proximal ‘contributing’ factors including completion of tests, assessment of patient, management of equipment and medicines, care plan, follow-up care and patient education; and distal ‘latent’ factors including discharge planning, referral processes, discharge timing, resources constraints, and organisational demands.

Conclusion

From the perspective of stakeholders, the study elaborates the relationship between patient harms and systemic factors in the context of hospital discharge. It supports the importance of communication and collaboration across occupational and organisational boundaries, but also the challenges to supporting such communication with the inherent complexity of the care system.