Better communication to inform the community nursing teams and district nurses is needed when planning to discharge patients from hospital, according to a new report.
The study by the Queen’s Nursing Institute found that frail, older people over 75 were more likely to be affected by ineffective discharge planning and called for better planning for end of life care discharges.
The report Discharge Planning: Best Practice in Transitions of Care included qualitative research, reviewed literature and also held focus groups in London, Birmingham, Hull, Sheffield and Darlington.
A range of community nursing staff including district nurse (DN) students, DNs, community staff nurses and service leads, managers and educators shared their experiences.
Queen’s Nurse Candice Pellet, who carried out the research said: “Three key themes emerged which would enable effective discharge planning: improved communication, improved co-ordination of services and improved collaboration.”
She said commissioners and provider organisations should look at the processes they have in place for discharge planning.
They should ensure the transfer of care is always planned around the needs of patients, their families and carers, she said.
“At a practitioner level, there needs to be willingness from nurses both in hospital and community to improve partnership working, to ensure that patients, carers and families experience a seamless service when discharged from hospital to home, with good discharge planning and post discharge support,” she added.
Half the respondents said the community team was “rarely” involved with hospital decisions before discharge.
Three quarters of community respondents said ineffective discharge planning mainly affected patients aged 75 to 84.
The majority of them (94.3%) said they did not have a discharge keyworker on their team and 60% of hospital respondents said they did know if there was one in community.
One district nurse said they always phoned the ward before a patient returned home for end of life care “as I do not rely on the often scant details given to the Single Point of Access (SPA) phone line”.
The SPA was used to inform 52% of community respondents about discharge.
They described one instance where they were told a patient was in the ambulance on their way home. The family was also unaware of the plan and had been told the discharge was scheduled for the following week.
The report found that 74% of community nurses were informed on the day of discharge, with vey little notice.
Pellet said there is willingness among both the community and hospital nurses to improve discharge but called for changes to the barriers created by existing systems and cultures.
“There needs to be greater understanding of the boundaries, not only of each other’s roles but also the capacity of their services.”
The report can be found here.