Nurse Facilitated Hospital Discharge Planning in an Elderly Unit - Literature review Example

Nurse Facilitated Hospital Discharge Planning in an Elderly Unit Patients with complex care needs, including frail and elderly or those with mental problems, may require continuing care in special housing, residential or nursing homes, and need a ‘package of care’ to support them back to good health after hospital discharge (McKenna et al, 2000, p.594-601). Such population demand effective discharge arrangements. Discharge planning is “a facet of overall care of patient, developed through the application of the nursing process” (Watts, 2005). It is a process “that is dependent on inter-professional collaboration between health and welfare professionals” (Atwal, 2002). Study of problems of discharging patients from hospitals have been in focus during the last two decades, and some of the shortcomings identified are: “poor communication between hospital and community; inadequate notice of discharge; over-reliance in informed support and lack of support; inattention to patient’s needs before leaving hospital; and wasted or duplicated visits by community nurses” (McKenna et al, 2000, p.594-601). “Cost effective, coordinated, high-quality discharge planning” is integral to control increasing healthcare costs and hospital personnel must become more adept at preparing patients for discharge as there is decrease in length of acute hospital stay, and increase in care shift to communities and homes (Lalani & Gulzar, 2001). “Aged care assessment team (ACAT)” model, operating in Australia, may be helpful in streamlining hospital discharge process in the U.K. (Robinson & Street, 2003). ACAT, a key multidisciplinary group primarily comprising nurses and paramedical staff, is involved in determining the discharge needs of older people Hence, decreasing length of patient stay in hospitals is paramount agenda in every health care planner and eliminating long waiting lists and freeing up of ‘blocked beds’ could be possible with effective and efficient discharge planning procedures. Discharge planning concepts: The American Nurses’ Association defines discharge planning as ‘the part of the continuity of care process which is designed to prepare the patient for the next phase of care and to assist in making any necessary arrangements for that phase of care” (Quoted by Watts& Gardner, 2005). Watts and Gardner (2005) investigated the relevance of the term ‘discharge planning’ to nurses, who working in an acute care environment. They used a qualitative approach to gather data by interviewing twelve volunteer registered nurses working in a large metropolitan Victoria hospital in Australia. Since discharge planning has ‘multifaceted definition’ analysing the perception, concept, and process of discharge panning of 12 registered nurses, from a single acute care environment, could not help generalise the findings in a wider perspective. Lalani and Gulzar (2001) also had concentrated on identifying nurses’ knowledge, perceptions, and practices of discharge planning. They hypothesized that inadequate knowledge of discharge procedures is a major factor that reduces the quality of discharge care given by nurses to patients. A descriptive, cross-sectional, questionnaire study, using a triangulation approach of data collection, was conducted in three 60-bed medical-surgical units of Aga Khan University Hospital in Pakistan. Descriptive statistics was used to analyse the data collected from select nurses and patients. This study also points to the fact that there is dearth of knowledge among nurses regarding the definition and concept of discharge planning and various factors, such as increased work load and lack of time, role confusion, and interdisciplinary struggles, discourage nurses’ participation in discharge process. Findings by Lalani and Gulzar strongly recommend that nurses’ role and their knowledge regarding discharge planning need to be strengthened and reinforced. Their recommendations have been instrumental in bringing changes in the Aga Khan University hospital indicates validity and adaptability of the study report. Discharge planning process: Development of “hospital discharge policies and procedures in the United Kingdom” was established under the 1990 National Health Services (NHS) Community Care Act, and gave clear distinction between acute and intermediate care for facilitating discharge planning (Pearson et al, 2003, Atwal, 2002, p.450-458). Effective discharge planning is important for health care professionals, patients, and their family members when health care environment is encountering fiscal constraints. Watts (2005), relying on literature review, identified four distinct phases of discharge planning, as: “(1) assessment of the patient’s discharge needs; (2) development of the discharge plan; (3) provision of services or implementation of the discharge plan (included in this phase is patient education and referrals to services); (4) and evaluation of the discharge plan.” The study findings by Bull and Roberts (2001) indicates that “a proper discharge occurred in stages and was characterized by involvement of multi-disciplinary team (MDT) members, interacting circles of communication, and sufficient time to involve the various members of the team in identifying the elder’s need for aftercare.” (Bull & Roberts, 2001, p.571-581). Hence, it is proposed that 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” (Person et al, 2004). Since no previous studies provided a detailed description of the discharge planning process Bull and Roberts (2001) hypothesized that “Explicating the components of effective discharge planning is critical in order to replicate the process in a variety of health care settings and predict the outcomes associated with effective discharge planning.” They conducted qualitative, semi-structured interviews in two wards of 78-bed geriatric rehabilitation hospital under the National Health Service (NHS) Trust in South-West London, to validate the assumption. Data included semi-structured interviews and documents related to discharge planning, care delivery, and community resources. Snowball sampling was used to identify key persons involved in discharge planning for elders. The findings indicate that a multidisciplinary team approach was vital for effective discharge planning. Communication gap posed an impediment to a proper hospital discharge. Providing continuing education opportunities for hospital nurses to acquire better understanding of the community nurses’ role might expedite improved communication between hospital and community teams. Small sample size and variation in involvement of elder’s in discharge planning are the limitations of the study. Discharge management: It is well established that geriatric patients with complex and chronic needs are at risk of early hospital readmission and premature institutionalization. Among many models developed to reduce the risk of readmission, case management is considered as useful model for hospital discharge management. A nationwide case management initiative, as an instrument for supporting discharge, was evaluated by Steeman and colleagues (2006) in Belgium.The objective of the study was to evaluate efficacy of discharge management by trained social workers or nurses in reducing hospital readmission and institutionalization of geriatric patients. Using a quasi-experimental design a representative sample of 824 patients, 355 belonging to experimental group and 469 in general care, from six general hospitals in Belgium were covered in this study. Primary outcomes assessed were readmission and institutionalisation within 15 and 90 days after discharge. In-hospital discharge planning was undertaken by trained social worker or nurse, using the methods of case management. Since there were two groups, multivariate binary logistic regression analysis was performed, using Statistical Package for the Social Sciences (SPSS). Data analysis revealed that discharge management resulted in fewer institutionalizations (14.9%) compared with the usual care (23.7%). The evaluation showed that a discharge planning intervention significantly reduced institutionalization rates of elderly patients. This reduction in institutionalisation is construed as a shift in mindset of the discharge managers, who focused primarily on social risk factors in discharge preparation by nature of their role. However, the researchers perceive that since the patients were not randomly assigned to the groups it would have introduced a selection bias. In addition, occurrence of contamination was possible, because three hospitals sites had both group of subjects and that the practice staff may be aware of the intervention practices. Even then, it is concluded that comprehensive discharge planning for high-risk geriatric patients is effective, and the study establishes positive influence of teamwork. Moreover, the study triggered policy initiative to implement discharge management in the geriatric department of Belgium hospitals. Barriers to discharge planning: Discharge needs of patients admitted to critical care unit are complex, diverse, and dynamic as gravity of the illness exaggerates patient’s physical and psychological status. Watts and team conducted a 31-item questionnaire survey by involving 502 critical care nurses, identified from the Australian College of Critical Care Nursing, Victoria. The selection was made using an exploratory descriptive approach and eligible 218 participants completed the survey. Direct, semi-structured interviews with 13 Victorian critical care nurses were also conducted. Participants reported that a lack of time was barrier to discharge planning. Communication could enhance or impede the discharge process, and adopting critical pathways, used in the care of cardiothoracic patients, did assist with communication of discharge planning , hence enhancing the project. Perceived barriers to delayed discharge: Identifying barriers to timely discharge is expected to decrease unnecessary hospital days, and thereby reducing health care costs and making room for new admissions. In order to understand the barriers to timely discharge identifying caregivers’ perceptions of reasons for discharge delay is crucial. Minichiello et al (2001) carried out a survey and free-form written responses using a convenience sample at an academic medical centre for identifying perceived barriers to delayed discharge. The study was conducted at Moffitt-Long Hospital, a 520-bed tertiary care teaching hospital affiliated with the University of California, San Francisco. There were a total 171 (68%) responses, of which 104 were housestaff, 34 attending physicians, and 33 nurses. Most nurses (70%) felt that patient discharge was delayed because plans were not made on time, whereas few house staff (11%) and attendings (21%) agreed with the nurses’ view. Similar trend was found in respect of poor communication between nurses and physicians, and waiting for procedure. Nurses identified inadequate communications as reason for discharge delays, and the perceived times of discharge-related activities differed among caregivers. Aligning with the findings of Selker and colleagues (1980 quoted by Minichiello et al, 2001) who found that delays in tests and procedures, lack of availability of post discharge facilities, and waits for attending or consultant input, Minichiello et al (2001) suggests that delay due to the physician’s morning schedules and communication deficits between physicians and nursing and social work staff also act as barriers to discharge. Though the study has several limitations like response bias, and study being institution specific, it highlights new areas for potential improvement. It is proposed that improving communication between care teams may have beneficial effects, as studies revealed that decisions made jointly by nurses, physicians, and other caregivers reduced lengthy stay, improved staff satisfaction, and did not increase readmission rates. Comprehensive discharge planning Naylor et al (1999 ) point out that though comprehensive discharge planning by advance practice nurses has been experimented in elderly care, benefits of more intensive follow-up of hospitalized elderly with complex care needs had not been studied. As such, a study was done to examine the effectiveness of advanced-practice-nurse-centred discharge planning and home follow-up for the elderly at risk of hospital readmission. It was conducted in two urban academically affiliated hospitals in Philadelphia. The study design was randomised clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. The participants were patients 65 years or older and had one or several medical and surgical reasons for admission. Main outcome measures used include readmission, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. A total of 363 patients (186 in the control group and 177 in the intervention group of which 70% of intervention and 74% of control subjects completed the trial) were enrolled in the study. Advance practice nurses (APN) are Masters-prepared in gerontology, expected to having more capabilities and skills in discharge planning. A comprehensive discharge planning follow-up protocol, designed specifically for elderly patients at risk of poor outcomes, was implemented by advanced practice nurses and outcome data collected by a research assistant blind to study groups and hypotheses. The interventions included medication management, symptom management, diet, activity, sleep, medical follow-up, and enhancing the emotional status of the patient and care-givers. After 24 weeks of index hospital discharge this method showed that ‘fewer intervention people had multiple readmissions, and had fewer hospital days per patient’ and the between discharge and readmission was greater with costs of care being less.’ The Medicare reimbursements for health services were about $ 1.2 million in the control group against about $0.6 million in the intervention group. So far as post discharge acute care visits, functional status, depression, or patient satisfaction is concerned there were no significant group differences. Naylor et al (1999, p 286) conclude that the intervention of practice nurse-centred discharge planning has great potential in promoting positive outcomes for hospitalised elders at high risk for rehospitalization while reducing costs. Risk of unsuccessful discharge: Unsuccessful discharge is defined as “unplanned readmission within 6 weeks of discharge, or delayed discharge” (Pearson et al, 2004). It is well documented that major reason for unsuccessful discharge are ‘pressure on hospital beds, poor liaison between hospital and community staff, lack of preparation for discharge, difficulties in managing at home and limited provision of health and social services in the post-discharge period’. In addition, study by Person et al (2003) adds that exacerbation of chronic disease, withdrawal of some resource, or the experience of additional stressors as well as complex situations encountered by patients at home may result in hospital admission. The study by Pearson et al (2004) concentrated on the risk of experiencing unsuccessful discharge by patients and carers, through an interview survey. The study was in three stages with quantitative first phase that contained data on medical discharge information between April 1993 and March 1995. Stage two and three were qualitative in nature, as it was guided interviews associated with discharge process, and development of discharge policy and planning. The data collected were analysed thematically depending on the experience of four distinct groups, such as patients, carers, hospital staff and community staff. The study points out that patients and carers negotiate their social roles to maintain and secure an acceptable quality of life dependent on their knowledge and experience. Addressing complex needs of patients and maintaining quality of life require concerted effort by health care professional and they should use hospitals as sanctuaries of care rather than places of technological excellence. Factors predicting unsuccessful discharge: Service providers are responsible for smooth discharge of patients from hospital and ensuring appropriate community services are in place to support patient and their informal carer after discharge. Procter et al (2001) attempted to provide an in-depth understanding of the hospital discharge process experienced by carers of patients ‘at risk’ of unsuccessful discharge from medical wards. It is hypothesized that there is a need for practitioners to be sensitive to the dynamics of patient-carer relationship and not assume that their needs are synonymous. They have studied 1500 patient records, using logistic regression, from three hospitals in the North of England to identify factors predicting unsuccessful discharge. The study, second phase of a large study, combined qualitative and quantitative methods to identify factors leading to unsuccessful discharge. Using the predictive factors for unsuccessful discharge, 30 patients were identified from the three health authorities and guided interviews were conducted with patient, and detailed, in-depth, open-ended interviews with their nominated carer. All in-depth interviews were tape recorded, and brief interviews recorded as written interviewer notes. Analysis of the data was done using constant comparative methods. Nurses cited inadequate communications as a reason for discharge delays, besides rounds and other conferences upsetting the process. However physicians cited delay in testing and availability of subacute care beds. House staff responded that discharge decisions were generally made in the morning. This observations highlight that caregivers at the same institution perceived different barriers to discharge. Individual case studies also suggest that the extent to which practitioners can address the needs of patients/carers following discharge will be constrained by the strength of technical rationality within the various organizations involved in the discharge process. In addition, individual experience stress that carers’ needs should be identified and that they have voluntarily and independently consented to the obligations associated with the role also ensured. Hence, it is concluded that people experiencing repeated readmission or long length of stay are often living in complex circumstances. This necessitate fundamental shift from disease management to a focus on ‘communicative action’ within a framework of ethical decision making, provided by Habermas (1984, cited by Procter, 2001), designed to promote quality of life for all people involved in the discharge process. Problems encountered by aged care nurses: Gentles and Potter (2001, p.373-378), quoting National Bed Inquiry report on proposed ‘Intermediate Care’, indicates that “up to 20% of older people might be inappropriately occupying acute hospital beds and could be discharged if alternative services were available. Robinson and Street (2004) used action research project, because action research focuses on knowledge development and action that leads to practical solutions to clinical problems that have been encountered by nurses of aged care assessment team (ACAT). This cyclical study using stakeholders as co-researchers was part of a major study conducted in ACATs in Australia. The steering committee, after consolidation of field data from the first of the three action cycles, found that ward nurses have a limited knowledge and understanding of aged care system and they need assistance to develop their knowledge of services available to support older people following discharge. Robinson and Street observe that practical strategies to support collaboration between ward nurses and community providers will empower nurses to become more involved in discharge planning. Since the data is collected from a purpose sample that actively participated as co-researcher to establish a series of interactive forum the findings can be generalised for ACAT setting. Using a survey approach Dunnion & Kelly (2005) attempted to explore ‘dimensions of the management of the older persons admitted in emergency department in preparation of discharge. A purposeful sample comprising the total population of all grades of medical nursing staff, and medical staff in the primary care area were included as design. Standardized questionnaire, comprising open and closed questions, were used to collect data, and the raw data were analyzed using statistical package for the social science (SPSS ). Their findings are similar to those reported by Mckenna et al (2000), and support earlier conclusion of need to increase the level of communication between emergency department and the primary care sector. Time and resource constraints limited participation of willing medical and nursing staff, and restricted data collection, which adversely affected research findings Nurses’ perception of discharge planning: Evaluation of nurses’ perception of discharge planning by Watts (2005) found that “organizing’ and ‘planning’ were key words used by registered nurses to define the term ‘discharge planning’.” Since nurses act as intermediary between patients, doctor, medical staff and other members of health care staff, and social worker, effective communication among these members is central to discharge planning. Watts (2005) suggests that communication (especially between nursing staff and medical staff) rather than patient participation is the major factor that either enhances or impedes the discharge planning process, because ‘communication of information is vital to ensure that the identified continuing needs of the patient are transferred to the next caregiver. To provide an in-depth understanding of nurses’ perception of the hospital discharge process in a London teaching hospital, Atwal A (2002) carried out a case study. Critical incident approach was used to interview 19 nurses to obtain their perceptions of the discharge process. It was found that discharge process was a neglected area and lack of time was the biggest barrier affecting inter-professional working. The limitation of the study is that it was carried out in a single health care trust, with less representation from medical consultants. Relevance of communication interface: Bull & Roberts (2001, p.571-581) points out that the researchers recognised “communication as key to effective discharge planning,” but little attempt has been made to identify nature of communication and effective discharge planning process of elders. Primary functions of communication is to establish a trusting relationship between patient and care givers, and to provide exchange of information necessary to access patient’s health condition, charter treatment plans and implementing them, and to evaluate how the treatment affects patient’s quality of life. The primary areas of communication gap experienced by health care providers, identified by previous studies were: (1) between hospital-community interface within the hospital 2) between patients; and (3) between family caregivers for elders. Deficiency in timely receipt of information on discharge summaries was one area of communication gap encountered by clinicians, nurses, and social workers. So far as community nursing staff is concerned, it was the delay in communication concerning the information related to diagnosis, prognosis, self-care ability, and services already initiated affecting discharge process. Other area was communication gap between providers and elderly patients pertaining to the medications to be adopted and physical condition at the time of discharge, information on managing special diets and home situation, and instructions on activities to be followed or avoided after discharge. Similarly, there was lack of information dissemination between health care providers related to elder’s condition, medications, diet, and signs of complications. Mckenna et al (2000) used a structured, pre-coded questionnaire survey using a series of tape-recorded interviews to examine the current process of preparation for discharge; to review the communication interface between acute hospital staff district nursing services; to ascertain preliminary information about the satisfaction of patients and relatives through the perception of nurses; and to examine the quality of standard of documentation in use. Questionnaire surveys are quantitative in nature and the model consisted random sample of 50% of all hospital based nurses (n=115) and the entire population of community-based nurses (n=73) in one Trust Area in the U.K. Being an exploratory study that has been carried out in one trust area the findings could not be generalised. However, the study conclusively ascertain previous findings that lack of communication hinders discharge process and main solution is re-education of both hospital and community nurses about each others’ present day roles. The study also affirms poor discharge related information documenting. Discharge training needs: A thematic training needs analysis, using discharge training needs analysis (DTNA) tool, was conducted by Lees and Emmerson (2006), at the Heart of England Foundation Trust in 2005. It aimed to assess the skills of ward nurses in effective discharge planning. The DTNA tool, originally developed in 2004, was modified for using a continuous cycle of learning, audit, and revisiting the location of study. It was formatted using a Microsoft Excel spread sheet covering 49 aspects of discharge practice subdivided into four areas, such as. corporate, operational, clinical, and nurse-led discharge. The representative themes were categorized into three key areas: behaviour, knowledge, and decision-making, and other aspects of discharge date estimation, reimbursement and nurse-led discharge were also assessed. Lees & Kelly concludes that simple and easy to use DTNA tool provides useful data for baseline analysis with feed backs to improve patient and staff experiences of the discharge process. However, DTNA tool still require addition of more competencies. They suggest that identification of training needs of nurses is crucial, and should be included in existing clinical governance process. Moreover, acquiring discharge skill and training requires initiative and sustained commitment from staff in wards or clinical areas. (Lees & Emmerson, 2006). Best practice interventions: For identifying best practice interventions to improve the management of older people in acute care settings, Hickman and colleagues (2007) had done a literature review. They searched MEDLINE and CINHAL data bases and internet, for literature, published between 1985 and 2006, containing key words ‘elderly, older, geriatric, and aged care’ using a modified integrative literature review technique. The ultimately screened papers were evaluated independently against a standardized assessment tool. The evaluation revealed that there is lack of randomized controlled trials, especially looking at nursing interventions. The concept of ‘patient-centred care,’ as part of communication process, links strongly to the needs of the individual and their family. In the absence of evidence-based solutions for caring of older people in acute care facilities, a multidisciplinary team approach and effective communication strategies are recommended. Conclusion: Literature on discharge planning suggests that there are recurring problems in the interface between secondary and primary care, leading to ‘lack of coordination, communication, collaboration, and understanding’ that negatively impact on patient and family wellbeing and contentment. (Mckenna et al, 2000, p.594-601). Lalani and Gulzar (2001) points out that lack of documented clinical policy or procedure for discharge planning results in increased length of stay, recurrent readmission, increased health care costs, and dissatisfaction to the patients. Inadequate knowledge of discharge procedures and lack of organizational support and community resources among nurses is major hindrance to quality of discharge care. Studies reveal that there are relationships between the nurses’ knowledge, their perception, and their actual practice of discharge planning. The factors that discourage nurses from participating in discharge planning are concerns about the time required, failure to recognize the discharge planning needs of all patients, interdisciplinary struggles, or role confusion (Rorden & Taft, 1990 quoted by Lalani & Gulzar, 2001). Education of nurses on effective discharge planning and providing them with regular updates on changes to the aged care system, process of referral to community services, and relevant referral documents are projected to be the best approach for effective ward nurse/community networking. Bull & Roberts conclude that an awareness of the circle of communication and the persons who need to be involved in planning at different stages of discharge planning; and recognizing the characteristics of each stage in discharge planning, might help nurses to identify required actions in planning for elder’s follow-up of care and to encourage participation from other professionals, patients, and family. Formulating a clinical discharge policy in coordination with the policy and procedure committee; establishing a separate discharge planning team that involves nurses, physicians, and the nursing administrators; and constituting task force for locating community resources for proper referral and follow-up of patients after discharge, are better strategies for effective discharge planning. Reference Atwal, A. (2002). Nurses’ perception of discharge planning in acute health care: a case study in one British teaching hospital. Journal of Advanced Nursing, 39 (5), 450-458. Bull, M.J., & Roberts, J. (2001). Issues and Innovations in Nursing Practice: Components of a proper hospital discharge for elders. Journal of Advanced Nursing, 35 (4), 571-581. Gentles, H & Potter, J. (2001). Alternative to acute hospital care. Reviews in Clinical Gerontology, 11 (4), 373-378. Retrieved February 11, 2009 from http://journals.cambridge.org/action/displayAbstract;jsessionid=5C2A2C4A092D1A4ED3A570896F67632F.tomcat1?fromPage=online&aid=114993 Lalani, NS & Gulzar, AZ. ( 2001). Nurses’ role in patients’ discharge planning at the Aga Khan University Hospital, Pakistan. Journal for Nurses in Staff Development, 17 (6), 314-310. Lippincot Williams & Wilkins, Inc. Lees, L & Emmerson, K. (2006). Identifying discharge practice training needs. Nursing Standard, 20(29), pp. 47-51. McKenna, H., et al. (2000). Discharge planning an exploratory study. Journal of Clinical Nursing, 9 (4), 594-601. Blackwell Science Ltd. Minichiello, Tracey M., et al. (2001). Effective clinical practice: Caregiver Perceptions of the Reasons for Delayed hospital discharge. ACP: American college of physicians. Retrieved February 11, 2009 from http://www.acponline.org/clinical_information/journals_publications/ecp/novdec01/minichiello.htm Pearson, P; Procter, S; Wilcockson, J; & Allgar, V. ( 2004). The process of hospital discharge for medical patients: a model. Advanced Nursing, 46(5), 496-505. Procter S, Wilcockson J, Pearson P, $ Allgar V. (2001). Going home from hospital: The carer/patient dyad. Journal of advanced Nursing, 35 (2), 206-217. Robinson, A & Street, A. (2003). Improving networks between acute care nurses and an aged care assessment team. Journal of Clinical Nursing, 13, 486-496. Steeman, E et al. (2006). Implementation of discharge management for geriatric patients at risk of readmission or institutionalization. International Journal for Quality in Health Care, 18 (5), 352-358. Retrieved February 11, 2009 from http://intqhc.oxfordjournals.org/cgi/content/full/18/5/352 Watts, R & Gardner, H. (2005). Nurses’ perceptions of discharge planning. Nursing Health Science. Watts, Rosemary., Garnder, Heather., & Pierson, Jane. (2005). Factors that enhance or impede critical care nurses’ discharge planning practices. Intensive and Critical Care Nursing, 21 (5), 302-313. Retrieved February 11, 2009 from http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WGN-4FN76M8-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=45a0681222152381fc47d0617910efcd Read More