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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)
Emergency and acute medical care in over 16s: service delivery and organisation.
Show details35. Discharge planning
35.1. Introduction
Planning for a patient’s discharge from hospital is a key aspect of effective care. Many patients who are discharged from hospital will have ongoing care needs that must be met in the community. This ongoing care comes in many forms, including the use of specialised equipment at home such as a hospital-type bed, daily support from carers to complete the activities of daily living, or regular visits from district nurses to administer medication.
There is a wide variety of care available in the community, but it needs to be planned in advance of the patient’s return home, to ensure that there is no gap in the provision of care between the discharge from hospital and the initiation of community services. Furthermore, information about the patient must be handed over from the hospital team to the community team so an informed plan of care can be put into place.
Discharge planning is the process by which the hospital team considers what support might be required by the patient in the community, refers the patient to these services, and then liaises with these services to manage the patient’s discharge. Poor discharge planning can lead to poor patient outcomes and delayed discharge planning can cause patients to remain in hospital longer than necessary, taking up valuable inpatient beds when they could be more easily and comfortably cared for in the community.
While the guideline committee affirmed the value of discharge planning based on experience, they wanted to review any evidence available about the efficacy and cost implications of discharge planning for patients following an acute medical emergency.
35.2. Review question: Does discharge planning facilitate early hospital discharge?
For full details see review protocol in Appendix A.
35.3. Clinical evidence
Ten studies (11 papers) were included in the review;8,16,23,32,33,36,42,52,53,59,64 these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix G.
35.4. Economic evidence
Published literature
No relevant health economic studies were identified.
The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.
35.5. Evidence statements
Clinical
Ten studies comprising 3,271 people evaluated the role of discharge planning for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that discharge planning may provide a benefit in reduced avoidable adverse events expressed as falls (1 study, very low quality), length of stay (5 studies, moderate quality), quality of life SF-12 mental ratings (1 study, very low quality) patient and/or carer satisfaction defined as preparedness to leave hospital (1 study, low quality). The evidence suggested there was no effect on quality of life (St Georges Respiratory questionnaire and SF-12 physical ratings) (1 study, low to very low quality), staff satisfaction (1 study, low quality) avoidable adverse events defined as adverse medicine reaction (1 study, very low quality) and patient and/or carer satisfaction (1 study, very low quality).
The evidence suggested a benefit for discharge planning in reducing readmissions in 3 studies (low quality) but in 1 study that reported a hazard ratio there was no difference in readmission (very low quality). The evidence suggested a benefit for discharge planning in reducing mortality at 6 months (1 study, very low quality) and during admission (1 study, very low quality). However, evidence from 4 studies suggested an increase in mortality from 5 days-12months (moderate quality).
Economic
No relevant economic evaluations were identified.
35.6. Recommendations and link to evidence
Recommendations |
|
Research recommendation | - |
Relative values of different outcomes | Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction and length of stay were considered by the committee to be critical outcomes to decision making. Readmission, delayed transfers of care and staff satisfaction were considered important outcomes. |
Trade-off between benefits and harms |
A total of 10 studies were identified that assessed the role of discharge planning for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that discharge planning may provide a benefit in reduced avoidable adverse events (falls), length of stay, quality of life (as measured by SF-12 mental rating in 1 study) and patient and/or carer satisfaction measured by the preparedness to leave hospital. The evidence suggested there was no effect on quality of life (as measured by either the St Georges Respiratory questionnaire or SF-12 physical ratings), staff satisfaction and patient and/or carer satisfaction assessed by patient rating of the discharge process. Discharge planning was beneficial in terms of reducing readmissions in 3 studies but in 1 study that reported a hazard ratio that there was no difference in readmission. The evidence from 1 study reporting results only as hazard rations suggested a benefit for reduced mortality at 6 months and another study suggested reduced in hospital mortality for discharge planning. However, evidence from 3 studies suggested an increase in mortality from 1 day -12 months. It should also be noted that 2 of the studies23,59 in the meta-analysis suggesting an increase in mortality post discharge; discharge planning were small studies and there is evidence to suggest that the frailty of the patients in the discharge planning groups was more pronounced than in the control group which may explain the excess mortality in the study groups. No evidence was identified for delayed transfers of care. The discharge planning interventions evaluated by the studies varied in terms of their composition and focus. Whereas some were grounded in facilitating the organisation of community, social care and living arrangements, others were more focused on improving post-discharge management of clinical conditions through patient education and management of follow-up appointments and prescriptions. Some interventions also included post-discharge components such as follow-up telephone calls and visits. However, despite these differences, pooled analyses showed no significant heterogeneity. The committee felt that if no plan for discharge is made, it can result in bed blocking if a patient is medically fit for discharge, but is unable to be discharged because the appropriate community and social care measures, if required, are not in place. This plan should be made on admission to enable adequate time to make arrangements for the point where the patient is medically ready for discharge. Therefore, the committee decided to make a recommendation based on the evidence and their wide experience within primary, secondary and community care. |
Trade-off between net effects and costs |
No economic studies were included. One of the studies included above found substantial cost savings but this has not been included since (as outlined in the review protocol) the US setting is unlikely to make the economic findings generalisable to the UK. Unit costs of ED attendances and hospital admissions were provided to aid the consideration of cost-effectiveness. The review above indicated a reduction in readmissions and length of stay associated with discharge planning, which could result in substantial costs savings. The committee noted that implementing a form of early discharge planning is likely to be low cost and therefore it is likely to be cost saving overall. Safeguards need to be in place to ensure that earlier discharge is safe and the patients have appropriate support in the community. |
Quality of evidence |
The evidence was graded very low to moderate quality due to risk of bias, imprecision and indirectness. There was no economic evidence included in the review. |
Other considerations |
The committee considered current practice with regard to discharge planning. Discharge planning of some form occurs throughout all hospitals in the UK but is not standardised across hospitals. Although it is stated that it should begin at the point of admission (and before admission in the case of elective admission), this often does not happen. The Department of Health has guidelines and a tool for discharge planning.57 Discharges are divided into ‘simple’ and ‘complex’. Simple discharges account for 80% of discharges and should be easily achieved with the appropriate training, planning and resources. The processes to achieve a simple discharge are predictable and reproducible. In these cases, when the discharge process does not occur as planned, it is most likely to be a consequence of a failure in communication. Complex discharges account for the remaining 20%. These are patients with more complex needs such as multimorbidity or frailty, who may need additional input from other professionals such as social workers and therapists. The involvement of additional services, staff and specialties makes prior co-ordination and planning even more critical. This is of particular importance in the frail elderly and those patients with mental health issues. These patient groups are vulnerable to poor communication and co-ordination which have a disproportionate impact on the discharge process. Doctors are not usually specifically trained in discharge planning. It is assumed that they gain knowledge and skills through clinical practice. Training in discharge planning would benefit doctors early in their career and junior nursing staff so that it is embedded in the management plan. The committee decided to make a positive recommendation as they considered it good practice to start planning discharge at the point of admission. This would ensure that discharge gets equal prominence with the ongoing management of the acute illness which should mitigate the risk of delayed discharge once the patient is fit to return to the community. |
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Appendices
Appendix A. Review protocol
Table 4Review protocol: Discharge planning
Review question | Discharge planning |
---|---|
Guideline condition | Acute medical emergencies. |
Review population | Adults and young people (16 years and over) with a suspected or confirmed AME (discharged from the acute hospital). |
Adults | |
Line of therapy not an inclusion criterion. | |
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated) |
Discharge planning; discharge planning as defined by study. Usual care; as defined by study. Standard processes; usual practice. |
Outcomes |
|
Study design | Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified. |
Unit of randomisation |
Patient. Hospital. Ward. |
Crossover study | Not permitted. |
Minimum duration of study | Not defined. |
Subgroup analyses if there is heterogeneity |
|
Search criteria |
Databases: Medline, Embase, the Cochrane Library, CINAHL. Date limits for search: none. Language: English only. |
Appendix B. Clinical article selection
Appendix C. Forest plots
C.1. Discharge planning versus standard processes
Figure 9Quality of life (minimal clinically important difference on St. George’s Respiratory Questionnaire)
Appendix D. Clinical evidence tables
Download PDF (569K)
Appendix E. Economic evidence tables
No relevant health economic studies were identified.
Appendix F. GRADE tables
Table 5Clinical evidence profile: Discharge planning versus standard processes
Quality assessment | No of patients | Effect | Quality | Importance | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
No of studies | Design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Discharge | standard processes | Relative (95% CI) | Absolute | ||
Readmission (follow-up 30 days; assessed with: number readmitted) | ||||||||||||
1 | randomised trials | serious1 | no serious inconsistency | serious2 | serious3 | none | - | 0% | HR 1.17 (0.79 to 1.73) | - |
⨁◯◯◯ VERY LOW | IMPORTANT |
Readmission (follow-up 5-30 days; assessed with: number readmitted) | ||||||||||||
3 | randomised trials | serious1 | no serious inconsistency | no serious indirectness | serious3 | none |
74/493 (15%) | 20.7% | RR 0.74 (0.56 to 0.98) | 54 fewer per 1000 (from 4 fewer to 91 fewer) |
⨁⨁◯◯ LOW | IMPORTANT |
Mortality (follow-up 5 days -12 months; assessed with: number of deaths) | ||||||||||||
4 | randomised trials | no serious risk of bias | no serious inconsistency | no serious indirectness | serious3 | none |
98/824 (11.9%) | 10% | RR 1.13 (0.87 to 1.48) | 13 more per 1000 (from 13 fewer to 48 more) |
⨁⨁⨁◯ MODERATE | CRITICAL |
Mortality (follow-up 6 months; assessed with: number of deaths) | ||||||||||||
1 | randomised trials | no serious risk of bias | no serious inconsistency | serious2 | very serious3 | none | - | 0% | HR 0.54 (0.23 to 1.27) | - |
⨁◯◯◯ VERY LOW | CRITICAL |
Mortality (in-hospital) (follow-up during admission; assessed with: number of deaths during admission) | ||||||||||||
1 | randomised trials | no serious risk of bias | no serious inconsistency | serious2 | very serious3 | none |
3/51 (5.9%) | 8.3% | RR 0.71 (0.18 to 2.81) | 24 fewer per 1000 (from 68 fewer to 150 more) |
⨁◯◯◯ VERY LOW | CRITICAL |
Avoidable adverse events (follow-up 1-5 days; assessed with: adverse medicine reaction) | ||||||||||||
1 | randomised trials | very serious1 | no serious inconsistency | serious2 | very serious3 | none |
3/30 (10%) | 6.7% | RR 1.5 (0.27 to 8.34) | 34 more per 1000 (from 49 fewer to 492 more) |
⨁◯◯◯ VERY LOW | CRITICAL |
Avoidable adverse events (follow-up 12 months; assessed with: falls) | ||||||||||||
1 | randomised trials | very serious1 | no serious inconsistency | no serious indirectness | very serious3 | none |
13/30 (43.3%) | 50% | RR 0.87 (0.5 to 1.49) | 65 fewer per 1000 (from 250 fewer to 245 more) |
⨁◯◯◯ VERY LOW | CRITICAL |
Quality of life (follow-up 180 days; assessed with: minimal clinically important difference on St. George’s Respiratory Questionnaire) | ||||||||||||
1 | randomised trials | serious1 | no serious inconsistency | serious2 | very serious3 | none |
24/63 (38.1%) | 41.7% | RR 0.91 (0.6 to 1.39) | 38 fewer per 1000 (from 167 fewer to 163 more) |
⨁◯◯◯ VERY LOW | CRITICAL |
Quality of life (follow-up 7 days; measured with: medical outcomes study short form 12 - physical ratings; Better indicated by higher values) | ||||||||||||
1 | randomised trials | very serious1 | no serious inconsistency | no serious indirectness | no serious imprecision | none | 91 | 98 | - | MD 0 higher (1.23 lower to 1.23 higher) |
⨁⨁◯◯ LOW | CRITICAL |
Quality of life (follow-up 7 days; measured with: medical outcomes study short form 12 - mental ratings; Better indicated by higher values) | ||||||||||||
1 | randomised trials | very serious1 | no serious inconsistency | no serious indirectness | serious3 | none | 91 | 98 | - | MD 1.5 higher (0.11 lower to 3.11 higher) |
⨁◯◯◯ VERY LOW | CRITICAL |
Patient satisfaction (follow-up 7 days; measured with: rating of discharge process; Better indicated by higher values) | ||||||||||||
1 | randomised trials | very serious1 | no serious inconsistency | no serious indirectness | serious3 | none | 91 | 98 | - | MD 0.21 higher (0.05 to 0.37 higher) |
⨁◯◯◯ VERY LOW | CRITICAL |
Patient satisfaction (follow-up 30 days; assessed with: preparedness to leave hospital (prepared or very prepared)) | ||||||||||||
1 | randomised trials | serious1 | no serious inconsistency | no serious indirectness | serious3 | none |
197/307 (64.2%) | 52.9% | RR 1.21 (1.06 to 1.39) | 111 more per 1000 (from 32 more to 206 more) |
⨁⨁◯◯ LOW | CRITICAL |
Length of stay (measured with: days in hospital; Better indicated by lower values) | ||||||||||||
5 | randomised trials | serious1 | no serious inconsistency | no serious indirectness | no serious imprecision | none | 661 | 676 | - | MD 0.58 lower (1.45 lower to 0.28 higher) |
⨁⨁⨁◯ MODERATE | CRITICAL |
Staff satisfaction (follow-up 7 days; measured with: GP satisfaction; Better indicated by higher values) | ||||||||||||
1 | randomised trials | very serious1 | no serious inconsistency | no serious indirectness | no serious imprecision | none | 91 | 98 | - | MD 0.18 lower (0.37 lower to 0.01 higher) |
⨁⨁◯◯ LOW | IMPORTANT |
- 1
Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
- 2
Downgraded by 1 or 2 increments because the majority of the evidence was based on indirect interventions (interventions included post discharge components).
- 3
Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.
Appendix G. Excluded clinical studies
Table 6Studies excluded from the clinical review
Study | Exclusion reason |
---|---|
Altfeld 20131 | Incorrect interventions (post discharge intervention) |
Anderson 20022 | Systematic review (not relevant or unclear PICO) |
Anon 200015 | Systematic review (not relevant or unclear PICO) |
Anon 2004 | Study summary |
Atienza 20043 | Incorrect intervention (multicomponent intervention – patient and family education prior to discharge, post discharge visit with primary care physician and regular follow up visits at a heart failure clinic) |
Azzalini 20154 | Incorrect interventions. early supported discharge |
Balaban 20085 | Said to be an RCT but patients were not randomised |
Beech 19996 | Incorrect interventions. early supported discharge |
Braet 20127 | Systematic review protocol |
Clemson 20169 | Incorrect comparison (discharge planning with home follow up vs. in-hospital discharge planning) |
Cotton 200010 | Data not useable (no SDs provided) |
Cunliffe 200411 | Not guideline condition (fracture) |
Davies 200712 | Incorrect study design |
Domingo 201213 | Systematic review protocol |
Durvasula 201514 | Incorrect study design |
Farren 199117 | Incorrect study design |
Finn 201118 | Incorrect interventions (nurse discharge facilitator assigned to patients who were ready for discharge to assist with discharge processes) |
Fox 201321 | Systematic review (not relevant or unclear PICO) |
Fox 201620 | Commentary |
Fjaertoft 200419 | Incorrect interventions. early supported discharge |
George 201322 | Letter |
Goncalves-bradley 201624 | Systematic review is not relevant to review question or unclear PICO |
Haggmark 199725 | Incorrect population (cancer patients) |
Harrison 199026 | Article |
Harrison 200227 | Inappropriate comparison - both arms received the same discharge planning |
Hesselink 201228 | Systematic review (not relevant or unclear PICO) |
Hofstad 201429 | Incorrect interventions (early supported discharge) |
Hyde 200030 | Incorrect interventions (post discharge intervention; supported discharge) |
Indredavik 200031 | Incorrect interventions (early supported discharge) |
Kleinpell 200434 | Not guideline condition. outcomes not useable (no SDs given) |
Kotowycz 201035 | Incorrect interventions (early supported discharge) |
Langhorne 200537 | Systematic review (not relevant or unclear PICO) |
Langhorne 200738 | Systematic review (not relevant or unclear PICO) |
Laramee 200339 | Incorrect interventions - congestive heart failure case manager, multicomponent intervention (early discharge planning and coordination of care, patient education, enhanced telephone follow up and promotion of CHF medications) |
Legrain 201140 | Inappropriate comparison (discharge planning in both arms) |
Linden 201441 | Incorrect intervention (multicomponent intervention including several post discharge components) |
Lockwood 201543 | Systematic review is not relevant to review question or unclear PICO |
Mahler 201544 | Systematic review (not relevant or unclear PICO) |
Mazloum 201645 | Non-OECD country |
Mcclellan 201346 | Incorrect population (soft tissue injury) |
Mcinnes 199947 | Incorrect interventions. GP input in to discharge planning |
Mcnamee 199848 | No useable outcomes |
Melberg 201549 | Incorrect interventions. early discharge for low risk patients |
Mistiaen 200750 | Systematic review (not relevant or unclear PICO) |
Moher 199251 | Incorrect interventions - medical team coordinator (27% of the time spent on activities related to discharge planning, rest of the time participating in ward rounds, generating bed census, retrieving missing medical information etc.) |
Naylor 199954 | Incorrect intervention (discharge planning and home follow up protocol implemented by advanced practice nurses 4 weeks post discharge) |
Naylor 1999B55 | Incorrect intervention (discharge planning and home follow up protocol implemented by advanced practice nurses 4 weeks post discharge) |
Nazareth 200156 | Incorrect interventions - pharmacy discharge plan at discharge |
Palmer 200158 | Incorrect study design |
Parfrey 199460 | Incorrect population |
Parkes 200061 | Systematic review (not relevant or unclear PICO) |
Phillips 200462 | Systematic review (not relevant or unclear PICO) |
Pray 199263 | Narrative article |
Puhr 201565 | Systematic review is not relevant to review question or unclear PICO |
Rich 199367 | Incorrect interventions - multicomponent intervention (intensive patient education, analysis of medications, early discharge planning and enhanced follow up through home care and telephone contact |
Rich 199566 | Incorrect interventions - multicomponent intervention (intensive patient education, dietary assessment, consultation with social services personnel, analysis of medications, intensive post discharge follow up by hospital’s home care services |
Rousseaux 200968 | Systematic review (not relevant or unclear PICO) |
Rudd 199869 | Correction |
Saleh 201270 | Incorrect interventions (intervention is post discharge) |
Sharif 201471 | Non-OECD country |
Shepperd 200472 | Systematic review (not relevant or unclear PICO) |
Shepperd 200973 | Systematic review (not relevant or unclear PICO) |
Shepperd 201075 | Systematic review (not relevant or unclear PICO) |
Shepperd 201374 | Systematic review (not relevant or unclear PICO) |
Sulch 200076 | Incorrect interventions - inpatient rehabilitation |
Torp 200677 | Inappropriate comparison. discharge planning in both arms |
Utens 201279 | Incorrect intervention (early supported discharge) |
Ulin 201478 | Incorrect study design |
Weinberger 199680 | Incorrect interventions - increased access to primary care before and after discharge |
Zhu 201581 | Systematic review (incorrect PICO); references screened |
Appendix H. Excluded health economic studies
No health economic studies were excluded from this review.
- Discharge planning - Emergency and acute medical care in over 16s: service deliv...Discharge planning - Emergency and acute medical care in over 16s: service delivery and organisation
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