Current problems at discharge

Discharge from hospital is known to be fraught with issues. Transfer of patient care has been identified as a vulnerable point in the care process as this presents an increased opportunity for errors that may result in patient harm.^(65,66) The common problems that arise at discharge are discussed below.

2.7.1 Delayed discharges

Delayed discharges are common and add to the increasing burden on the NHS. A delayed discharge occurs when a clinical decision has been made that a patient is ready for transfer from a hospital bed, but is still occupying that bed.⁽⁶⁷⁾ When patients are medically fit for discharge, but there another factor is causing delay to their discharge this is commonly referred to as ‘bed-blocking’. Bed-blocking is a term used to refer to elderly patients that are medically fit for discharge, but are unable to leave the hospital due to other reasons, examples of which are discussed below. Bed-blocking is a huge problem for the NHS, who are under pressure to reduce this. The Carter report published that on any given day, up to 8500 beds could be blocked by patients with delayed discharge. This is estimated to cost the NHS around £900 million per year⁽⁶⁸⁾ and has gained a lot of interest in the media over recent years who have informed the public about the issues with patient discharge, often sensationalising stories.^(69–72)

There are various causes of delayed discharges. Examples of potentially long-term causes of delay include patients awaiting social care packages, or care home placement.⁽⁶⁷⁾ The wait for medications at discharge can also delay patient discharge.

This is a short-term delay, but the process of discharging patients from hospital can be time consuming, often resulting in patients waiting for their medicines and temporarily blocking beds⁽⁷³⁾ leading to a delayed discharge.

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2.7.2 Medication errors at discharge from hospital

The time of discharge is a point at which prescribing errors are likely to occur.⁽⁷⁴⁾ A significant percentage of older patients experience medication discrepancies after transferring from hospital to home⁽⁷⁵⁾ leading to medication errors. Medication errors can cause unnecessary harm to patients and can result in readmission to hospital.⁽⁷⁶⁾ According to a 2014 report, preventable harm from medicines is thought to cost the NHS anywhere between £1 billion-£2.5 billion annually.⁽⁷⁷⁾

There are a number of well documented factors that can contribute to medication discrepancies as a result of hospital discharge.^(51,54) These include: incomplete information in discharge summaries sent to GPs,(51,54,78,79) lack of prompt transfer of discharge information to GPs,(48,51,54,79) patient misunderstanding of discharge instructions^(51,54,80) or lack of adequate patient counselling.⁽⁴⁹⁾

Research indicates that if discharge summaries do not contain sufficient information about any changes to the treatment plan that occurred during the inpatient episode, this can result in treatment failures, continuation of inappropriate medication and discontinuation of required medication.⁽⁷⁹⁾ A study conducted across 45 hospitals in England found that two-thirds of discharge prescriptions were inaccurate or incomplete prior to pharmacy screening. Clinical screening by pharmacists was thought to contribute significantly to patient safety.⁽⁸¹⁾ A further study in Switzerland found that drug omissions and unjustified medications on discharge prescriptions were frequent.⁽⁸²⁾ In another study conducted in one hospital in New Zealand, an audit of 100 medication charts and discharge summaries found that there were 1.42 discrepancies in medication per medicine discharge summary^.(83)

Issues can arise when patients’ regular medication is not noted on admission to hospital and therefore not included in the discharge summary. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis.⁽⁸⁰⁾ Patients’

regular medications that are not directly involved with the reason for admission will often be omitted on admission and therefore will not be included on the discharge

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prescription. One study found that errors in preadmission medication histories lead to more discharge reconciliation errors.⁽⁸⁴⁾ Other studies have found that more accurate medicines reconciliation on admission and rectifying any problems identified will lead to more accurate medication lists on discharge from hospital. One audit of discharge summaries received by GP surgeries highlighted that regular medication was documented in only 30% of summaries. Regular medication was stopped for 59% of patients during their hospital stay with no reason stated and, at discharge, 39% were prescribed new drugs, again with no reason stated.⁽⁷⁹⁾

Another problem can occur as a result of patient confusion. Patients tend to view their hospital medication and home medication as different and may take both, thus taking double doses of some medicines.⁽⁵⁴⁾ This can be dangerous with many medications and requires adequate patient counselling to reduce this risk. Conversely, some patients inappropriately revert to their pre-admission medication after discharge.⁽⁵⁴⁾ This would be especially problematic for patients who were originally admitted with adverse drug reactions caused by their pre-admission medication.

Lack of adequate communication on discharge from hospital leads to situations where patients will struggle to obtain the correct medication,⁽⁴⁹⁾ or struggle to understand what medication they should be taking, how they should be taking it and why. Inevitably, this will leave the patient confused and at risk of emergency readmission to hospital.

As previously mentioned in section 2.6.2 The discharge process, prompt transfer of information to the relevant parties is essential for continuity of care. It is an expectation that discharge summaries should be sent to patients’ GP surgeries within 24 hours of discharge. One audit in 2011 indicated that GP surgeries only received discharge summaries in 58% of cases. Of these, only 6% arrived within 48 hours of discharge from hospital.⁽⁷⁹⁾ The advent of electronic transfer of discharge information may have improved these figures, however if the GP does not receive discharge information promptly, this can disrupt patient care. Problems and adverse reactions can arise for patients because GP computer prescriptions following discharge are not always

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date with the revised hospital medication plan.⁽⁵⁴⁾ This can be due to the discharge letter arriving at the practice after the repeat prescription has been issued by the GP,⁽⁸⁵⁾ or if the discharge letter has been received but the GP system has not been updated with the information. This leads to medication errors, omissions, confusion, and all that follows from poor communication.⁽⁸⁵⁾

2.7.3 Problems with community pharmacist involvement after discharge from hospital

Recommendations have been made previously to improve communication on discharge, including involving the patient’s community pharmacist,⁽⁴⁹⁾ however these are not always followed in practice. Despite the evidence suggesting the patient benefits of community pharmacist involvement after discharge from hospital, a lack of communication between the hospital pharmacist and the patient’s community pharmacist is common.^(51,54) In the main, community pharmacists are not aware that their patients have been into hospital.⁽⁸⁶⁾

Little work has been done to develop the role of the community pharmacist in managing patients after discharge from hospital. Evidence-based community pharmacist services are available, however studies show that uptake of discharge medication reviews is limited.^(87,88) A questionnaire-based study carried out involving 19 community pharmacists demonstrated that despite community pharmacists’ positive responses about providing discharge MURs, patient engagement was difficult.⁽⁸⁹⁾

2.7.4 Patient perspectives of discharge

Effectively managing the patient journey is crucial to improving patient experience of the NHS⁽⁴⁹⁾ and patient discharge from hospital back into the community is an important aspect of the patient journey. Hospital discharge is a complex, multistage process with many potential sources of error and delay, particularly with regards to the supply of discharge medicines.^(90,91) Medication problems caused by discharge from hospital are discussed in section 2.7.2 Medication errors at discharge from hospital. Despite the

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evidence suggesting problems affecting patients are common after hospital discharge, few studies explore this from the patients’ perspective.

Of the studies that have assessed hospital discharge from the patient's perspective there are some conflicting results. Surprisingly Horwitz found that despite the gaps in their discharge care, patients were uniformly positive in their assessments of discharge care and education.⁽⁹²⁾ Similarly, the National NHS Inpatient Survey which assesses patient experience at hospitals across England showed that 84% of respondents rated their hospital experience as at least 7 out of 10, despite 42% of respondents’ discharges being delayed.⁽⁹³⁾ A large proportion (61%) of those delayed discharges were perceived to be caused by waiting for medicines.⁽¹²⁾These studies suggest that patients may not be aware of some of the internal problems that occur during discharge, or that patient and service providers priorities may not align.

One study found that 42% of older patients reported at least one post-discharge problem.⁽⁴⁸⁾ Current evidence suggests that many problems on discharge occur due to a breakdown in communication. Patients highlighted that they experienced breakdowns in communication between different healthcare providers during transitions of care^(94,95) and between themselves and their healthcare providers.⁽⁹⁵⁾ Inadequate information regarding follow up care after discharge from hospital was a particular concern to patients.^(95–97) Patients in various studies experienced anxieties about their impending discharge, whether or not these were expressed to hospital staff.⁽⁹⁸⁾ These anxieties could be reduced by improving patient–provider communication. Patients perceived that healthcare professionals did not sufficiently prioritise discharge consultations with patients and family members due to time restraints and competing care obligations.⁽⁴¹⁾

A collaboration between patients, carers and healthcare professionals in Devon led to the development of a list of good outcomes on discharge for patients with complex needs.⁽⁹⁹⁾ Many of the statements were around joined up, coordinated care involving the patient. With regards to their medications, patients stated that they would like to be provided with a supply of medication to last until they could see their GP, along with

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sufficient information that they or their carer could manage the medication. Whilst a good basis, these vague statements are open to interpretation as they do not provide much detail around patient needs. Further research is required to identify if these outcomes are routinely experienced by patients.

There are gaps in the evidence around patient experience of hospital discharge. More needs to be known about what patients want with regards to the supply of medication at discharge.

2.7.5 Patient involvement during discharge

Research suggests that patient involvement appears to be limited during hospital discharge. The National Inpatient Survey 2014 found that 54% of patients strongly agreed that they were involved in decisions about their discharge,⁽⁷⁾ this increased to 56% in the 2015 survey⁽¹⁰⁰⁾ but clearly there needs to be an increase in patient involvement at discharge.

Several studies have explored the reasons for low levels of patient participation at discharge. Patients cited the following reasons: many older people can be passive in relation to discharge planning,⁽⁹⁸⁾ some people may be less assertive when they are ill^(96,98) and perceive their contribution to be unnecessary or not valued by their providers.⁽¹⁰¹⁾ Interestingly, one study suggests that healthcare professionals’ and patients’ views differ on whether patients are involved.⁽⁹⁸⁾

2.7.6 Patient counselling

Counselling patients on their prescribed medication is considered beneficial for patient outcomes. A study carried out in elderly heart failure patients demonstrated that providing patient counselling improves medication adherence and decrease readmission rates.⁽¹⁰²⁾ Another study demonstrated that patient knowledge of medicines newly prescribed in hospital is increased by targeted counselling by hospital pharmacists. This was in comparison to patients receiving counselling by the doctor or nurse looking after them. Not all patients benefitted from this intervention and the

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authors considered the impact of hospital discharge being a potentially stressful time when patients are waiting to be allowed to go home and therefore not ideal for information provision.⁽⁸⁸⁾ Despite positive associations between patient counselling and patient outcomes, the extent to which inpatient counselling routinely occurs during admission to hospital was found to be limited.⁽¹⁰³⁾