As outlined above, participant narratives helped identify potential adverse safety events (involving harm) as well as active and latent‘risk factors’(producing, enabling or conditioning the possibility for harm). In all cases, this analysis was limited to activities, situations and, importantly, knowledge-sharing processes related to discharge planning and care transition, i.e. where safety events were described in relation to othercare-related activities, they werenotconsidered in the analysis. Analysis of participants’narratives led to the identification of seven broad categories or types of safety events and/or risk factors associated with discharge planning and care transition, with extracts of supporting data provided inAppendix 5.
To support the coherence of this analysis, these categories were cross-referenced with the World Health Organization’sInternational Classification for Patient Safety148conceptual framework. These include:
l falls
l medicines
l infection
l clinical procedure
l equipment
l timing and scheduling
l communication.
Before elaborating these risks, it is worth noting that‘falls’,‘infection’and‘medication’risks were typically associated with more direct threats to patient safety, but each was also associated with a range of wider contributory or latent factors, i.e.‘falls risks’or‘medication risks’. In contrast,‘clinical procedure’,
‘equipment’and‘timing and scheduling’were all described as more contextual or latent risks that framed or conditioned patient safety, i.e. where the immediate impact on safety was less clear or direct.
As the analysis shows, these risks often overlap or combine in the context of patient safety, for example where medication risks relate to infection and together lead to a fall. This is especially the case for
‘communication’, which was widely described as a systemic or latent source of risk that often framed or explained many of the other identified risks. Given the centrality of communication or, more precisely, knowledge sharing to the overall analysis, this theme is discussed through the chapter in relation to these other risks. Each described risk category is illustrated and data presented in the previous chapter are used to interpret the link between participants’perceived threats to discharge safety and the observed patterns of knowledge sharing.
Falls
Falls, including slips, trips and collapses, were described by almost all participant groups as a common safety event in relation to discharge. Falls can occur at almost any time within a patient’s care journey and have a range of causes. It was usual for those in hospital and community settings to describe different situations where falls occurred, but in general these related to falls from the patient’s bed, when using a chair, the toilet or other bathroom facilities, when ascending or descending stairs or steps, and when being mobilised during therapy. It is important to note, however, that many of these accounts described falls as part of general care management, and not with specific reference to discharge planning and care transition. With specific reference to the falls and falls risk factors associated with discharge planning and care transition, a number of specific issues were identified. These were broadly related to processes of‘transportation’and‘resettlement and adjustment’, with the second group also associated with the use of equipment and devices (seeEquipment).
In terms of‘transportation’, two issues were raised by patients and/or family members. First, it was described how falls could happen when being moved or handled between hospital, vehicle and community location. For example, the process of helping patients into the ambulance or back into their own home was often described by patients as challenging because they were still adjusting to their mobility constraints and because carers were seen as unsure how best to move the patient or were unfamiliar with the home layout. This suggested underlying concerns about the knowledge and skills of some support groups, i.e. porters and ambulance crews, to appropriately and safely move patients. Second, it was also described how, on occasion, ambulances used for transportation might not be suitable for certain types of patients in terms of seating arrangements, availability of chairlifts or having the necessary devices to support the care of frail patients. A number of patients on hip precaution following hip replacement described how the wrong type of ambulance was provided as there were no high-seats or supports to enable safe transfer between hospital and home. A number of ward clerks also described how inappropriate ambulances were provided when transferring very frail, bed-bound patients to community hospital, because they could not accommodate a bed. In such cases, it was usual for participants to describe unnecessary delay, rather than an actual fall, but where alternative transportation could not be arranged then the risk of fall remained. In general, patients and their relatives reflected negatively on the transportation process and often referred to falls and other risks associated with both the physical movement of patients and the suitability of the vehicle. When describing these risks it was common for hospital-based participants (doctors, nurses, HCAs, ward clerks) to highlight deficiencies in the regional ambulance service, especially where bookings for a particular time, location and ambulance type were not fulfilled. For some participants, this reflected a communication problem between the wards and the ambulance service, especially where booking systems and the ambulance control did not accurately record or meet provided instructions. Representatives from the ambulance service acknowledged these problems but also described themselves as overburdened by the demands of emergency care and often struggling to manage service provision. It is also important to recognise the potential for missing information at the time of booking, for example if the ward clerk had not been informed about specific needs and could not therefore relay this to the ambulance service.
More prominent were falls associated with‘resettlement and adjustment’within a domestic setting, usually home. Three safety events were described within patient and family narratives. The first group comprised trips, slips and falls within the home that seemed, in general, to be associated with everyday activities, such as using furniture, tripping over rugs and internal steps, ascending or descending stairs, using
bathroom facilities or getting in or out of bed or a chair. For many participants, these were associated with patient confidence following discharge and the need to readjust to the home setting after prolonged hospitalisation. It was also described how certain aspects of the home layout could be taken for granted rather than moved to reduce the risk of fall, such as the position of rugs and tables. A widely understood risk related to the use of bathroom facilities, which were especially problematic for hip fracture patients. For example, patients often described minor slips or falls when sitting or rising from a toilet seat or when entering the bath. A range of possible risk factors were described as increasing the likelihood of falls around the time of discharge, including cognitive impairment, medicines use or adverse effect, infection [especially urinary tract infection (UTI)], patients’understanding of their ability to mobilise, lack of support from carers and the use of equipment or devices (seeEquipment). It seemed that, for many, these risks were accepted as normal for patients needing to readjust to their home or care home and, as such, extra vigilance was needed in the early days following discharge. However, some also raised the possibility that these risks were heightened by a lack of thoroughness in, or poor communication of, clinical assessments, i.e. where cognitive impairment was not adequately determined, or information on the use of medicines or equipment was incomplete (seeEquipment).
The second group of resettlement-related falls risks were associated with the provision and use of home adaptations and equipment to support recovery and mobilisation around the house (see alsoEquipment). Both hip fracture and stroke patients were commonly provided with a range of grab rails, seat and bed risers, steps, frames, walking sticks and wheelchairs to support their recovery outside hospital. Two specific issues were associated with this equipment. First, patients and carers (including reablement teams)
described problems with the availability and appropriateness of equipment and devices. A common example described essential equipment, such as grab rails, walking frames, commodes, steps/ramps, beds and mattresses, being delivered or fitted after the patient had arrived home. In such situations, patients were at risk of fall or accident because everyday activities, such as washing, toileting or walking, were not appropriately supported. As explained below, these delays were often linked to problems in the ordering of equipment, especially in contacting suppliers, or disagreements between nurses and OTs about whose responsibility it was to order commodes, or between health and social care about who should fund certain adaptions, especially steps and ramps. Second, patients, relatives and carers also experienced complications in the use of certain devices, such as hoists or pressure mattresses. For example, one patient described a fall when using the toilet because he did not realise that his weight needed to be evenly distributed on the support frame. These risks are elaborated below, but again participants described shortcomings in supporting patients and carers in the use of equipment.
The third group of falls risks relate, in very general terms, to the quality and appropriateness of the domestic settings to which the patient is transitioned. A number of city-centre patients were discharged to Victorian-era homes with several steps between pavement and door, narrow and steep staircases and relatively small bathroom facilities. In contrast, a number of other patients were discharged to more rural settings, to small cottages or farms. These property types were commonly described by community nurses or other social carer workers as poorly suited to patient recovery, some with outside toilets, making it difficult to accommodate necessary home adaptations and requiring patients to take unnecessary risks. The failure of social work and community health-care teams to recognise and consider these issues in discharge planning was seen by community nurses as putting patients at risk. In many instances, it was suggested that patients needed further rehabilitation at an intermediate facility before returning to these home settings.
In general, falls and falls risks featured more often in the narratives of patients and families, but they were also included in those of community-based carers (reablement teams, community nurses, OTs) following hospital discharge. It was more usual for community nurses to discuss the link between falls and cognition, medicines use or infection, reflecting their enhanced clinical understanding of the possible causes. It was more usual for community stroke nurses (Farnchester) and the discharge liaison nurses (Glipton) to mention property type in relation to discharge planning. There were no variations between sites in terms of
perceptions of risk associated with falls as it seemed a general issue related to postdischarge recovery. Drawing on participant narratives and, where possible, cross-referencing these with observational data, falls and falls risks associated with discharge planning and care transition are summarised inFigure 8.
Falls
Transport
Moving and handling
Vehicle type
Mobility related Medicines, cognition Availability and use Equipment related Housing type Residential
The above paragraphs describe how participants understood the risk of falls. Relating this to the patterns of knowledge sharing explicated in the previous chapter, we can begin to make a number of suggestions about how knowledge sharing contributed to the source of risk. Although falls can be brought about by a range of local and environmental factors, a number of knowledge-sharing dynamics condition or mitigate this potential. In relation to hospital transportation, the booking process involved an important opportunity for knowledge sharing between ward clerk, ambulance control and ambulance crews. The study found that this could be complicated, i.e. missed or incorrect, when the ward clerk was not on duty and other ward staff would be required to arrange transportation, for example nurses or HCAs. Although booking transport was relatively straightforward, the ward clerks appeared to have a developed understanding of the types of transportation available and an interpersonal relationship with staff at the ambulance service. As such, they were often more accurate in booking ambulances or appreciating the daily demands and schedules of the ambulance service. The absence of the ward clerk and reliance upon other staff could, on occasion, lead to the dispatch of inappropriate transportation or lead to delays. As such, the ward clerk provided an important knowledge-sharing resource on the day of discharge.
In relation to the patient’s general well-being and mobility, and also his or her use of equipment, a key knowledge-sharing dynamic was found in the interaction between the patient, his or her relatives and the ward-based therapist team. Specifically, OTs and PTs had an essential role in assessing the patient’s overall mobility, ability to undertake activities of daily living and cognitive function. They also provided individualised information and training to patients and relatives on the use of specific equipment and devices to be used after discharge. These types of activities relied upon relatively detailed, close and personalised knowledge-sharing relationships in day-to-day ward-based interaction across all sites, for example explaining to patients how best to use walking aids or climb stairs. At some sites, however, this pattern of interaction and knowledge sharing could become more fragmented, less patient-centred and not integrated into other ward-based activities. At Farnchester, for instance, therapist teams worked across the entire hospital and had sessional visits to the orthopaedic unit (note that the stroke unit had a
dedicated therapist team). It was observed how OTs and PTs often had limited time with individual patients, could not always co-ordinate their sessions with family visits and were often marginalised from ward-based decision-making, such as MDT meetings. As such, the opportunities for both giving and receiving knowledge to and from patients and ward staff were limited. A similar format of therapist input was observed at the Glipton orthopaedic unit, but here there was closer involvement of therapists in ward-based activities. The two stroke units, however, featured dedicated therapist teams which facilitated closer, regular and more timely interaction with patients and families, and thereby more continuous exchange of knowledge. A related feature at Farnchester stroke unit was the explicit emphasis on family-centred care, including the use of family meetings, which enabled closer working with family members so that they were better aware of their relative’s ongoing needs and use of equipment. A further issue related to the provision of equipment related to ordering and supply, which is discussed below.
A further knowledge-sharing issue was the involvement in discharge planning of specialist staff who could provide knowledge about specific devices, medicines or housing. In particular, a key contribution was made by discharge liaison nurses at Glipton, and also the community stroke nurse at Farnchester, who had detailed, even‘encyclopaedic’, knowledge of local housing quality, including steps from pavement to door, layout and bathroom arrangements. Their involvement in discharge planning could often avoid the need for home visits, but more commonly enhanced the decision-making processes of therapists, for example when ordering equipment (seeEquipment) or supporting patient use of devices. A similar contribution was also found in the role of both hospital- and community-based pharmacists, who could inform patients and family members about the potential medicine-related complications that might reduce stability
(seeMedicines). Where these actors were not present, or were marginal, it seemed that discharge planning was often more generic and less specific to the needs of individual patients.
Infection
As with falls, infections were identified as a patient safety concern for both stroke and hip fracture patients, especially where both patients and staff were attentive to the problems of hospital-acquired infections, such as methicillin-resistantStaphylococcus aureus(MRSA). Notwithstanding these broader infection risks, two types of infection risk were discussed in relation to hospital discharge, usually by ward and community nurses. The first was associated with‘extended admission’, where patients would be exposed unnecessarily to hospital-acquired infections because of delayed discharge. For example, ward nurses talked of the risks of contracting pneumonia andClostridium difficile, especially for frail older patients. As outlined below, clinicians describe a‘window of opportunity’for care transition, which once missed could lead to patients being‘trapped’within a cycle of infection and recovery, which could have little direct connection to their stroke or hip fracture but reflect other comorbidities and the general risks of admission. Similarly, the risk of pressure sores was discussed for extensive inpatient admissions, where a lack of mobilisation and extended confinement to bed could lead to sores and chest problems. This was usually related to problems with ongoing patient monitoring after delayed discharge, when the patient was seen as ready for discharge and hence levels of direct active medical care were reduced, but monitoring and mobilisation were still required. As such, infection risks were often related to delays in discharge and the changing patterns of care giving (seeTiming and scheduling).
The second group of infection risks were associated with‘follow-up care’, when infection developed or was identified immediately after discharge. A prominent concern, for example, was UTI, which was seen as relatively common among both patient groups. Community nurses, in particular, described the need to monitor patients for signs of increased temperature and confusion in case of UTI, and also the need to involve the patient’s GP to prescribe antibiotics. An additional, but less common, infection risk related to sepsis, again following surgery, which might not develop until the patient was discharged into a community setting. This was raised by community nurses and ward nurses in community hospitals;
for example, one Glipton hip fracture patient was found to have developed sepsis due to a surgical clip being left undetected at the time of care transition. A more common problem was with wound care and whether or not the reablement teams had the appropriate nursing skills to thoroughly clean and bandage surgical wounds or to detect potential problems. A more general concern for community nurses was the patient’s adherence to prescribed medicines after leaving hospital. It was described by one pharmacist, for example, that patients often attend the community pharmacy confused about their changed medicines regime (seeMedicines). Such confusion and lack of adherence to prescribed antibiotics was seen as contributing to the potential risk for infection.
It was more usual for nurses within community hospitals to highlight the potential for postoperative