Great Expectations (of discharge)
Brian Booth, RGN
"But I've only just arrived..."
I have always tried to teach staff that the expected date of discharge should be planned from admission.
Then along came the box tickers. It shouldn’t have been a problem; set a nominal date and work towards it but while managing patient expectation.
I once campaigned (unsuccessfully) to ban staff of all disciplines giving a patient or their family an EDD (expected/estimated discharge date). So over the decades, I have developed what I call ‘scripts’, set pieces which are honest but elastic. One of these is ‘you may hear people talking about estimated or expected discharge dates. These are random dates, necessary for administrative purposes; you could go home before that day, or later. The longer we look after you, the more accurate will that date be.’
At a previous place of work – a PCT - I spent a good part of a shift consoling a man who had had packed his bags, then taking angry and distressed calls from the family, wondering why he wasn’t home yet. All because someone had previously told him his EDD. In this case, everything I had said to the patient and family was forgotten; they had a date in their heads. Gospel; a nurse, physiotherapist or occupational therapist had told them, after all.
My firm belief is that the more patients know about their care, the easier the process becomes. But the EDD is something that should only be shared with disclaimers.
Yet there will always be the prat that gives them a specific date.
I speak from experience outside my work; an elderly family member fell foul of this, involving a lot of travel and expense as we tried to sort it out. In addition to the EDD, they were told they were ‘medically fit for discharge’. But because of various logistical problems – including a suggestion that the privatised ambulance service could take him home at 11pm – their medical condition was compromised. Primary care could not be arranged at that time, at such short notice; but the person was fortunate in having nurses in the family, ready to travel and step in.
I am increasingly frustrated by the way information is shared or not shared in the NHS (RIP). I have more than once had to take the phone from a registered nurse saying ‘I’m sorry, I have no proof that you are who you say you are’, informing them ‘it’s Brian, can I help?’ – and finding that the query was along the lines of ‘how did my dad sleep last night?’
Information governance; important yes, but poorly explained.
Working outside my once beloved NHS now, it’s a culture shock to see how much better things can be done. There’s no question of patient confidentiality being forgotten; it’s a bigger picture, where all the drivel about ‘client involvement’ is taken seriously, and that includes families.
To reiterate: I’m not advocating the model of Sir Lancelot Spratt in the Doctor in the House movies, shouting at patients asking questions ‘It’s nothing to do with you, man!’
But we need to think hard about what we share.
Brian is quite correct – discharge planning should start almost as soon as the patient walks through the door, be that A & E or a ward. But who is doing this; is it the nurses, social workers, doctors? If so, who are they liaising with? Does documentation record dates, discussions and outcomes?
O should there be a dedicated discharge planner in each organisation? There’s a lot to be said for having one person doing the job; one person who has to be listened to; one person other community agencies talk to and agree care plans with, one person who checks and double checks everything is in place so that the patient can leave at an appropriate time.
Have Continuing Health Care assessments and the newly launched Patient Activation Measures (https://www.england.nhs.uk/ourwork/patient-participation/self-care/patient-activation/pa-faqs/) muddied the discharge planning waters, or helped to ease the process?
We would welcome your experiences of discharge planning. What works for you? Please drop us a line: http://firstname.lastname@example.org