The Hospital Discharge Process: A Review of Its Main Barriers and Quality Improvement Strategies
By: Elizabeth Kaplan and Darlene Lien
Introduction
Hospital discharge is the process where patients transition from in-patient care to another care setting, such as primary, community, or domestic units. As hospitals become confronted with the urgency to discharge patients in the face of high patient occupancy rates and a shortage of hospital beds, shortcomings in the hospital discharge process have only been exacerbated. The high-risk and unstandardized nature of hospital discharge can decrease the quality of patient care and expose patients to cost and medical related risks. Hence, calling attention to the issue and enhancing hospital discharge processes are vital initiatives that can be taken in order to improve patient outcomes upon discharge from the hospital.
Communication among all parties involved in the discharge process is essential to prevent post hospital adverse events, readmission, and mortality. It was found by two recent North American studies that the incidence of post-discharge adverse events ranges from 19% to 23%, with more than one half of these adverse events being traced back to poor communication between hospital staff, patients, and primary care physicians during the discharge process. More specifically, ineffective discharges are primarily a result of different health care providers’ perceptions of patient health literacy, lack of standardized discharge protocols, and lack of post-discharge support. This clearly signifies the role of discharge planning, which according to the Cochrane Database System Review, is “the development of an individualized discharge plan for the patient prior to leaving the hospital, with the aim to reduce medical costs, improve patient outcomes, and reduce length of stay and unplanned readmissions” (Okoniewska et al., 2016).
Barriers in the Discharge Process
Looking particularly at the discharge process from acute care to community care, miscommunication has been found to be the main discharge barrier. A qualitative study was conducted to analyze health care providers’ views on communication barriers to effective discharge planning over the course of a one month rotation at a hospital affiliated with the University of Calgary in Alberta, Canada. Utilizing the responses from 26 nurses, 25 internal medicine residents, and seven attending medical staff, the study found that communication gaps, lack of role clarity, and lack of resources, both in acute care and community care, are perceived as the three largest barriers to discharge.
Similarly, in another study conducted by Wong et al., communication and coordination were identified as key components of an effective discharge planning process. Researchers in the study examined the discharge planning process specifically in Hong Kong and utilized participants from different healthcare professions that were involved in the discharge planning in public hospitals. In order to facilitate discussion relating to the discharge process, participants were directed to answer a series of open-ended questions on current patient discharge planning, barriers encountered in hospital discharge, and suggestions on effective discharge planning. The study found that ineffective hospital discharge was driven primarily by a lack of standardization in hospital discharge policies as well as a lack of coordination between healthcare providers and patients. However, participants also pointed to systemic barriers, such as a shortage of hospital beds, in hindering discharge planning by inducing shorter hospital stays and consequently, earlier hospital discharges.
Methods for Improving Discharge
Findings from the aforementioned studies suggest the need to improve the discharge planning process in order to improve the quality of patient care. The study conducted in Alberta, Canada identified methods for improvement of the discharge process, specifically creating discharge documents including follow-up and patient education, increasing effectiveness of discharge rounds, improving communication between healthcare providers, and developing greater leadership in the process. In particular, communication can be improved through the use of electronic discharge summaries and bullet rounds, which are a condensed form of discharge rounds involving various members of the hospital team and occuring on a daily basis. Designating a discharge coordinator or having all the relevant parties involved at the time of discharge planning to clarify their tasks can help with role clarity.
Another important component for effective discharge planning is implementing a standard screening process and policy-driven approach across hospitals. By having patients participate in an early screening tactic, hospitals can not only more efficiently identify high-risk readmitted patients but the readmission of such patients would be known to all healthcare providers (Wong et al. 2011). Aside from screening through information technology, participants from the Wong et al. study indicated that a thorough strategy in targeting patients’ psychosocial needs as well as in educating patients on medications and treatments is paramount in discharge planning. Furthermore, part of addressing patient needs is ensuring that they have access to all necessary discharge information, whether it entails bridging communication barriers or designating certain nurses/physicians as contact sources.
Conclusion
Hospital discharge, as patients transition from the hospital to another care setting, is oftentimes a very high-risk and vulnerable period of time. Rather than viewing patient discharge from the hospital as an end to obligatory care, healthcare personnel should handle the process with care and safety — in other words, an important facet of quality patient care is effective discharge planning. The aforementioned studies present common issues encountered within the discharge process, which revolve around communication, role clarity, and lack of resources. More importantly, the studies underline key strategies that can be employed and introduced in order to enhance the discharge process and thereby strengthen patient needs. At the end of the day, effective discharge planning would only help improve patient health outcomes and reduce hospital readmission and mortality rates.
References
Okoniewska, B., Santana, M. J., Groshaus, H., Stajkovic, S., Cowles, J., Chakrovorty, D., & Ghali, W. A. (2015). Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers’ perceptions. Journal of multidisciplinary healthcare, 8, 83–89. https://doi.org/10.2147/JMDH.S72633
Wong, E.L., Yam, C.H., Cheung, A.W. et al. Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals. BMC Health Serv Res 11, 242 (2011). https://doi.org/10.1186/1472-6963-11-242
Elizabeth Kaplan is a third year Biology major at UCLA and is a THINQ 2022 member.
Darlene Lien is a third year Human Biology and Society major at UCLA and is a THINQ 2022 member.
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