An exploration of the issues regarding the discharge process and assessment of patient and their caregivers for discharge, which underpin the practice of staff, in an Acute Medicine Unit, in a large NHS Foundation Trust: A Yin-Style Case Study.

Abstract

ABSTRACT Background: The efficient planning of patient discharge from hospitals remains a pivotal issue influencing the timely availability of beds and bed capacity in the United Kingdom. The Department of Health introduced treatment time targets in emergency care in 2004, mandating that patients be seen, admitted/discharged within four hours. This policy aimed to facilitate the smooth flow of patients from emergency departments to hospital wards. This study was based in an acute medicine unit (AMU), which is part of emergency care. Such units have grown exponentially to assist in managing patient flow by treating acutely ill medical patients. Moreover, where admission to a traditional ward can be circumvented, up to 35% of patients are discharged from the AMU on the study site. To date, scarce attention has been paid in the literature regarding how the acute discharge process functions and how patients and their caregivers are assessed for discharge by staff in an acute medicine unit setting. The Nuffield Trust reported that readmissions to emergency care within ‘one day after discharge represent the highest proportion’ and have risen by 24.8% (p3) between 2016/17’ (June 2018). This has heightened attention regarding the quality of patient discharge from emergency care. Aim: This study aimed to describe the process of patient assessment for discharge in an AMU and the extent to which this process also involved their caregivers needs. Design: A single site Yin-Style Case Study with five embedded units and four study propositions. Methods: Data were collected through Focus Groups, Observations, Interviews and Documentary analysis together with Framework Analysis (after Ritchie and Spencer, 1994) supported by theoretical frameworks throughout the study. Findings: This study identified six overarching themes namely, Accelerated discharge process; Lack of patient centeredness; Visiting discharge team; Poor discharge communications; Pivotal discharge coordinator role; Moving patients to the discharge lounge and Approaches to and Assumptions regarding assessment. Bed management activities and the overriding preoccupation by nurses to ensure patient flow to free adequate bed capacity motivated expedited patient discharge from the AMU. Consequently, the assessment of patients for discharge is a very condensed process, initiated by nurses in an unstructured manner, but mostly delegated through discharge coordinators to the visiting discharge teams and other professionals. The motivation, attitudes and behaviours of the staff were interlinked indicating that patient assessment for discharge was not a planned activity in this setting. Patient and their caregivers were involved minimally in their discharge plans and consequently they felt that assumptions regarding their circumstances were made on their behalf. Conclusion: An in-depth insight into the acute discharge process and patient assessment for discharge has highlighted tensions and challenges related to this particular context, which are mostly attributed to the implementation of treatment time targets. AMU staff would benefit from support to modify their approach to patient assessment and the comprehensive aspects of the COM-B model (after Michie et al, 2011) would enable this process. Future research is warranted to understand the form and function of patient assessment for discharge using complex research methodology.

Date of Award	16 Oct 2018
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Ann-Louise Caress (Main Supervisor) & Janelle Yorke (Co Supervisor)