Bull, M and Roberts, J (2001). "Components of a proper hospital discharge for elders." Journal of Advanced Nursing 35(4): 571-81.

Significance: Effective discharge planning is a vital link in continuity of care for elders. Previous studies identify problems with planning for elders' discharge from the hospital and problems elders encounter managing care post-discharge. However, little attention has been given to identifying effective discharge planning processes. Explicating the components of effective discharge planning is critical to replicate the process in other health care settings and predict post-discharge outcomes.
Purpose: The purpose of this study was to identify the components of effective discharge planning for elders and factors that impede planning.
Methods: Ethical approvals were obtained from the University and National Health Service (NHS) Trust. Qualitative methods were used and data were collected from two wards in a 78-bed geriatric rehabilitation hospital that was part of a National Health Service Trust serving Southwest London. Data included semi-structured interviews and documents related to discharge planning, care delivery, and community resources. A total of 24 semi-structured interviews were conducted with health care professionals who were part of the hospital's multidisciplinary team, those affiliated with the Community Trust that provided aftercare, elders, and family carers.
Results: Participants consistently used the term 'proper discharge' when referring to effective discharge planning. The multidisciplinary team comprised a vital context for a proper discharge. The findings indicated that three circles of communication were central in a four stage discharge process. Different circles of communication were key at different stages.
Conclusions: The findings provide insights for educating nurses about effective planning practices and examining the global significance of impediments to a proper hospital discharge.

Early Supported Discharge Trialists (2000). "Services for reducing duration of hospital care for acute stroke patients (Cochrane Review)." The Cochrane Library 3.

Background: Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with community-based rehabilitation (early supported discharge, ESD).
Objectives: The objective of this review is to establish the costs and effects of ESD services compared with conventional services.
Search strategy: The Cochrane Stroke Group Specialised Register was searched and supplemented with information from individual trialists. Searching was completed in March 1999.
Selection criteria: Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.
Data collection and analysis: Two reviewers scrutinised trials and categorised them on their eligibility. Standardised information was then obtained from the primary trialists. Results were analysed for all trials and for two subgroups depending on whether the intervention was provided by a coordinated multidisciplinary team (coordinated ESD team) or not.
Main results: Outcome data are currently available for four trials. Patients tended to be a selected elderly group with disability. Overall, the odds ratio (95% confidence interval) for death, death or institutionalisation, death or dependency at the end of scheduled follow up were 0.87 (0.39-1.93), 0.69 (0.36-1.31) and 0.88 (0.49-1.57) respectively. Apparent benefits more evident in the three trials evaluating a coordinated ESD team. The ESD group showed significant reductions (P<0.001) in the length of hospital stay equivalent to approximately nine days.
Conclusions: ESD services provided for a selected group of stroke patients can reduce the length of hospital stay. However, the relative risks and benefits and overall costs of such services remain unclear.

McPherson, K (2001). "Safer discharge from intensive care to hospital wards." British Medical Journal 322: 1261-2.

FULL TEXT
Intensive care in the United Kingdom is certainly underprovided relative to many developed counties. The United States spends over 1% of its gross national product on providing intensive care, while Britain spends around 0.05%possibly twentyfold less.1 But intensive care remains largely outside the evidence based paradigm apparently for ethical reasons. Judging the appropriateness of intensive care provision still depends solely on apparent unmet need and observed associations of prognostic indicators with mortality. This week's BMJ sees another such study.2
It seems too easy to claim benefit in intensive care on the basis of biological plausibility and observational comparison alone. For example, a recent Cochrane overview of 30 trials on the effect of intravenous albumin for acute renal failure,3 which showed significant harm, was dismissed by some enthusiasts.4 The writings of respected and dispassionate authors who have held intensive care to be immune from randomisation do not help this apparent impasse. 5 6 In the absence of any rigorous measurement of attributable effect, intensive care will continue to be provided on the basis of evidence that is unacceptable in other areas of health enhancement. With 21st century medical technology this is particularly unfortunate.
The acute physiology score (APACHE) developed by Knaus and others7 was designed to provide reliable, physiology based, indices of likely benefit by predicting hospital mortality from measurements made among critically ill adults in hospital. This score has been shown to be a potent measure of casemix that predicts mortality well in the British context8 and hence enables comparisons of intensive care performance to be disentangled somewhat from practice variations, be they discretionary or enforced by shortage. Obviously cases that are refused admission to intensive care units cannot be readily compared, since scoring is impossible unless a patient is admitted.9 In this week's BMJ another score is proposed, which again predicts hospital mortality based on physiological measurements (p 1274).2
Daly et al looked at some 13 000 intensive care patients in 20 centres and derived a score based on physiological and other measurements on the last day in intensive care to predict risk of death before hospital discharge. The objective of the work is to provide intensivists with an index predicting risk of hospital death associated with discharge, so that patients may be discharged sensibly from scarce intensive care unit beds to make room for severely ill patients. The authors also use it to identify extra capacity needed in intensive care units to avoid the discharge of high risk patients. The main outcome of interest should not, of course, be mortality: it should also include a measure of survival duration and also be quality adjusted.
The measure was derived from a subset of data collected from one of the intensive care units and subsequently tested on a different subset from the same unit and on data from 19 other British centres.2 Having derived a score that predicted hospital mortality well on the test data, the authors then used the score to estimate the fate of those discharged while deemed to be at high risk compared with those who were not. Taking patients who were above the risk threshold at some stage during a minimum of a three day stay in the intensive care unit, Daly et al compared the high risk discharged patients with those discharged while at lower risk. The latter had lower actual mortality than the former. The crux of the paper is this comparison, and it is used to predict the consequence of one or two days extra stay in intensive care for high risk patients, when their score would then assign them to the low risk group.
These prognostic indices cannot explain all the intrinsic determinants of mortality in a dynamic system on any absolute scale, whatever the amount of discrimination shown, and sadly the shortfall cannot even be guessed at. Disentangling intrinsic patient risk from effects of care will remain impossible without randomisation. Such evidence about the risk of unnecessary death can be seriously misleading if intensive care is going to have to be assessed in this way. For example providing more intensive care beds in response to refused admissions to intensive care seems to lead, because of consequent changes in the threshold for referral and admission, to a greater total number of refusals10and thus, logically, to still more beds.
Similarly here the logic of these extrapolations seems to assume that all clinical decisions in intensive care units are made on the basis of intrinsic need, independently of extrinsic influence, in a static system of patient care. It assumes that experienced clinicians do not assess risk and possible benefit very well in individual patients which could give rise to some of the observed differences. Assuming that the dominant determinant of actual risk of hospital death is a physiological risk score, however discriminatory, is unwise. Who knows what complex processes led to discharge in each case, and how they might change under different influences on the individual clinical decision. The effect of high dependency beds, to name but one factor, is unassessed by this work.
We need to understand more about the determinants of death in critically ill patients because many lives are at risk and the care is expensive, but observational comparisons, incorporating sophisticated indices of risk, can only raise hypotheses. Daly et al certainly suggest a prospective test of their hypotheses but secure validation of the score itself (against, for example, current APACHE scoring, which has been validated) would be another prerequisite. In the end, intensive care provision at the margin of possible benefit simply has to be assessed by random allocation like everything else about which there is legitimate doubt. There is currently no substitute unless we are to end up spending 1% of gross national product on intensive care whatever its actual effect.
REFERENCES
1. Metcalfe A, McPherson K. Study of intensive care in England 1993. London: Department of Health, 1995.
2. Daly K, Beale R, Chang RWS. Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model. BMJ 2001; 322: 1274-1276
3. Roberts I. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998; 317: 235-240
4. Chalmers I. I would not want an albumin transfusion. BMJ 1998; 317: 885
5. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ 1996; 312: 1215-1218
6. Muir Gray JA. Evidence based health care. Edinburgh: Churchill Livingstone, 1997.
7. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastas PG, et al. The APACHE III prognostic system; Risk prediction of hospital mortality for critically ill hospitalised adults. Chest 1991; 100: 1619-1636
8. Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP. Intensive Care Society's APACHE II study in Britain and Ireland - II Outcome comparisons of intensive care units after adjustment for case mix by the American APACHE II method. BMJ 1993; 307: 977-981
9. Metcalfe A, Slogget A, McPherson K. Mortality among appropriately referred patients refused admission to intensive care units. Lancet 1997; 350: 7-12
10. McPherson K, Metcalfe A. Inadmissible evidence. Health Services Journal 2000; 20 Mar: 26-27

Naylor, M, Brooten, D, et al. (1999). "Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial." Journal of the American Medical Association 281(7): 613-20.

Context: Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied.
Objective: To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions.
Design: Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge.
Setting: Two urban, academically affiliated hospitals in Philadelphia, Pa.
Participants: Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission.
Intervention: Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses.
Main Outcome Measures: Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction.
Results: A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in post-discharge acute care visits, functional status, depression, or patient satisfaction.
Conclusions: An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs.

Victor, C, Healy, J, et al. (2000). "Older patients and delayed discharge from hospital." Health and Social Care in the Community 8(6): 443-52.

Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.