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I could clearly see the anxiety
and dread on Mrs D's face when I broke the news about
the planned discharge date this morning. Mrs D had been
under our care for the past 12 weeks after she suffered
a major stroke. Though she made a good recovery she
still has a long way to go. The stroke has affected
her left side rendering her partially paralysed on that
side. She at present needs assistance of one to manage
her ADL's; her speech is also dysarthric with continuing
difficulty in expressing herself. Mrs D expressed her
wish to live with her husband but her daughter raised
the issue about the safety and her ability to manage
things after this setback. Mrs D lives with her 84-year-old
husband who has Parkinson's disease. Mrs. D had been
doing the cooking and cleaning, as well as assisting
her husband with dressing and bathing before she suffered
a stroke. She claims they have been doing "just
fine" before this admission. She herself has declined
in her health due to diabetes, hypertension and arthritis.
Mrs. D's daughter Ms F, who
works full time, takes the patient shopping on weekends.
Ms F told the nurse that her parents have been having
some difficulty managing lately, so she has been encouraging
them to move to a nearby nursing home. Limited finances
make assisted living and hiring help unaffordable options.
Mrs. D will be discharged in a few days and with this
background she is more nervous now than at the beginning
when she was brought to the A&E with a stroke.
The above outlined arbitrary
scenario is commonly encountered in our geriatric wards
almost all over. This is one of many common discharge
dilemmas we face in our day to day medical practice.
The role of a geriatrician does not end in the hospital;
it continues well into the community post discharge.
We as geriatricians are the few generalists left in
today's modern medicine. Our role is not only confined
to the medical treatment but taking the leadership role
in facilitating safe discharge and regular follow ups
in the community.
Hospitalization can be an arduous
undertaking and sometimes hazardous for vulnerable elderly
patients(2,3,4). Too often their treatment is complicated
by delirium, depression, adverse drug reactions, malnutrition,
and loss of precious physical strength especially after
an acute illness. These patients make good progress
from the acute event but seldom regain the full independence
they once had enjoyed. This is mainly related to decline
in physiological reserves as we age. Aging is commonly
associated with functional and physiological changes,
such as a decline in muscle strength and aerobic capacity;
vasomotor instability; reduced bone density and joint
mobility; diminished pulmonary ventilation; altered
sensory, continence, appetite, and thirst; and a tendency
toward urinary incontinence. For many older persons,
hospitalization results in functional decline despite
cure of the medical condition for which they were admitted.
Hospitalization often results in complications unrelated
to the problem that led to admission or to its specific
treatment for reasons that are explainable and avoidable
(8). Hospitalization and bed rest commonly superimpose
factors such as enforced immobilization, reduction of
plasma volume due to dehydration, accelerated bone loss,
and sensory deprivation. Any of these factors may thrust
vulnerable older persons into a state of an irreversible
functional decline thereby making the discharge process
more complex and time consuming.
Henceforth facilitating safe
discharge from the hospital is a critical transition
point in a patient's care, who has suffered an acute
and major event. Incomplete handoffs at discharge can
lead to adverse events for patients as well as for the
family and usually result in avoidable re-hospitalisation,
anxiety, general deterioration, loss of confidence and
complaint. Care transitions are especially important
for frail elderly patients who have multiple co- morbidities.
People aged 65 years and over
are the largest consumer group of hospital and social
care in the UK(1). An important component of their
treatment is facilitating safe transfer back into the
community. Preparation and planning for discharge is,
therefore, an integral aspect of the care of older people
in any hospital in the UK. Anyone involved in the discharge
planning process knows that special challenges are inherent
in discharging an elderly patient from hospital to care
at home, proffering considerable challenges for those
concerned about the current mandate of quality management.
A great many professionals with different priorities
and organizational commitments are involved to aid a
safe and event free discharge.
A multidisciplinary, comprehensive
approach to geriatric assessment has evolved over the
past years as a way to improve the care of frail elderly
patients with complex conditions(2,3,4,5,6,7).
As the counterpart to hospital admission, hospital discharge
is a necessary process experienced by each patient individually.
For all patients except those being transferred to a
continuing care facility, discharge is a period of transition
from hospital to home that involves a transfer in responsibility
from the hospital team to the patient and his GP(10).
Self-care responsibilities also increase in number and
importance, presenting new challenges for patients and
their families as they return home.
The interval between hospital
discharge and the continuity provider's first post hospital
patient visit is being increasingly recognized as a
hazardous hiatus(11). The patient is vulnerable to
diverse factors that may result in morbidity or hospital
readmission, including the recurrence of symptoms that
prompted the initial hospitalization, adverse drug events
from new medications, new drug-drug interactions, or
issues of care coordination, such as follow-up visits
and tests. Inadequate social support can further exacerbate
the medical complexity of care transition from the inpatient
to the outpatient setting.
Many post discharge complications
are preventable or "ameliorable" by careful
discharge planning and timely follow-up(11).
The dilemma in any discharge
planning is one of conflicting values. On one hand,
our society deeply values an individual's autonomy and
independence - that personal liberty wherein the individual
has the right to choose his or her own course of action
if he is mentally competent to decide about his future.
For those assisting with discharge, this value creates
an obligation to provide full information and viable
alternative means like social and community support
among which the patient may choose what is right for
them. On the other hand, the professionals involved
in discharge planning are also obliged to contribute
to the patient's safety, health, and well-being after
discharge.
It is important to remember
that decisions made about discharge can have profound
impact on the patient's sense of well-being for the
remainder of his or her life. So it is essential to
respect the patient's wishes and, whenever possible,
make a reasonable effort to honour them. As for Mrs.
D, going home is most likely a viable choice. However,
it would also be appropriate for the physician to insist
that Mrs D be amenable to additional assistance, either
from her daughter or community services, at least for
the time being. This solution would be respectful of
Mrs. D's need to return home, yet would also attend
to the safety of those around her.
The discharge process starts
right from the day the patient is admitted; a complete
comprehensive assessment is made at all levels assessing
the patient's needs and identifying resources available.
This process incorporates the "Multidisciplinary"
team approach where different members of the teams contribute
and offer holistic patient care.
MDT
Team member's
- Lead Clinician: as
the team leader
- Core Members: Nursing
staff, Physiotherapist, Occupational therapist, Discharge
coordinator, Dietician/ SALT, Pharmacist, Social services,
- Non core members:
GP's, District nurses, ICT's, Community rehab team
The MDT team comprises - Physician,
as team leader, Nursing staff, Physiotherapist, Occupational
therapist, Discharge coordinator, Dietician/ SALT, Pharmacist
and Social support worker. Each member has an important
role to play in order to make the discharge a success.
Communication in the form of weekly meetings and discussion
paves the way towards quick, safe and successful discharge.
The role of our GPs, district nurse and community rehabilitation
team is vital especially when the patient is sent off
into the community.
The role of occupational therapist
and discharge coordinator is paramount during the initial
evaluation of the patient's needs, their potentials
and abilities to carry out the basic tasks of daily
living safely and with ease. These members undertake
various measures like family meetings, in-patient assessment
of various tasks, access visits, and home visit. The
report that they usually submit outlines the boundaries
of the safe discharge.
| Objective of discharge
planning |
- Identifying patient's
needs.
- Identifying the resources
& available support.
- Identifying the level
of involvement of Pt/ family in preparation
of continuing care.
- Identifying the discharge
team members.
|
- Education: patient,
family members. care-givers (wheelchairs, catheters,
NG Tube, PEG tubes).
- Strengthen the coordination & communication
within the family and MDT members.
- Develop a framework for the support of the
health care worker & other service providers.
|
The role of a physiotherapist
is to assess the mobility of the patient and to flag
up increase falls risk and other mobility problems.
Their main role is also of confidence building and providing
necessary mobility advice and arranging for equipment.
Taking preventative measures to minimise the risks and
effects of illnesses in the future is a much better
way of living life than waiting for problems to arise
and reacting to a crisis.
Longterm illnesses are also
a major cause of dependency, low self esteem and depression
in our elderly patients. Building "Good self esteem"
is another important aspect of promoting health. It
is known that those with high self esteem, and who feel
'good about themselves' manage life's normal ups and
downs far better than those with low self esteem. They
also manage change better and actually see change as
a challenge to enjoy and perform. Whether we like it
or not, change and problems are part of normal life,
so having good self esteem is important for us all.
With good mobility and building self-confidence we will
not only inject self esteem in our elderly patient but
also help them be self reliant and self caring.
The discharge or transfer
of care of an Older Adult from the hospital to the community
is one of the most satisfying aspects of Geriatric Medicine.
The complex health and social needs of this group requires
the experience and skills of a large number of professionals
from a range of different organisations. Without careful
coordination this process can disintegrate to the detriment
of the patient and their family(12,13).
REFERENCES
- Preparing the elderly for discharge from hospital:
A neglected aspect of patient care? Age and Ageing
Volume 17, Number 3 Pp. 155-163.
- Kane RA, Kane RL. Assessing the elderly: a practical
guide to measurement. Lexington, Mass.: Lexington
Books, 1981.
- Epstein AM, Hall JA, Besdine R, et al. The emergence
of geriatric assessment units: the "new technology
of geriatrics." Ann Intern Med 1987; 106:299-303.
- Applegate WB, Deyo R, Kramer A, Meehan S. Geriatric
evaluation and management: current status and future
research directions. J Am Geriatric Soc 1991; 39:
Suppl:2S-7.
- Stuck AE, Siu AL, Wieland D, Adams J, Rubenstein
LZ. Comprehensive geriatric assessment: a meta-analysis
of controlled trials. Lancet 1993; 342:1032-1036.
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N Engl J Med 1995; 332:1376-1378.
- Unguru G, Feinberg M. Geriatric assessment teams:
a review of the literature. Consult Pharm 1998; 13:553-63.
- Hazards of Hospitalization of the Elderly Morton
C. Creditor; February 1993 | Volume 118 Issue 3 |
Pages 219-223.
- Promoting Effective Transitions of Care at Hospital
Discharge: A Review of Key Issues for Hospitalists.
Sunil Kripalani, Amy T. Jackson, Jeffrey L. Schnipper,
Eric A. Coleman; Journal of Hospital Medicine; 2007;
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- Coleman EA, Smith JD, Frank JC, Min SJ, Parry C,
Kramer AM. Preparing patients and caregivers to participate
in care delivered across settings: the Care Transitions
Intervention. J Am Geriatric Soc. 2004; 52:1817-1825.
- Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates
DW. The incidence and severity of adverse events affecting
patients after discharge from the hospital. Ann Intern
Med. 2003; 138:161-7.
- Discharge from Hospital Pathway, Process and Practice
(2003), Health and Social Care Joint Unit and Change
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- Achieving timely simple discharge from hospital:
A toolkit for the multi-disciplinary team (2004),
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