Safe Discharge

“up to 80% of medical information provided to patients by healthcare practitioners may be forgotten immediately. ”

Discharging a patient is one of the riskiest areas of practice, it’s true. I find it easier to perform a thoracostomy these days than to discharge a patient, as the variable associated with the latter are so much greater! However, discharging appropriate patients is an important part of modern paramedic practice. Right back to “taking healthcare to the patient” [1] it was identified our part in modern health care involved discharging patients. Current NHS strategy requires ambulance services to further reduce avoidable conveyance in order to save £300 million for the NHS as well as improve ED waiting t, mes and hospital flow. [2]

Hospital isnt always safer:

Discharge is also at the heart of many patient centred decsions, not only do most patients want to avoid hospital where possible, but the risk of admission, particularly elderly and frail patients, is not insignificant. The risk of Hospital aquired infections (HAI’s) are ever present and present a greater risk to patinents who are already frail.
The Elderly VERY quickly become institutionalised. Where the adage of “10 days of bed rest in the elderly and frail is equivalent to 10 years of muscle aging” is strictly accurate can be argued [3], what is undoubtable is that prolonged periods in hospital and in bed, has a measurable and significant negative effect on functional ability and independance [4]. Additionally, elderly patients may be at greater risk of falling in hospital, due to fatigue and unfamiliar environments [5] Search #PJParalysis for more.

For more on this topic check out : Episode 1 - Fall Non-Injury

Once in hospital, patients are often harder to discharge than it would have been to treat them in the community. Delays in transfer of care accounted for a loss in 1.15 million bed days between 2013 and 2015, as a result it is an NHS recommendation for “home” to be the default pathway for assessment and discharge to assess pathways should be favoured. [6] In otherwords, we should be asking “why SHOULDN’T we stay at home” as opposed to “why SHOULD we go to hospital”.

Who to discharge?:

Who we discharge is out side of the scope of this podcast as it is so variable. However, here are some little pearls, that might help with that decision.

Consider the patients “Ideas, Concerns and Expectations”. This is a shared decision with them… so get their input. Read more here

Helmans “Folk” model of consultation tells us to as “What would happen if we do nothing?” Sometimes nothing is needed, only time for the patients body to heal its self. Other times, it is helpful to watch and wait for a obvious option to reveal itself.

What is safety netting:

“Safety netting is a diagnostic strategy, utilised to manage clinical uncertainty, highlight ‘red flags’, and help monitor patients until their symptoms are explained.”

— Article in british journal of general practice [7]

St Emlyns Blog also puts it nicely saying safety netting is “a term used to describe the advice we give to patients or their relatives or carers as we discharge them”.

So How do we do it? We really like the model used in Neighbours Model of assessment. Neighbour suggests we as ourselves the following questions

What if... Things go well?

Expain what you think is wrong
Explain how long it should last for and what the normal process is of getting better, including how long this should last.
Explain what the patient needs to do to get better
Explain if and when they need to return to healthcare for planned follow up

What if I’m wrong / What if they get worse?

Explain what to look for if the patient is getting worse or things that are NOT part of the predicted normal disease process
Explain when to recontact a healthcare provider and in which circumstances each is appropriate e.g. When to call a GP, when to go to ED.

Additional Layers of Safety:

Do we need to get the family involved or a carer to support the plan?
Can we arrange a call back with the patient for a few hours time?
Do they need refering to another service or HCP? Do we need to make a direct referal or can the patient do this?

Give WRITTEN Advice:

Memory is falliable, we don’t remember events accurately. We tend to remember events based on the last time we told that story. If we got it wrong the last time we recalled it then our memory of the event is permanantly altered.

“40-80% of medical information provided by healthcare practitioners is forgotten immediately. The greater the amount of information presented, the lower the proportion correctly recalled; furthermore, almost half of the information that is remembered is incorrect” [8]

Schemas: - Memory relies on “Schemas” or short cuts. If our advice today, deviates from a patinets current schema, then there exists the risk for misinterpretation or misremebering.

State dependency: – memory is best recalled in the state in which the original information is acquired. Thereofore, if advice given in a stressed environment, pain, upset, then when patient tries to recall this next day when not in pain / calmer then memory is impaired.

Diagnosis is the priority: - Patients tend to focus on diagnosis related information “its not your heart” is remembered “ it’s actually just a chest infection” may be remembered, but “unless you rest, and hydrate this will get worse” is a low priority of importance to the stressed patient who is just happy it isnt their heart.

Medical advice is also perceived as being more important if it is expressed in specific rather than general terms. Thus, ‘You need to get some rest’ will be remembered less accurately than ‘You must take the next two weeks off work’ .

Give consideration if there is a language barrier, the patient has learning difficulties or mental impairment, this may require a greater degree of follow up to ensure adherence to the plan and redflags arent missed.

Referrals:

CARE Plan…Cover Ass, Remain Employed. We’ve all heard this, and probably thought it was a great idea at first.

Don’t refer just to cover your ass… just because you weren’t the last HCP to see the patient, doesn’t mean you are free from any responsibility for them. Referring for a 2nd opinion is fine… but ask yourself do you really need it?

Refer for a reason, why do you want this HCP to give up their time to see this patient.

You would be pretty miffed if someone asked you to review a patient just so you’d seen them last and not them… doing this isn’t acceptable.
If you are really uncomfortable to discharge the patient off your own back, then you need to examine why this is. Maybe some shared decision making prior to discharge would be useful? But referring a patient simply to “cover your backside isn’t appropriate.”

Informing other healthcare providers – write a letter if cant send a GP notification, this is profesional and ensures clarrify around your diagnosis and plan. Don’t expect the patient to convey your information to the GP accurately.

Writing care plans:

Care plans should be detailed with all the main steps you expect to occur, made clear.
If we expect other care providers to support this plan, it must be documented so. Write in care folders or leave letters for other professionals key to supporting out patients health.

Hopefully, this has been a useful summary of Discharge and safety netting to support your practice! Don’t just take our work for it… navigate to the other resources to supplement your learning and make sure to reflect on this CPD in your portfolios.

Remember, clinicians are responsible for their own practice. These podcasts are produced for informative purposes and should not be considered solely sufficient to adjust practice. See "The Legal Bit" for more info.
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