Characteristics of effective discharge management at a geriatric ward

Abstract

Introduction: Shortened hospital stays raise questions about collaboration between residential and ambulatory care with its different types of services and ‘integration’ of activities. This project focused on the implementation of effective discharge management of patients admitted in a general hospital. The aim of the case study is to identify the content and organization of discharge management and to determine the characteristics of effective discharge management. Theory/Methods: A literature review was conducted on issues related to discharge management from hospitals The study was carried out in a geriatric ward of a University Hospital in Brussels, Belgium. Data was collected during August and September 2013. Qualitative research methods were used: participative observation, interviews and document analysis. Data from the different sources were triangulated and the analysis was done by two researchers and discussed with supervisors (researcher triangulation). 4 weeks of participative observations were carried out on a geriatric ward. The observations were supported by a thematic observation protocol to focus on tasks and roles in the discharge management process. The document analysis focussed on relevant hospital documents (protocols, procedures, information letters) handling issues of discharge from the geriatric ward, such were collected and analysed. Semi-structured interviews, using a topic list, were conducted with health professionals involved in the discharge of patients The interviews were carried out at reserved places in the hospital, according to subjects’ availability and choice, respecting anonymity. The research protocol was approved by an ethical review committee (Committee of Ethics and Research of the hospital). Results: The discharge process can analytically be disentangled in five processes: administration, communication, medication policy, care and logistics and emotional support. Key processes in daily practice are communication and medication policy . Administration and care and logistics are more supportive to the transfer. Emotional support is very little embedded in daily discharge management. The effectiveness of discharge management seems to be determined by: (1) organization and coordination of discharge activities (2) inter-professional collaboration and (3) communication and interactions with the patient. An interesting observation is that the daily practice is not always congruent with what is found on the discharge procedures developed on paper. With regard to the coordination of discharge activities we observed that the task differentiation and role attributes of professionals on the ward has grown rather organically rather than as standardized working procedures throughout the ward. A similar process can be observed with regard to the multidisciplinary consultations. These are considered as the junction of the discharge process. Here different disciplines assess the physical, social, functional and cognitive readiness of the patient for discharge, and they provide their assessment. In this process however, the medical assessment is decisive for the discharge decision. Interactions and communication with the patient start from admission and last until the discharge. This communication and preparation of the patient is integrated in other activities. Interestingly is that the preparation of the patient for discharge is mentioned in procedures and protocols of the ward. The communication is mostly oral; exceptionally supported by written information. Patient participation on how to prepare discharge is limited, while participation of the family network is bigger: probably the effect of being on a geriatric ward plays a role. Discussion & Conclusion: Methodologically this research is limited to one case study. We are very aware of the limitation of this type of research, and we are aware that we did not contextualise the practice of one ward in the more broader hospital strategy. We did not discuss at this stage on how the discharge is coordinated with the place of destination, which is a limitation to understand integration of care. However, the use of qualitative research methods enabled us to develop an in depth understanding of daily practice. The observation learned that discharge management on the ward is more a “practice by doing” than a systemised approach. Some efforts are needed to develop a more systematic insight and coordination between professionals (role attributes and task identification). Moreover a key agenda is still to be tackled with regard to communication processes and patient participation.