Transfer of care is defined as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location”.¹

The State Claims Agency has analysed incidents related to admission and discharge. Analysis of NIMS data shows that incidents related to admission and discharge occur during transfer of care between hospital and community services and between departments.

Incidents related to admission and discharge

Admission and discharge incidents reported on NIMS related to:

• Lack of admission coordination: e.g., patients arriving without pre-transfer confirmation of acceptance or bed availability in the receiving facility, lack of clarity about appropriate care pathways resulting in inappropriate transfers, unclear acceptance criteria resulting in admissions being declined / not accepted on arrival.

• Poor discharge planning: e.g., discharge before being medically fit and/or without appropriate care plan for management of needs, diagnostic tests not reviewed prior to discharge, unavailability of beds due to inefficient bed allocation and communication, discharge without appropriate referrals for future care management.

• Documentation issues: e.g., lack of admission notes stating reasons for admission, no accompanying medical charts on admission, unclear discharge care and treatment plan, no discharge notifications to public health nurse, and no / incomplete discharge letters.

• Lack of resources: e.g., lack of bed availability compromising care, insufficient personnel to meet demands resulting in discharge without been seen by the relevant healthcare professional, lack of availability of appropriate infection protection control environment.

Incidents related to admission and discharge can pose risks to patient safety. For example, delayed admission to inpatient beds can increase the risk of a poorer outcome and affect patient experience, while delayed discharge can result in healthcare associated infection (HCAI), deconditioning, and have detrimental effects on both emotional and mental wellbeing.^2,3

How to improve admission and discharge

Effective multidisciplinary working is needed to manage patients’ journeys at admission and discharge.⁴ Based on best practice the State Claims Agency has prepared the following advice:

Admission

• Clearly communicate criteria for acceptance and admission of patients to relevant stakeholders (patients, family, carers, ambulance service, referring services, and general practitioners (GPs)) ^5,6
• Streamline administrative processes through use of standardised admission notes, and where possible the implementation of integrated electronic health records
• Ensure clear communication pathways for pre-transfer acceptance⁵
• Ensure admission documentation is comprehensive and includes detailed medical history, reason for admission, estimated length of stay and expected date of discharge^5,7,8. View our video on documentation and recording in clinical practice.
• Ensure efficient ‘real-time’ bed management to reduce waiting times and improve service user experience, by use of data analytics and alignment of IT systems to enhance patient flow^5,6
• Shape or reduce demand by coordinating with other care providers: primary care, urgent care, community-based care services ^6,9

Discharge:

• Ensure early discharge planning and identify issues that would impact a patient’s discharge or transfer so that action may be taken early address them ^4,5,6
• Use checklists and standardised criteria to arrange prescriptions, discharge letters and any further care requirements prior to discharge^5,6
• Make use of discharge lounges, rehabilitation facilities and Transition Navigators (to manage and coordinate transition from hospital to discharge destination) where appropriate, to make available in-patient beds ^6,9
• Conduct discharge rounds at weekends to increase patient flow^5,10
• Follow up on the results of diagnostic tests or investigations and ensure appropriate action taken, including communication to the GP or community services’¹¹. The responsibility for following up on tests lies with the doctor who ordered them¹¹
• Ensure that discharge of a patient from care is accompanied by a timely and prompt discharge summary which clearly documents, at a minimum, a summary of relevant medical and treatment history, medication and medication changes, any planned follow-up by the discharging service, action required by primary care/community services (if involved) or / and by the receiving GP is clearly documented¹¹
• Ensure follow-up care coordination with community-based health and social care practitioners, who should maintain contact after discharge, and make sure the patient knows how to contact them when needed¹²
• Provide patients with information packs containing details of tests, procedures, medications and relevant contacts ^5,13

References available on request