Editor – I was delighted to read Dainty and Elizabeth's paper (Clin Med August 2009 pp 311–4).
While I agree that discharge planning should always begin early on in the admission process, practically this is not always possible. There may be detrimental steps when focus on discharge becomes the priority of the admissions unit. Making an accurate comprehensive diagnosis in the context of multiple pathology, delirium and complicated social circumstances takes time. There are always quality of care issues that are as important as length of stay. Inappropriate readmission may be an unfortunate consequence. Without the correct facts about social circumstances and a secure medical diagnosis and for that matter multidisciplinary assessment, you cannot predict length of stay or rehabilitation potential and requirements.
It really does undermine care when all professions focus on ‘what can we do to get them out’ rather than ‘how can we best help this patient’.
There is often a cocktail of chaos and conflicting information by the time a patient reaches a care of the elderly ward. The unpredictable nature of so many of our frail elderly compounds the story. Amid this chaos, informing a family or next of kin about forced untimely discharge will generate complaints and distrust. A typical example would be the very variable length of stay for an elderly lady with fractured neck of femur. Consider all the possible postoperative complications. Multiple bed moves and conflicting and contradictory information from different professionals becomes normality. One says ‘nil by mouth’ another says ‘dysphagic diet’. One ward says rehabilitation is required another says reablement or resource centre care is required. Not only are the family confused most of the junior doctors have little or no understanding of types of community care available in their own town, let alone neighbouring and often differing arrangements for out-of-area patients.
My opinion relating to timely discharge is that it can only be estimated when all the correct facts and medical information are available. And even then in the hands of an experienced physician and geriatrician it is not always easy. The phrase ‘fit for medical discharge’ is a misnomer. If the patient cannot walk and lives alone requiring a package of care from social services they are not fit for discharge. More accurately they are well enough not to require an acute hospital bed but so frail they cannot be discharged without social support.
I commend this article and timely preparation for discharge in all patients admitted to hospital. What may be lacking is the experience to know, and the honesty to admit at times we just have to wait and see.