Principle 1: Plan for discharge from the start

From the outset of a patient’s admission, the multidisciplinary team leading their care, plus the patient, their family and carers, all need to have a clear expectation of what is going to happen during their stay. Reducing unnecessary patient waiting should be a priority for all teams, with a patient’s time being viewed as the most important currency in healthcare.

As a first step, all patients’ cognitive, functional, and social status should be assessed prior to admission and on admission. Where possible, therapy input should also be increased in emergency departments and acute medical assessment units so patients can be assessed immediately, and a comprehensive geriatric assessment can be undertaken for people with frailty.

The first consultant contact may be the most appropriate time to set the Clinical Criteria for Discharge (CCD) and Expected Date of Discharge (EDD). However, this should be set no later than the first consultant post-take ward round the next morning.

The CCD is the minimum physiological, therapeutic and functional status a patient needs to achieve before discharge.

You should include a ‘functional’ element within the CCD. This is essential for older patients, who are more likely to have frailty or impairments to their daily living. The healthcare professional must be reflective of the patient’s ‘norms’ rather than any generalised expectations. For example, a patient with dementia, reduced mobility and a normal exercise tolerance of 25 yards may well be fit for discharge if their toilet is only five yards from their bedroom, they are mobile with a frame and they have the supervision of one person.

It is important to anticipate that patients will continue to recover at home with or without support. In fact, many patients need to leave the hospital to be able to complete their recovery fully.

Objectives should be set and reviewed every day. This should not be about one team or one healthcare professional assuming responsibility – it should truly be a multidisciplinary approach.

This process streamlines the transfer of care from the beginning of the inpatient journey.

If necessary, the EDD can be adjusted. However, it is crucial that you set the EDD assuming an ideal recovery pathway unencumbered by either internal or external waits, so that these aren’t hidden.

The CCD and EDD are essential care coordination tools. They are not tools for hospital management – they are there to support clinicians and patients. However, one of the key benefits of using the CCD and EDD is that hospital management can clearly identify where there may be unnecessary waits and focus on resolving these. What’s more, having plans in medical notes that include clear clinical criteria for discharge make it easier for non-medical teams to implement criteria led discharge.

It may appear more straightforward to implement this process for elective, surgical patients than for those admitted as an emergency. However, it is possible to do it for both, and all hospitals must have a policy in place. Even if a patient is only expected to stay for two days or less, you should still expect to set an EDD. The flexibility of this approach to discharge planning makes it suitable for all patients, regardless of the complexity or severity of their condition.

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