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Poor communication between hospital and community harming transition

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The report identifies good communication as key The report identifies good communication as key

Communication between nurses in hospitals and the community needs to improve to prevent poor discharges, in a report from the QNI.

The QNI’s report also said that the lack of co-ordination between healthcare and social care provision is a major issue. In the QNI’s survey, 83% of community nurses reported that communication with hospital staff was poor. The report recommends that multi-disciplinary team assessments and planning should include the community nursing team when appropriate to minimise delays in discharging frail, older patients. Additionally, discharge planning must commence on or soon after patient admission to hospital and should involve the community nursing team in decision making for patients with complex health needs.

‘Three key themes emerged which would enable effective discharge planning: Improved communication, improved co-ordination of services and improved collaboration,’ said Candice Pellett, the QNI’s district nurse project manager. ‘It is recommended that commissioners and provider organisations examine the local processes they have in place for discharge planning, ensuring that transfer of care between services is planned around the needs of patients, families and carers at all times.'

Elderly people are most at risk of suffering from a poorly planned discharge. The report found that 75.9% of community and 54% of hospital respondents said that the 75-84 year old age group were most likely to be affected. A further 63.29% community and 40% hospital based nurses responded that they felt the 85 years and above age group were most likely to have a poor discharge.

‘At a practitioner level, there needs to be willingness from nurses both in hospital and community to improve partnership working, to ensure that patients, carers and families experience a seamless service when discharged from hospital to home, with good discharge planning and post-discharge support,’ added Ms Pellett. ‘Nurses in every part of the NHS and care systems are at the heart of effective discharge planning and must continue to be the advocate for the patient the pursuit of excellent practice in transfers of care.’

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when I started in nursing 27 years ago, we had 'discharge liaison nurses' and now we don't. it is no surprise that lessons are not learnt from using best practice in how well the co-ordination of discharge planning was managed back then to now creating a blame culture between primary and secondary care. Even the OT's used to do planned 'home visits' pre-discharge to assess the patient ability to manage when they do go home eventually but that also ceased to happen. As the NHS moves forward two steps with advances in evidence based practice, we move one step back because we fail to recognise what actually worked well in the past.
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Poor communication creates major problems when patients are discharged without proper planning. There is more focus on medical issues than the practical issues of how patients will manage at home on discharge. Discharge planning should be commenced on day 1 of admission and reviewed daily as changes occur. Written information should also be given to relatives/carers to inform what has changed and who to contact if they have difficulties. Relatives/carers should always be involved in discharge planning.
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