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One thousand four hundred and twenty two patients in an Acute General Hospital in Mansfield were studied over a one year period, 1989-90, in order to determine their needs for formal and informal care on discharge. The research method included a screening project for 189 patients on admission, an analysis of 1064 referrals to the Hospital Social Workers, and 169 referrals to the Hospital Discharge Scheme for Volunteer support. Patient/client needs for formal and informal care were found, and unmet needs after Hospital discharge were identified. Problems relating to formal care systems and shortage of Public Sector resources were found to cause serious difficulties for patients and Carers. The availability of Carers and lack of family members in informal care structures was a key issue. The work showed how Volunteers from the Discharge Scheme were able to contribute to the work of formal and informal Carers and ensure that safe Hospital Discharges occurred for very vulnerable people.

Emergency Department (ED) congestion can be better understood by examining overall system impacts, in particular inpatient admissions and discharges. This study first investigates trends of inpatient admissions, volume of patients in the ED who have been admitted (ED “boarders”), length of stay, and bed resources of three major admitting services at our teaching institution. It was found that patients admitted to the General Internal Medicine (GIM) service constituted the majority of ED boarders by default rather than design, as GIM served as a safety net for specialty services. This study investigates operational factors that impact discharge and found that day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Based on these results, next, a system dynamics computer simulation was built to test the impact of various discharge smoothing strategies on the number of ED boarders. Next, this study uses the framework and tools of system dynamics methodology to design a conceptual model of the ED boarder problem that may be used as a generalizable roadmap to create sustainable improvements in ED congestion. Finally, this study introduces a novel real time metric of hospital operational discharge efficiency- daily discharge rate – to bring focus on the underlying causes of discharge variation and help indicate opportunities for improvement.

Emergency Department (ED) congestion can be better understood by examining overall system impacts, in particular inpatient admissions and discharges. This study first investigates trends of inpatient admissions, volume of patients in the ED who have been admitted (ED “boarders”), length of stay, and bed resources of three major admitting services at our teaching institution. It was found that patients admitted to the General Internal Medicine (GIM) service constituted the majority of ED boarders by default rather than design, as GIM served as a safety net for specialty services. This study investigates operational factors that impact discharge and found that day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Based on these results, next, a system dynamics computer simulation was built to test the impact of various discharge smoothing strategies on the number of ED boarders. Next, this study uses the framework and tools of system dynamics methodology to design a conceptual model of the ED boarder problem that may be used as a generalizable roadmap to create sustainable improvements in ED congestion. Finally, this study introduces a novel real time metric of hospital operational discharge efficiency- daily discharge rate – to bring focus on the underlying causes of discharge variation and help indicate opportunities for improvement.

Abstract This thesis discusses the age and sex distribution of previously hospitalised asthmatics and the number of new asthma-induced treatment periods as a proportion of all asthma-related hospital admissions. Seasonal fluctuations in treatment periods were analysed with respect to age, and seasonal fluctuations in mortality among previously hospitalised asthmatics by combining the hospital discharge register with the mortality statistics on the basis of the patients social security numbers. A total of 364,871 asthma-induced treatment periods were reported to the hospital discharge register in 1972-1992, of which 192,195 occurred in 1.1.1983-31.12.1992, and 28.6% of these were new cases. Treatment periods relative to population amounted to 2.76/1000 in 1972 and 3.43/1000 in 1992. The number of treatment periods among children was greatest at the age of 1 year, 11.2/1000 for boys and 5.5/1000 for girls, and lowest at 17 years among the boys, and 13 years among the girls. The numbers rose slowly in early adulthood (with the exception of men aged 18-22 years), reaching a new peak at 73 years of age for men, 10.3/1000, and 75 years for women, 9.5/1000, and decreasing gradually thereafter. A half of the treatment periods recorded for patients aged under 1 year or for men aged 20 years represented new cases, whereas otherwise the vast majority of the treatment periods were being readmissions. The seasonal peaks among the total of 59,624 hospital periods involving persons aged under 15 years reported to the discharge register in 1972-1992 occurred in May and October, and the lowest figures in January and July. Conscripts aged 18-22 years experienced 4894 asthma-induced treatment periods in 1982-1992, representing incidence rates of 8.5/1000 in 1982 and 27.7/1000 in 1992. The figure was highest in the month in which the conscripts entered service and the month following that. A total of 81,243 asthma-induced treatment periods were recorded for persons aged over 24 years in 1987-1992, the figures being highest in January-May, 18.2% above the monthly trend in January, and lowest in July, 26.1% below the monthly trend. 7622 of the asthmatics first admitted in 1977-1992 died at an age of over 24 years in 1987-1993, mortality being highest in December and January and lowest in August. Obstructive pulmonary diseases were the primary cause of death for 1283 persons, including 489 who died of asthma itself. Apart from children and men aged 18-22 years, asthma gives rise to a large number of treatment periods among the middle-aged and the elderly. Measures should be taken to diagnose it at an early stage in these groups and to intensify the treatment provided. In addition, the factors provoking asthma during military service should be minimised and preventive measures enhanced in the case of children in May and September. As far as adults are concerned, asthma-related hospitalisation may involve a greater fatality risk in winter, so that aggravations occurring in winter should be treated with particular care.

Yes / Introduction: There are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating a safer, resilient medicines management at a common transition of care. Methods: Qualitative interviews with 60 cardiology patients six weeks after their discharge from two UK hospitals explored patients’ experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis. Results: During interviews twenty-three patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and identified their strategies to enhance their own reliability in adherence and resource management. Conclusion: Patients experience the impact of vulnerabilities in the medicines management system across the secondary-primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities – with caveats – to elicit, develop and formalise patients’ capabilities which would contribute to safer patient care and more effective medicines management.

Yes / Avoidable harm associated with medicines is widespread – particularly at care transitions – and unintended discrepancies in patients’ medicines after discharge from hospital affect more than half of all patients. Patients with heart failure are frequent service users (including readmission to hospital), and susceptible to deficiencies in medicines management. Heart failure is responsible for approximately 5% of medical admissions and the readmission rate within 3 months of discharge may be as high as 50%.[1] The Improving Safety and Continuity of Medicines management at Transitions of care (ISCOMAT) study is an NIHR-funded programme of research in patients with heart failure. The first work package, described here, aimed to map and evaluate current medicines management pathways across care transitions, describing the core characteristics of best practice and effective systems at each stage. Mixed-methods research collecting data centred on patients’ journey out of hospital and back home exploring current practice relating on heart failure. NHS REC approval was obtained (16/NS/0018). Following a process of informed consent, data were collected from patients (n=16) in four health economies in England using semi-structured interviews conducted shortly after their discharge from hospital and again after two and six weeks and included video recording. Non-participant observation was conducted on cardiology wards in the four areas to understand predominant systems employed by the hospitals to deliver information to patients and to primary care. Interviews with staff in hospitals and primary care explored policy, practice and systems across the transition. Data were analysed using integrative ‘parallel mixed’ analysis. Several themes emerged that described the resilience of the system that manages patients’ medicines across the whole pathway. Spatial dimensions – including local working conditions – impacted on staff who managed transfers. Process efficiencies and effectiveness, including the degree of staff training and policy awareness, both enhanced and hindered communication with patients and health care professionals (HCPs) in primary care. The system did not allow staff to assess the impact of the management of medicines at discharge across the transition into primary care. Patients themselves were found to have different levels of knowledge and confidence in their medicines once back at home and, where their pathway included this, to value the care co-ordination functions of heart failure nurses. Primary care staff operated varying systems for managing discharge communication and implementing recommendations and some reported positive outcomes from integration of practice pharmacists into the system. To our knowledge this is the first UK study of medicines management along the patient’s journey from hospital into primary care for patients with heart failure. A whole pathway analysis has enabled a detailed understanding of resilience in each part of the healthcare system. These findings will be used in the co-design of an intervention to improve medicines management in the next phase of the research.

Yes / Background: medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity. Methods: a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible. Results: twenty-four studies (total participants=17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone followup (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions. Conclusion: our results suggest that interventions that best support older patients’ medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions. / National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant PB-PG-0317-20010).

No / This research aims to develop a better understanding of how cardiology patients experience the care provided by community pharmacy after discharge from hospital. • Contact with community pharmacists is infrequent and can be via a proxy. Patients’ experiences of community pharmacy care are limited and many patients have unmet medicines use support needs. • Community pharmacy misses opportunities to support patients in their medicines use after hospital discharge

Yes / Women are discharged home from hospital increasingly early, but there is little evidence examining the postnatal hospital discharge process and how this may impact on the health of women and babies. In particular, there is little on sepsis prevention advice, despite it being the biggest direct cause of maternal mortality. Aim To explore the perceptions of women and senior student midwives related to the postnatal hospital discharge process and maternal sepsis prevention advice. Methods Three focus group interviews were undertaken, involving 9 senior student midwives and 14 women attending paid or specialist classes for vulnerable migrant women. Findings All participants believed that the postnatal hospital discharge process was inadequate, rushed and inconsistent. Sepsis advice was patchy and the condition underplayed. Conclusions Cost effective, time-efficient and innovative ways to impart vital information are required to support the postnatal hospital discharge process.