Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers’ perceptions

Figures & data

Table 1 Key themes perceived as barriers to discharge by health care providers

Key theme	Subthemes	Supporting quotes
Communication gaps	Between health care providers and patients	“Patient doesn’t tell us they have concerns or want help/home care etc until the last minute” “MD’s often forget if patients are from out of town and have to arrange rides. Need 2–3 days’ notice of discharge for families to rearrange work/family” “Patient doesn’t know what their admission medications are so it is hard to consolidate them on discharge” “Inconclusive information about further follow up with other services that were consulted during admission”
	Amongst medical residents	“Poor communication within the medical team (eg, patient still on IV meds, SC meds (insulin SS), home meds not restarted) – all delay discharge” “Doctors should put in discharge order have summary and prescription done evening before discharge. If stable in the morning, then discharge at 0900 hours” “Weekend discharges are tricky to arrange, especially if person left to discharge patient does not know him/her. Cannot book appointments usually”
	Between medical residents and nurses	“Discrepancy between the information given to patient/nurse and final decision after rounds” “Discharge plan not clearly documented in chart – this is the main way of communication between MD and RN, then RN caught off guard with discharge orders because it was not clearly communicated”
	Between medical residents and allied health	“Teams don’t always alert allied health services of our discharge plans. Patient may be ready medically for discharge, but not from a rehabilitation point of view. We need communication with these services probably more than once a week at discharge rounds” “Does not seem that teams review our [allied health] documentation. It is frustrating when I am reconsulted on a patient I am already involved with and working through a treatment plan”
	Between allied health and nurses	“TS are notorious for not charting or charting in unknown location … we as floor staff need to know what is going on – are they waitlisted? Are they eligible? It is usually us that attempt to answer the patient’s questions. As well, knowing this information helps us get prep work ready in advance”
	Amongst nurses	“Communication between charge nurse and unit clerks to organize paper work, fax med list and discharge summary, etc”
	Between acute care physicians and community care physicians	“I think the largest issue is that our patients are very complicated and dictation’s can take weeks post discharge. This can result in delay of important medical information to the primary physician. Although we write written copies, they often are not brought to follow up appointments. I think we need to hire more transcriptions” “All tests that are to be done as outpatient should be written on discharge planning sheet with dates listed. Same for follow up appointments. Ensure consultation service who requests follow up leaves MD name and office number on chart”
	Amongst the health care providers/multidisciplinary team	“What is communicated/discussed/decided in discharge rounds is very rarely passed on to nursing (floor) staff. We need to be involved and in the loop. As often it is us that have parts to play as does PT/OT etc. We all need to know what goes on and what we can do to get patients ready to go” “Discharges don’t always have 24 hours notice – cause communication breakdown when everyone is rushing”
Lack of role clarity		“Unclear who ultimately has the responsibility to review the discharge plans, medications, follow up appointments (ie, RN, person who wrote the discharge summary, senior resident)” “Unclear roles of professionals at times, overlook the whole picture, lack of case management in a specified role” “Lack of clear understanding of rehab role”
Lack of resources		“Biggest issues in delayed discharges is lack of resources (eg, rehabilitation beds, nursing home beds, etc …). We usually plan early, whole team involved and there is nowhere for the patient to go!”

Abbreviations: MD, Doctor of Medicine; SC, subcutaneous; PT, physiotherapist; RN, registered nurse; OT, occupational therapist; SW, social worker.

Table 2 Identified opportunities for improvement

Opportunities for improvement	Supporting quotes
Structure and function of the medical team
Discharge documents including follow-up and patient education	“… I think all patients should receive copies of the investigations done during admission and discharge summary to facilitate out-patient follow up (family doctors, etc …)” “Patient should go home with a copy of the discharge summary” “Discharges as rushed or later in the day”
Effectiveness of the discharge rounds	“Current design of weekly multidisciplinary rounds is not helpful in discharge planning … it would be better to have quick bullet rounds each morning with everyone on the team (MDs, nursing, rehab, SW) where we quickly run through the day’s plan for each patients (have done this in other academic hospitals I have worked at and it works very well)… can get through 15 patients in under 15 minutes … this also helps to get to know all members of your healthcare team”
Communication between health care providers	“Clear documentation of intent to discharge should be in chart as this is one place where all team members have access” “I didn’t find much problems in discharge planning as long as I let nursing know what the plans are and the sooner I communicate with nursing the better”
Need for leadership	“a team care coordinator is vital …”

Abbreviations: MD, Doctor of Medicine; SW, social worker.