Discharge planning

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 35Discharge planning

35. Discharge planning

35.1. Introduction

Planning for a patient’s discharge from hospital is a key aspect of effective care. Many patients who are discharged from hospital will have ongoing care needs that must be met in the community. This ongoing care comes in many forms, including the use of specialised equipment at home such as a hospital-type bed, daily support from carers to complete the activities of daily living, or regular visits from district nurses to administer medication.

There is a wide variety of care available in the community, but it needs to be planned in advance of the patient’s return home, to ensure that there is no gap in the provision of care between the discharge from hospital and the initiation of community services. Furthermore, information about the patient must be handed over from the hospital team to the community team so an informed plan of care can be put into place.

Discharge planning is the process by which the hospital team considers what support might be required by the patient in the community, refers the patient to these services, and then liaises with these services to manage the patient’s discharge. Poor discharge planning can lead to poor patient outcomes and delayed discharge planning can cause patients to remain in hospital longer than necessary, taking up valuable inpatient beds when they could be more easily and comfortably cared for in the community.

While the guideline committee affirmed the value of discharge planning based on experience, they wanted to review any evidence available about the efficacy and cost implications of discharge planning for patients following an acute medical emergency.

35.2. Review question: Does discharge planning facilitate early hospital discharge?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

35.3. Clinical evidence

Ten studies (11 papers) were included in the review;⁸^,¹⁶^,²³^,³²^,³³^,³⁶^,⁴²^,⁵²^,⁵³^,⁵⁹^,⁶⁴ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence summary: Discharge planning versus standard processes.

35.4. Economic evidence

Published literature

No relevant health economic studies were identified.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

35.5. Evidence statements

Clinical

Ten studies comprising 3,271 people evaluated the role of discharge planning for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that discharge planning may provide a benefit in reduced avoidable adverse events expressed as falls (1 study, very low quality), length of stay (5 studies, moderate quality), quality of life SF-12 mental ratings (1 study, very low quality) patient and/or carer satisfaction defined as preparedness to leave hospital (1 study, low quality). The evidence suggested there was no effect on quality of life (St Georges Respiratory questionnaire and SF-12 physical ratings) (1 study, low to very low quality), staff satisfaction (1 study, low quality) avoidable adverse events defined as adverse medicine reaction (1 study, very low quality) and patient and/or carer satisfaction (1 study, very low quality).

The evidence suggested a benefit for discharge planning in reducing readmissions in 3 studies (low quality) but in 1 study that reported a hazard ratio there was no difference in readmission (very low quality). The evidence suggested a benefit for discharge planning in reducing mortality at 6 months (1 study, very low quality) and during admission (1 study, very low quality). However, evidence from 4 studies suggested an increase in mortality from 5 days-12months (moderate quality).

Economic

No relevant economic evaluations were identified.

35.6. Recommendations and link to evidence

Recommendations	21. Start discharge planning at the time of admission for a medical emergency.
Research recommendation	-
Relative values of different outcomes	Mortality, avoidable adverse events, quality of life, patient and/or carer satisfaction and length of stay were considered by the committee to be critical outcomes to decision making. Readmission, delayed transfers of care and staff satisfaction were considered important outcomes.
Trade-off between benefits and harms	A total of 10 studies were identified that assessed the role of discharge planning for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that discharge planning may provide a benefit in reduced avoidable adverse events (falls), length of stay, quality of life (as measured by SF-12 mental rating in 1 study) and patient and/or carer satisfaction measured by the preparedness to leave hospital. The evidence suggested there was no effect on quality of life (as measured by either the St Georges Respiratory questionnaire or SF-12 physical ratings), staff satisfaction and patient and/or carer satisfaction assessed by patient rating of the discharge process. Discharge planning was beneficial in terms of reducing readmissions in 3 studies but in 1 study that reported a hazard ratio that there was no difference in readmission. The evidence from 1 study reporting results only as hazard rations suggested a benefit for reduced mortality at 6 months and another study suggested reduced in hospital mortality for discharge planning. However, evidence from 3 studies suggested an increase in mortality from 1 day -12 months. It should also be noted that 2 of the studies²³^,⁵⁹ in the meta-analysis suggesting an increase in mortality post discharge; discharge planning were small studies and there is evidence to suggest that the frailty of the patients in the discharge planning groups was more pronounced than in the control group which may explain the excess mortality in the study groups. No evidence was identified for delayed transfers of care. The discharge planning interventions evaluated by the studies varied in terms of their composition and focus. Whereas some were grounded in facilitating the organisation of community, social care and living arrangements, others were more focused on improving post-discharge management of clinical conditions through patient education and management of follow-up appointments and prescriptions. Some interventions also included post-discharge components such as follow-up telephone calls and visits. However, despite these differences, pooled analyses showed no significant heterogeneity. The committee felt that if no plan for discharge is made, it can result in bed blocking if a patient is medically fit for discharge, but is unable to be discharged because the appropriate community and social care measures, if required, are not in place. This plan should be made on admission to enable adequate time to make arrangements for the point where the patient is medically ready for discharge. Therefore, the committee decided to make a recommendation based on the evidence and their wide experience within primary, secondary and community care.
Trade-off between net effects and costs	No economic studies were included. One of the studies included above found substantial cost savings but this has not been included since (as outlined in the review protocol) the US setting is unlikely to make the economic findings generalisable to the UK. Unit costs of ED attendances and hospital admissions were provided to aid the consideration of cost-effectiveness. The review above indicated a reduction in readmissions and length of stay associated with discharge planning, which could result in substantial costs savings. The committee noted that implementing a form of early discharge planning is likely to be low cost and therefore it is likely to be cost saving overall. Safeguards need to be in place to ensure that earlier discharge is safe and the patients have appropriate support in the community.
Quality of evidence	The evidence was graded very low to moderate quality due to risk of bias, imprecision and indirectness. There was no economic evidence included in the review.
Other considerations	The committee considered current practice with regard to discharge planning. Discharge planning of some form occurs throughout all hospitals in the UK but is not standardised across hospitals. Although it is stated that it should begin at the point of admission (and before admission in the case of elective admission), this often does not happen. The Department of Health has guidelines and a tool for discharge planning.⁵⁷ Discharges are divided into ‘simple’ and ‘complex’. Simple discharges account for 80% of discharges and should be easily achieved with the appropriate training, planning and resources. The processes to achieve a simple discharge are predictable and reproducible. In these cases, when the discharge process does not occur as planned, it is most likely to be a consequence of a failure in communication. Complex discharges account for the remaining 20%. These are patients with more complex needs such as multimorbidity or frailty, who may need additional input from other professionals such as social workers and therapists. The involvement of additional services, staff and specialties makes prior co-ordination and planning even more critical. This is of particular importance in the frail elderly and those patients with mental health issues. These patient groups are vulnerable to poor communication and co-ordination which have a disproportionate impact on the discharge process. Doctors are not usually specifically trained in discharge planning. It is assumed that they gain knowledge and skills through clinical practice. Training in discharge planning would benefit doctors early in their career and junior nursing staff so that it is embedded in the management plan. The committee decided to make a positive recommendation as they considered it good practice to start planning discharge at the point of admission. This would ensure that discharge gets equal prominence with the ongoing management of the acute illness which should mitigate the risk of delayed discharge once the patient is fit to return to the community.

References

1.: Altfeld SJ, Shier GE, Rooney M, Johnson TJ, Golden RL, Karavolos K et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. Gerontologist. 2013; 53(3):430–440 [PubMed: 22961467]
2.: Anderson C, Ni Mhurchu C, Brown PM, Carter K. Stroke rehabilitation services to accelerate hospital discharge and provide home-based care: an overview and cost analysis. Pharmacoeconomics. 2002; 20(8):537–552 [PubMed: 12109919]
3.: Atienza F, Anguita M, Martinez-Alzamora N, Osca J, Ojeda S, Almenar L et al. Multicenter randomized trial of a comprehensive hospital discharge and outpatient heart failure management program. European Journal of Heart Failure. 2004; 6(5):643–652 [PubMed: 15302014]
4.: Azzalini L, Sole E, Sans J, Vila M, Duran A, Gil-Alonso D et al. Feasibility and safety of an early discharge strategy after low-risk acute myocardial infarction treated with primary percutaneous coronary intervention: the EDAMI pilot trial. Cardiology. 2015; 130(2):120–129 [PubMed: 25612789]
5.: Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. Journal of General Internal Medicine. 2008; 23(8):1228–1233 [PMC free article: PMC2517968] [PubMed: 18452048]
6.: Beech R, Rudd AG, Tilling K, Wolfe CD. Economic consequences of early inpatient discharge to community-based rehabilitation for stroke in an inner-London teaching hospital. Stroke. 1999; 30(4):729–735 [PubMed: 10187870]
7.: Braet A, Weltens C, Vleugels A. Effectiveness of discharge interventions from hospital to home to reduce readmissions: a systematic review. JBI Database of Systematic Reviews and Implementation Reports. 2012; 10:S105–S117 [PubMed: 27820399]
8.: Chan B, Goldman LE, Sarkar U, Schneidermann M, Kessell E, Guzman D et al. The effect of a care transition intervention on the patient experience of older multi-lingual adults in the safety net: results of a randomized controlled trial. Journal of General Internal Medicine. 2015; 30(12):1788–1794 [PMC free article: PMC4636586] [PubMed: 25986136]
9.: Clemson L, Lannin NA, Wales K, Salkeld G, Rubenstein L, Gitlin L et al. Occupational therapy predischarge home visits in acute hospital care: a randomized trial. Journal of the American Geriatrics Society. 2016; 64(10):2019–2026 [PubMed: 27603152]
10.: Cotton MM, Bucknall CE, Dagg KD, Johnson MK, MacGregor G, Stewart C et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax. 2000; 55(11):902–906 [PMC free article: PMC1745631] [PubMed: 11050257]
11.: Cunliffe AL, Gladman JRF, Husbands SL, Miller P, Dewey ME, Harwood RH. Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people. Age and Ageing. 2004; 33(3):246–252 [PubMed: 15082429]
12.: Davies CWH, Wimperis J, Green ES, Pendry K, Killen J, Mehdi I et al. Early discharge of patients with pulmonary embolism: a two-phase observational study. European Respiratory Journal. 2007; 30(4):708–714 [PubMed: 17567672]
13.: Domingo GRR, Reyes FC, Thompson FV, Johnson PM, Shortridge-Baggett LM. Effectiveness of structured discharge process in reducing hospital readmission of adult patients with community acquired pneumonia: a systematic review. JBI Library of Systematic Reviews. 2012; 10(18):1086–1121 [PubMed: 27820311]
14.: Durvasula R, Kayihan A, Del Bene S, Granich M, Parker G, Anawalt BD et al. A multidisciplinary care pathway significantly increases the number of early morning discharges in a large academic medical center. Quality Management in Health Care. 2015; 24(1):45–51 [PubMed: 25539490]
15.: Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews. 2001; Issue 2:CD000443. DOI:10.1002/14651858.CD000443 [PubMed: 10796365] [CrossRef]
16.: Evans RL, Hendricks RD. Evaluating hospital discharge planning: a randomized clinical trial. Medical Care. 1993; 31(4):358–370 [PubMed: 8464252]
17.: Farren EA. Effects of early discharge planning on length of hospital stay. Nursing Economics. 1991; 9(1):25–63 [PubMed: 1899919]
18.: Finn KM, Heffner R, Chang Y, Bazari H, Hunt D, Pickell K et al. Improving the discharge process by embedding a discharge facilitator in a resident team. Journal of Hospital Medicine. 2011; 6(9):494–500 [PubMed: 22042739]
19.: Fjaertoft H, Indredavik B, Johnsen R, Lydersen S. Acute stroke unit care combined with early supported discharge. Long-term effects on quality of life. A randomized controlled trial. Clinical Rehabilitation. 2004; 18(5):580–586 [PubMed: 15293492]
20.: Fox M. Nurse-led early discharge planning for chronic disease reduces hospital readmission rates and all-cause mortality. Evidence-Based Nursing. 2016; 19(2):62 [PubMed: 26701748]
21.: Fox MT, Persaud M, Maimets I, Brooks D, O’Brien K, Tregunno D. Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysis. BMC Geriatrics. 2013; 13:70 [PMC free article: PMC3707815] [PubMed: 23829698]
22.: George S, Atwal A. Discharge planning reduces length of stay and re-admission rates for older people admitted with a medical condition. Australian Occupational Therapy Journal. 2013; 60(5):375–376 [PubMed: 24089992]
23.: Goldman LE, Sarkar U, Kessell E, Guzman D, Schneidermann M, Pierluissi E et al. Support from hospital to home for elders: a randomized trial. Annals of Internal Medicine. 2014; 161(7):472–481 [PubMed: 25285540]
24.: Goncalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews. 2016; Issue 1:CD000313. DOI:10.1002/14651858.CD000313.pub5 [PMC free article: PMC7073416] [PubMed: 26816297] [CrossRef]
25.: Haggmark C, Nilsson B. Effects of an intervention programme for improved discharge-planning. Nordic Journal of Nursing Research. 1997; 17(2):4–8
26.: Harrison LL. Patient education in early postpartum discharge programs. MCM American Journal of Maternal Child Nursing. 1990; 15(1):39 [PubMed: 2153889]
27.: Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A, Graham ID. Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition. Medical Care. 2002; 40(4):271–282 [PubMed: 12021683]
28.: Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C et al. Improving patient handovers from hospital to primary care: a systematic review. Annals of Internal Medicine. 2012; 157(6):417–428 [PubMed: 22986379]
29.: Hofstad H, Gjelsvik BEB, Naess H, Eide GE, Skouen JS. Early supported discharge after stroke in Bergen (ESD Stroke Bergen): three and six months results of a randomised controlled trial comparing two early supported discharge schemes with treatment as usual. BMC Neurology. 2014; 14(1):239 [PMC free article: PMC4301654] [PubMed: 25528166]
30.: Hyde CJ, Robert IE, Sinclair AJ. The effects of supporting discharge from hospital to home in older people. Age and Ageing. 2000; 29(3):271–279 [PubMed: 10855913]
31.: Indredavik B, Fjaertoft H, Ekeberg G, Loge AD, Morch B. Benefit of an extended stroke unit service with early supported discharge: a randomized, controlled trial. Stroke. 2000; 31(12):2989–2994 [PubMed: 11108761]
32.: Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Annals of Internal Medicine. 2009; 150(3):178–187 [PMC free article: PMC2738592] [PubMed: 19189907]
33.: Jennings JH, Thavarajah K, Mendez MP, Eichenhorn M, Kvale P, Yessayan L. Predischarge bundle for patients with acute exacerbations of COPD to reduce readmissions and ED visits: a randomized controlled trial. Chest. 2015; 147(5):1227–1234 [PubMed: 25940250]
34.: Kleinpell RM. Randomized trial of an intensive care unit-based early discharge planning intervention for critically ill elderly patients. American Journal of Critical Care. 2004; 13(4):335–345 [PubMed: 15293587]
35.: Kotowycz MA, Cosman TL, Tartaglia C, Afzal R, Syal RP, Natarajan MK. Safety and feasibility of early hospital discharge in ST-segment elevation myocardial infarction - a prospective and randomized trial in low-risk primary percutaneous coronary intervention patients (the Safe-Depart Trial). American Heart Journal. 2010; 159(1):117 [PubMed: 20102876]
36.: Lainscak M, Kadivec S, Kosnik M, Benedik B, Bratkovic M, Jakhel T et al. Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial. Journal of the American Medical Directors Association. 2013; 14(6):450–456 [PubMed: 23623520]
37.: Langhorne P, Taylor G, Murray G, Dennis M, Anderson C, Bautz-Holter E et al. Early supported discharge services for stroke patients: a meta-analysis of individual patients’ data. The Lancet. 2005; 365(9458):501–506 [PubMed: 15705460]
38.: Langhorne P, Holmqvist LW, Early Supported Discharge Trialists. Early supported discharge after stroke. Journal of Rehabilitation Medicine. 2007; 39(2):103–108 [PubMed: 17351690]
39.: Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P. Case management in a heterogeneous congestive heart failure population: a randomized controlled trial. Archives of Internal Medicine. 2003; 163(7):809–817 [PubMed: 12695272]
40.: Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino JP, Paillaud E et al. A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults: the optimization of medication in AGEd multicenter randomized controlled trial. Journal of the American Geriatrics Society. 2011; 59(11):2017–2028 [PubMed: 22091692]
41.: Linden A, Butterworth S. A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial. American Journal of Managed Care. 2014; 20(10):783–792 [PubMed: 25365681]
42.: Lindpaintner LS, Gasser JT, Schramm MS, Cina-Tschumi B, Muller B, Beer JH. Discharge intervention pilot improves satisfaction for patients and professionals. European Journal of Internal Medicine. 2013; 24(8):756–762 [PubMed: 24075842]
43.: Lockwood KJ, Taylor NF, Harding KE. Pre-discharge home assessment visits in assisting patients’ return to community living: a systematic review and meta-analysis. Journal of Rehabilitation Medicine. 2015; 47(4):289–299 [PubMed: 25782842]
44.: Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation: Cardiovascular Quality and Outcomes. 2015; 8(2):195–203 [PMC free article: PMC4413911] [PubMed: 25737484]
45.: Mazloum SR, Heidari-Gorji MA, Bidgoli-Gholkhatmi M, Agayei N. Effectiveness of discharge-planning on physical quality of life of patients with ischemic heart disease. International Journal of Applied and Basic Medical Research. 2016; 6(2):129–133 [PMC free article: PMC4830153] [PubMed: 27127744]
46.: McClellan CM, Cramp F, Powell J, Benger JR. A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management. BMJ Open. 2013; 3(1):e001116 [PMC free article: PMC3549250] [PubMed: 23293239]
47.: McInnes E, Mira M, Atkin N, Kennedy P, Cullen J. Can GP input into discharge planning result in better outcomes for the frail aged: results from a randomized controlled trial. Family Practice. 1999; 16(3):289–293 [PubMed: 10439984]
48.: McNamee P, Christensen J, Soutter J, Rodgers H, Craig N, Pearson P et al. Cost analysis of early supported hospital discharge for stroke. Age and Ageing. 1998; 27(3):345–351
49.: Melberg T, Jorgensen M, Orn S, Solli T, Edland U, Dickstein K. Safety and health status following early discharge in patients with acute myocardial infarction treated with primary PCI: a randomized trial. European Journal of Preventive Cardiology. 2015; 22(11):1427–1434 [PubMed: 25398704]
50.: Mistiaen P, Francke AL, Poot E. Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review. BMC Health Services Research. 2007; 7:47 [PMC free article: PMC1853085] [PubMed: 17408472]
51.: Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay. CMAJ Canadian Medical Association Journal. 1992; 146(4):511–515 [PMC free article: PMC1488427] [PubMed: 1737315]
52.: Naughton BJ, Moran MB, Feinglass J, Falconer J, Williams ME. Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomized trial. Journal of the American Geriatrics Society. 1994; 42(10):1045–1049 [PubMed: 7930327]
53.: Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine. 1994; 120(12):999–1006 [PubMed: 8185149]
54.: Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA - Journal of the American Medical Association. 1999; 281(7):613–620 [PubMed: 10029122]
55.: Naylor MD, McCauley KM. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of Cardiovascular Nursing. 1999; 14(1):44–54 [PubMed: 10533691]
56.: Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for hospitalized elderly patients-a randomized controlled trial. Age and Ageing. 2001; 30(1):33–40 [PubMed: 11322670]
57.: NHS Institute for Innovation and Improvement. Quality and service improvement tools: discharge planning, 2008. Available from: http://webarchive.nationalarchives.gov.uk/20121108093302/ http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/discharge_planning.html
58.: Palmer HC, Armistead NS, Elnicki DM, Halperin AK, Ogershok PR, Manivannan S et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. American Journal of Medicine. 2001; 111(8):627–632 [PubMed: 11755506]
59.: Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A, Dewailly P. Benefits of home visits for falls and autonomy in the elderly: a randomized trial study. American Journal of Physical Medicine and Rehabilitation. 2002; 81(4):247–252 [PubMed: 11953541]
60.: Parfrey PS, Gardner E, Vavasour H, Harnett JD, McManamon C, McDonald J et al. The feasibility and efficacy of early discharge planning initiated by the admitting department in two acute care hospitals. Clinical and Investigative Medicine Medecine Clinique Et Experimentale. 1994; 17(2):88–96 [PubMed: 8004854]
61.: Parkes J, Shepperd S. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews. 2000; Issue 4:CD000313. DOI:10.1002/14651858.CD000313 [PubMed: 11034682] [CrossRef]
62.: Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA - Journal of the American Medical Association. 2004; 291(11):1358–1367 [PubMed: 15026403]
63.: Pray D, Hoff J. Implementing a multidisciplinary approach to discharge planning. Nursing Management. 1992; 23(10):52–56 [PubMed: 1407840]
64.: Preen DB, Bailey BE, Wright A, Kendall P, Phillips M, Hung J et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. International Journal for Quality in Health Care. 2005; 17(1):43–51 [PubMed: 15668310]
65.: Puhr MI, Thompson HJ. The use of transitional care models in patients with stroke. Journal of Neuroscience Nursing. 2015; 47(4):223–234 [PubMed: 25906245]
66.: Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine. 1995; 333(18):1190–1195 [PubMed: 7565975]
67.: Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study. Journal of General Internal Medicine. 1993; 8(11):585–590 [PubMed: 8289096]
68.: Rousseaux M, Daveluy W, Kozlowski R. Value and efficacy of early supported discharge from stroke units. Annals of Physical and Rehabilitation Medicine. 2009; 52(3):224–233 [PubMed: 19522037]
69.: Rudd AG. Correction: randomised controlled trial to evaluate early discharge scheme for patients with stroke (British Medical Journal (1997) 25 October (1039-1044)). BMJ. 1998; 316(7129):435 [PMC free article: PMC2127677] [PubMed: 9366727]
70.: Saleh SS, Freire C, Morris-Dickinson G, Shannon T. An effectiveness and cost-benefit analysis of a hospital-based discharge transition program for elderly Medicare recipients. Journal of the American Geriatrics Society. 2012; 60(6):1051–1056 [PubMed: 22690981]
71.: Sharif F, Moshkelgosha F, Molazem Z, Najafi Kalyani M, Vossughi M. The effects of discharge plan on stress, anxiety and depression in patients undergoing percutaneous transluminal coronary angioplasty: a randomized controlled trial. International Journal of Community Based Nursing and Midwifery. 2014; 2(2):60–68 [PMC free article: PMC4201194] [PubMed: 25349846]
72.: Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews. 2004; Issue 1:CD000313. DOI:10.1002/14651858.CD000313.pub2 [PubMed: 14973952] [CrossRef]
73.: Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P et al. Early discharge hospital at home. Cochrane Database of Systematic Reviews. 2009; Issue 1:CD000356. DOI:10.1002/14651858.CD000356.pub3 [PMC free article: PMC4175532] [PubMed: 19160179] [CrossRef]
74.: Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews. 2013; Issue 1:CD000313. DOI:10.1002/14651858.CD000313.pub4 [PubMed: 23440778] [CrossRef]
75.: Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A et al. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews. 2010; Issue 1:CD000313. DOI:10.1002/14651858.CD000313.pub3 [PubMed: 20091507] [CrossRef]
76.: Sulch D, Perez I, Melbourn A, Kalra L. Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke. 2000; 31(8):1929–1934 [PubMed: 10926959]
77.: Torp CR, Vinkler S, Pedersen KD, Hansen FR, Jorgensen T, Willaing I et al. Model of hospital-supported discharge after stroke. Stroke. 2006; 37(6):1514–1520 [PubMed: 16645132]
78.: Ulin K, Olsson L-E, Wolf A, Ekman I. Person-centred care - an approach that improves the discharge process. European Journal of Cardiovascular Nursing. 2014; 15(3):e19–e26 [PubMed: 25648848]
79.: Utens CMA, Goossens LMA, Smeenk FWJM, Rutten-van Molken MPMH, van Vliet M, Braken MW et al. Early assisted discharge with generic community nursing for chronic obstructive pulmonary disease exacerbations: results of a randomised controlled trial. BMJ Open. 2012; 2(5):e001684 [PMC free article: PMC3488726] [PubMed: 23075570]
80.: Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. New England Journal of Medicine. 1996; 334(22):1441–1447 [PubMed: 8618584]
81.: Zhu QM, Liu J, Hu HY, Wang S. Effectiveness of nurse-led early discharge planning programmes for hospital inpatients with chronic disease or rehabilitation needs: a systematic review and meta-analysis. Journal of Clinical Nursing. 2015; 24(19-20):2993–3005 [PubMed: 26095175]

Appendices

Appendix A. Review protocol

Table 4Review protocol: Discharge planning

Review question	Discharge planning
Guideline condition	Acute medical emergencies.
Review population	Adults and young people (16 years and over) with a suspected or confirmed AME (discharged from the acute hospital).
	Adults
	Line of therapy not an inclusion criterion.
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)	Discharge planning; discharge planning as defined by study. Usual care; as defined by study. Standard processes; usual practice.
Outcomes	- Quality of life (Continuous) CRITICAL - Mortality (Dichotomous) CRITICAL - Avoidable adverse events (Dichotomous) CRITICAL - Length of stay (Continuous) CRITICAL - Patient/Carer/Family satisfaction (Dichotomous) CRITICAL - Readmission up to 30 days (Dichotomous) IMPORTANT - Staff satisfaction (Dichotomous) IMPORTANT - Delayed Transfers of care (Dichotomous) IMPORTANT
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient. Hospital. Ward.
Crossover study	Not permitted.
Minimum duration of study	Not defined.
Subgroup analyses if there is heterogeneity	- Frail Elderly (Frail; Not Frail); Different outcomes - People with mental illness (Mental illness; No mental illness); Different outcomes - Multimorbidity (Multimorbidity; No multimorbidity); Different outcomes - Early versus late (Early; Late); Different outcomes - MDT versus no MDT (MDT; No MDT); Different outcomes - Discharge co-ordinator (Nurse; Manager); Different outcomes
Search criteria	Databases: Medline, Embase, the Cochrane Library, CINAHL. Date limits for search: none. Language: English only.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of discharge planning

Appendix C. Forest plots

C.1. Discharge planning versus standard processes

Figure 2Readmission (30 days)

Figure 3Readmission (5-30 days)

Figure 4Mortality

Figure 5Mortality

Figure 6Mortality (in-hospital)

Figure 7Avoidable adverse events (adverse medicine reaction)

Figure 8Avoidable adverse events (recurring falls)

Figure 9Quality of life (minimal clinically important difference on St. George’s Respiratory Questionnaire)

Figure 10Quality of life (SF12 physical)

Figure 11Quality of life (SF12 mental)

Figure 12Patient satisfaction (rating of discharge process; 5 point Likert scale)

Figure 13Patient satisfaction (prepared or very prepared to leave hospital)

Figure 14Length of stay

Figure 15Staff satisfaction (5 point Likert scale)

Appendix D. Clinical evidence tables

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Appendix E. Economic evidence tables