Read Standard 11: Care in hospital

Rationale

Older people living with frailty make up a large proportion of hospital patients. Staying in hospital often leads to a decrease in physical activity, function and continence.¹⁰⁸ Lights or noise in hospital wards can increase distress and delirium, as can moving between wards.¹⁰⁹ Older people with frailty are at increased risk of healthcare associated infections.¹¹⁰ When in hospital, older people with frailty should have full, timely access to high dependency units, intensive care units, surgery and other treatments when clinically appropriate. Staff should be aware of and act upon any communication needs, including sight or hearing loss.

Over half of all surgery is performed on people who are over 65 years of age.¹¹¹ Older people having surgery are more likely to experience complications compared with younger people.³² This includes a higher mortality, longer length of stay and increased need for support on discharge.¹¹²

People who stay in hospital longer than clinically necessary have an increased risk of infections and reduced mobility and independence.¹¹³ Delayed discharges can reduce hospital capacity and reduce the system’s ability to respond to increased demand.¹¹⁴ Older people should have access to services to support them to return home or into a care setting as soon as possible. Effective discharge planning should begin before or at the time of admission and involve a multidisciplinary team.¹¹⁵

An immediate discharge letter should provide clear guidance to support recovery. It should include information on follow up and changes to medication.²⁶ Unpaid carers should be involved in discussions about discharge as detailed in the Carers (Scotland) Act 2016.²⁶

There can be delays in recognising and acknowledging dying in hospital. This can lead to investigations and treatments that may be unnecessary or inappropriate. Hospital staff should be skilled at providing palliative care at a generalist level. People should have prompt access to specialist palliative care when required.

Criteria

11.1

Plans for scheduled admission to hospital are:

discussed with the person and their unpaid carer or care partner
documented in the person’s care plan.

11.2

People scheduled for planned surgery:

receive a risk assessment before the surgery
receive multidisciplinary support to maximise their strength and function
are involved in planning their rehabilitation on discharge.

11.3

People with frailty:

receive direct admission to the most appropriate area in the first instance
are not moved between wards or into non-designed patient areas unless there is a clinical need.

11.4

Wards caring for people who may be at risk of frailty:

have appropriate lighting and noise levels for the time of day
provide a private space for older people with frailty who are dying
are designed to promote safe mobility and routine activity
provide inclusive public information for example large signage
support visitors where appropriate
promote healthy sleep.

11.5

Staff in hospitals promote and enable:

dignity and privacy
independence
engagement in physical and social activity
continence
skin care
oral health.

11.6

NHS boards promote rapid discharge to Hospital at Home or enhanced community support where this is the person’s choice and is deemed clinically appropriate.

11.7

NHS boards ensure hospital staff have access to specialist palliative care assessment and advice 7 days a week.

11.8

People being discharged to a care home have a future care plan which is shared with unpaid carers or care partners, the care home and the GP practice.

11.9

An immediate discharge letter is produced and available to all relevant staff, including social care staff, within 24 hours of discharge.

11.10

Clinical information about a person’s experience in hospital is updated in the person’s shared care plan including:

tests and assessments undertaken and the results
changes to the person’s health or care needs
changes to medicines
experience of delirium
experience of stress and distress.

11.11

Organisations act in the best interests of people who experience delayed discharge.

11.12

The care and support needs of people who are delayed from hospital discharge are reviewed weekly.

What does this standard mean for...

What does the standard mean for people in hospital?

You will be cared for in a clinical environment that meets your needs.
You will be safe and able to maintain your independence.
Planning for discharge will begin as soon as you get to hospital and will be regularly reviewed.
You will be involved in decisions about what will happens when you leave hospital.
If there are changes to plans, you are kept informed and are involved in decisions.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

recognise and respond to signs of frailty in people in hospital
undertake assessments in line with their roles and responsibilities
ensure ward environments empower people to maintain physical activity and continence, where possible
have sufficient and timely information at point of discharge
work collaboratively to support discharge without delay
share information to enable continuity of care.

What does the standard mean for the organisation?

Organisations:

ensure ward environments meet the specific needs of people with frailty
encourage independence and autonomy
work collaboratively to address the underlying causes that contribute to delayed discharges
develop plans and policies to reduce transfer between wards or care settings
provide access to specialist palliative care assessment and support 7 days a week.

Examples of what meeting this standard might look like

Data related to number of people in hospital waiting for discharge.
Data related to reasons for delayed discharge.
Data related to admission and readmission rates.
Data related to number of moves within the hospital.
Audit of timeliness and content of immediate discharge letters.
Audit of proportion of people who have an up-to-date future care plan at point of discharge.