Level 6 Discharges from Bradford Teaching Hospitals: Destination and Survival Dr Kath Lambert SpR in Palliative Medicine BRI

Aims To find out what happens to patients discharged from hospital on a Level 6 discharge How well do we predict survival? If the patient’s aim is to die at home how often is this achieved? If patients are readmitted following discharge then is this appropriate? How many of these discharges are the Palliative Care Team involved in?

Level 6 discharges from Bradford Hospitals Number of Level 6 discharges from hospital is increasing They are all coordinated by the Discharge Team Discharge Team consists of 7 nurses, 2 admin staff with close links to an OT Takes an average 7-10 hours to organise a Level 6 discharge

Role of the Discharge Team Liaise with patients and families Nursing needs assessment Organise OT to perform an environmental visit Then organise MDT with D/N and Hospice at Home Plan discharge date Order equipment

Methods Review of outcomes for all patients referred to the Discharge Team for Level 6 funding between Nov 04 and Jan 05 Follow up after discharge from Hospital notes, Systm One records, Hospice at Home records, Hospital PAS, Nursing Home records

Results 41 patients 18 females 23 males Age range discharges from hospital on Level 6 funding 5 patients died in hospital before they could be discharged to their preferred place of care

Distribution of patients by speciality

Distribution of patients by diagnosis

Length of hospital stay before discharge Range days Median 16 days

Previous place of care

Preferred place of discharge

Time between Level 6 funding form signing and discharge Range days Median 4 days

Place of discharge 7 out of 41 patients did not get discharged to their preferred place of care 5 patients died in hospital before they could be discharged to their preferred place (1 home/1 hospice/3 N/H) 1 patient wanted home but was discharged and died in hospice due to difficult symptoms 1 patient discharged to community hospital while waiting for services later discharged home

2 patients had Level 6 funding withdrawn 1 patient was discharged following a CVA and had funding reduced after 1 month 1 patient had End Stage COPD and had funding reduced after 2 months Both these patients still “alive and well”

Time between discharge and death Range 3 – 112 days 30 out of 34 patients died within 42 days of discharge

Place of death

Admissions/readmissions after discharge 1 patient was readmitted to hospital for ascitic drain (died at home) 6/36 patients did not die in their place of discharge 3 patients were admitted to hospice from home for symptom control and died in hospice

Admissions/readmissions after discharge 1 patient was admitted to and died in hospice because 24 hour care was not possible at home 1 patient was readmitted to hospital from home with significant GI bleed. He died in hospital 31 days later 1 patient with terminal bowel obstruction on discharge was readmitted by GP with “dehydration” and died in hospital 23 days later

Outcomes for discharges to Nursing Homes All 4 patients discharged to N/H died in N/H 3 of these patients had been admitted to hospital from N/H These 3 patients all died on the 5 th day after their discharge These 3 patients all had non-malignant diagnoses The 4 th patient had lung cancer and died after 112 days (longest in study)

Outcomes for patients who lived alone on admission 12 patients lived alone 4 patients were discharged and died at home 2 patients died before discharge (1 wanted hospice, 1 N/H) 1 patient wanted hospice but died in hospital before transfer

Outcomes for patients who lived alone on admission 1 patient went to live with his son and died there 1 patient’s daughter moved into her home but was admitted to and died in hospice 1 patient went home but was admitted to and died in a hospice 1 patient went home but was readmitted to hospital and died there 1 patient went home (niece moved in) but now no longer Level 6

Outcomes for patients with non-malignant diseases 1 died prior to discharge 3 returned to previous nursing home and died there 2 had Level 6 funding withdrawn 3 went home and died at home (1 heart failure/1 COPD/1 CVA)

Palliative Care involvement 27/41 patients were reviewed by the Hospital Palliative Care team 13/27 patients who went home needed input from Specialist Palliative Care

Conclusions Level 6 discharges are evenly distributed throughout specialities Good proportion of non-malignant cases The hospital Palliative Care Team are involved in a large number of these discharges 68% patients wanted to return home 85% patients were discharged to their preferred place of care

Conclusions 18% patients did not die in their preferred place of care Majority of admissions following discharge seemed to be appropriate and unavoidable Level 6 discharges for patients who live alone are more difficult but not impossible

Limitations Only 3 months of data Accuracy depends on medical records Readmissions may have occurred to other hospitals Preferred place of care is recorded after MDT

Discussion How many patients were offered the choice of remaining in hospital? Are there more patients dying in hospital (particularly of non-malignant conditions) that we should be offering Level 6 discharges to?

Summary Very positive results! Although Level 6 discharges are increasing in number, in the hospital setting we are appropriately allocating funding for these discharges Planning of discharges and local services are enabling many patients to be discharged to, and die in their chosen place of care