Table 2 Brief description of hospital discharge functions

Review of hospital inpatients—classifying patients that are medically fit for discharge.

Normally, hospital discharge is initiated by conducting a pre-ward round. The activity involves a clinical process in which the clinical care of hospital inpatients is reviewed. The responsible doctor reviews the patient’s progress and determines whether the patient is medically fit for discharge. The activity normally involves knowledge sharing among a multidisciplinary team, including the lead consultant, interns, junior doctors, responsible nurse (primary nurse or team nurse depending on the nursing care model applied at the ward), and sometimes physiotherapists. It is essential that all relevant information is shared to support the appropriate care decisions; this indicates that input is needed from multiple sources (i.e., information about the patient’s medical records, lab results, test results, medications, and functional and cognitive status). This function is controlled by guidelines for assessment stated in the regulations on municipal co-funding of patients ready for discharge [24].

Activates the discharge process.

Notifying the municipality that the patient is medically fit.

When the lead consultant has classified the patient as being ready for discharge, a message is sent to the receiving municipality (electronically, by phone or fax). For this notification to be considered valid, certain preconditions concerning discharge planning must be fulfilled as agreed upon in the cooperation agreements between the hospitals and municipalities.

Activates the discharge process in the receiving municipality; assigns an appropriate post-discharge site of care.

Informing the patient that they are ready for discharge.

The patient is normally informed about the decision for medical fitness during the ward rounds, which are the daily formal opportunity for dialogue and interaction among the patient, doctor, and care team. From the patient’s perspective (preparedness and satisfaction), it is essential that they have been prepared and involved in the discharge planning process prior to the day of discharge (to reduce anxiety, distress, and strain). The ward round normally takes place after the pre-ward round activity is completed, and it is conducted at the patient’s bedside. Normally, several professionals attend the ward rounds. In general, the round is led by the senior doctor or doctor in charge of the ward, with junior doctors or medical students and nursing staff present. This function is controlled by regulations stating the patient’s right to information, participation, and involvement [25].

Prepares and provides the patient with discharge information or instructions and plans for follow-up care.

Assigning an appropriate post-discharge site of care and notifying the hospital.

The receiving municipality has (according to the cooperation agreement) a 3-hour response time (from the time the notification of the patient being medically fit is received—if sent correctly) to contact the hospital and indicate whether and when a post-discharge site of care is available. For the municipality to determine the most appropriate setting for post-discharge care, it is essential that there is compliance with the discharge planning agreements and that the hospital provides accurate and sufficient information. Different ways of organizing the coordination in discharge planning are recognized depending on the municipality size. In a city region, patient coordinators in the municipality are responsible for organizing the information exchange during the discharge. In a rural region, a helpline has been established across municipalities with an assigned person (i.e., head nurse at a nursing home) responsible for coordination in each municipality. In the city region, information is exchanged electronically between the hospital and patient coordinators in the municipality; in the rural region, this is done over the phone or via fax.

Avoids delayed discharges. Determines the most suitable post-discharge site or level of care.

Notifying and informing the patient’s next of kin (if any).

Normally, the patient’s nurse contacts (usually over the phone) the patient’s next of kin (if any) to inform them about the discharge and plans for follow-up care when clarified. From the next of kin’s perspective, it is essential that they are provided with information and are involved in the discharge planning process prior to the day of discharge. This function is controlled by regulations stating that the patient’s next of kin should receive information about the patient’s state of health, treatment, and care provided (if the patient has given their consent) [25].

Prepares and provides the patient’s next of kin with discharge information and plans for follow-up care.

Preparing a nursing discharge record.

The nursing discharge record is completed according to statutory regulations [26], stating that the patient’s record shall be sent to the professionals who need the information to provide the patient with appropriate follow-up care. The nursing record should include descriptions of the nursing care delivered, the patient’s status, assessments, and recommendations for continuing care.

Ensures written information transfer and continuity of care.

Preparing a medical discharge letter.

The medical discharge letter is similarly governed by regulations [26], stating that the discharge summary must contain information about the patient’s medical diagnosis and former medical history, treatment performed during hospitalization, functional level and assessment, a complete medical list, and prescriptions for new medications. Plans for follow-up care are also provided. The nursing and medical record is normally not prepared until after the patient is deemed medically fit for discharge.

Ensures written information transfer and continuity of care.

Providing oral information about the transfer to post-discharge care providers.

When post-discharge arrangements have been clarified and confirmed by the receiving municipality, the patient’s nurse contacts the assigned care facility to provide direct oral information about the patient. The function depends on pre-conditions, such as information and knowledge about the patient, follow-up care plans, hospital course, treatment, and current medications. The latter is emphasized as important to ensure that the receiving care providers or site of care have the patient’s current medications available.

Ensures the continuity of care and agrees on a time of transfer.

Ordering transportation.

Transportation can be arranged and ordered after it has been clarified when and where the receiving municipality has availability. Patients can either be transported to the post-discharge site of care by ambulance, by taxi, or by next of kin, according to their conditions and preferences. If an ambulance is required, an order is sent electronically, which also specifies the time the patient will be ready for transfer.

Arranges suitable transportation.

Transferring the patient to the post-discharge site of care and ensuring the transfer of written information.

To ensure the continuity of care, it is crucial that written information be present and available when the patient leaves the hospital. This function is controlled by regulations [26], the cooperation agreement, and by established routines or procedures at the wards, which state the information that is to be provided. The information (nursing record and discharge letter) is sent with the patient on discharge in addition to being sent electronically or by post (to the receiving care providers and the patient’s general practitioner). From the perspective of those assuming responsibility for post-discharge care, it is desirable that the patient be transferred and arrives during the daytime (9 a.m. to 3 p.m.) since more resources and greater competence are available then. There is also a challenge for health-care personnel in the municipality to contact hospital staff for clarification if the responsible doctor or nurse has ended their shift and the next shift has little knowledge of the patient. Similarly, hospital personnel prefer to transfer patients that are ready for discharge during the day shift to safeguard the process and avoid shift handover issues.

Ensures the continuity of care. Ends the hospital discharge process: the patient physically leaves the hospital, and the municipality takes over responsibility.