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Table 2 Illustrative Extracts of Data

From: A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service

Falls He fell because he wanted to go to the loo. Bill shouldn’t have really gone unassisted, he did have a Zimmer frame, but he should have had a nurse,… he went off on his own. (Relative)
I daren’t let go of the furniture you know to walk about. I need a frame or something all the time to get around. I borrow them (Patient)
There’s always a risk of stroke patients, especially those that have gone home with a weakness of falling. There’s nothing we can do… (Nurse)
Medicines We ask them if they’re still taking their bone protection medication and often they say no (Nurse)
[I was] Given bag of medications but no instructions. No idea what they are for. (Patient)
A lot of patients go home and for whatever reason don’t take the medicines as we have told them and experience problems (Doctor)
Equipment Everything had gone in, except the mattress. The delivery man, why didn’t they just match it up, or say why are we sending this out without a mattress (Occupational Therapist)
Infections, Sores, Ulcers I think a hospital is a place of safety when you’re ill and you’re brought in. There’s a saying. If you’re carried into hospital, you might walk out, but if you walk into hospital, you might be carried out. And there is an element of truth to that. (Hospital doctor)
There is always a risk that patients will develop a pressure sore and the longer they stay in hospital with rehabilitation and without the normal activities, that risk gets bigger (Therapist)
Hospitals are not safe places for older people. The longer they stay in, there is more chance of them picking something up. That is another reason why discharge is so important (Hospital doctor)
Relapse What you really don’t want to see is the patient being re-admitted with another fracture, whether its from a fall or from a dislocation, you just don’t want it (Doctor)
There is no certainty. You can make your best assessment and think the patient will be better cared for at home, but you can never really tell. A lot will go home and have another stroke, and we then wonder whether we pushed them out too quick or didn’t provide the necessary support (Doctor)
Patient Assessment A concern is whether the patient is appropriately assessed and suitable to be discharge. The surgeon might see the patient as surgically fit, but there can be a lot of rehab and therapy input still needed. But its not always easy getting that point across (Physiotherapist)
You sometimes get the sense that the patients are being rushed out of the door, what with all the patients coming in the front door. So we are seeing patients arrive home who are still really unwell and poorly. (Community nurse)
Ordering Equipment & Medicines …every Friday … one of the doctors
throws her hands up in horror if she has to do any TTO’s and quite often she’ll say she’s too busy, so then that means we’ve got to wait then till Monday. (Nurse)
quite often there tends to be a day or two where the equipment isn’t in stock and it’s going to be delivered (Physiotherapist)
we’ll fight over who orders what, who’s budget it’s going to come out of? ‘No. It’s a social commode.’ What on earth is a social commode? (Social Worker)
Follow-up We see patients when they get home and we look for their care plan, and its nothing, its just a few notes about mobilisation or medicines. There is nothing detailed about what level of care they need. So we spend a lot of time re-assessing the patient and devising new care plans (Social care)
We always try to see the patient after they get home, but we have a lot of patients and it wont be straight away. We usually rely upon the social care re-ablement teams to provide that initial general support. The GP doesn’t really get involved unless there is a problem. (Community nurse)
Education We spend a lot of time with the patients providing structure rehabilitation with support for them to manage at home, but it is not always easy to get the messages across especially when the patient is very frail (Occupational Therapist)
A lot of the burden falls on the family to provide support and they are not always available or informed about what their relative needs (Nurse)
Planning I think the key thing is lack of continuity and all the stuff that centres around that, the documentation, the proper information, the Social Worker is not there that day…(Nurse)
The MDTs are pretty poor. They are completely driven by the surgical and nursing priorities, and we go no look in to the decision (Occupational Therapist)
I think sometimes the junior doctors get an awful lot of responsibility. They don’t know that patient but they’re expected to complete that discharge when they’ve never set eyes on that patient. (Nurse).
Referrals We can’t actually refer them to any outside services until they are medically fit. So until they reach a point where they’re medically fit for discharge we can’t actually do anything about referring them on to anybody until that point. (Nurse)
It should be pretty straight forward, but each time it is different, and you never know which social worker you are after. And they keep changing any way. So it makes you think there is no continuity of care once they leave hospital (Nurse)
Timing & Scheduling …if you stay in hospital longer than you should, you get a chest infection or you fall and fracture your hip and you die. (Doctor)
From half-past five in the morning to strip my bed and I was sitting on a chair from that time till I got home. It had gone eight o’clock at night. I felt like I wanted to cry because, you know, I felt they just didn’t care. (Patient)
Resource Constraints They’re closing these homes and the services are not available. We’re actually dealing with a very, I would say, an increase in need and service, but the services are not being put out there for whatever reason (Occupational Therapist)
Organisational Pressures It’s a process machine. I often think of it and I know it sounds a bit inhumane, but I think of it like a sausage factory…. (Nurse)
That’s what I’m on about with the pressure to get people out and maybe not come through the social work route because it comes out of their budget because we’re not joined-up are we with budgets (Nurse)
Every morning a manager will come down to the ward and ask use to go through the daily discharges…pushing us to move get these one’s one or prioritise these patients. They never really look at the cases (Nurse)