Abstract
Background: Patient referral to tertiary hospitals is currently problematic and faces many obstacles. At large state hospitals and teaching hospitals, consistently high inpatient occupancy rates limit the ability of the hospitals to admit new patients, including referral patients. Since the issues with high inpatient occupancy rates partially stem from patients not being ready to leave hospital care at the time of discharge and prolonging hospital stay, it is important to understand the reasons why this happens.
Methodology: The study focused on cases of difficult discharges at a large tertiary hospital by analyzing the situation around the discharges and other relevant factors on the part of the hospital, the patients, their families and societal attitudes. It is divided into four parts, each with different methodologies designed to give a comprehensive view of the issues from various stakeholders: 1) compilation of consensus opinions of medical experts, 2) a survey of difficult discharges, 3) in-depth interviews, and 4) a knowledge exchange workshop.
Results:
Part 1: The first part of the study looked at the opinions of medical personnel towards difficult discharge cases. A multidisciplinary panel viewed the issue from two perspectives, patients with prolonged length of hospital stays and those with difficult discharges. The main difference between the two was that difficult discharge cases resulted in feelings of anxiety for the patients and other involved. The panel classified the main factors affecting difficult discharges into six categories: medical, patient, family, social, organization and health care system.
Part 2: The second part of the study looks at the magnitude of the problem at one teaching hospital in the Bangkok metropolitan area. A survey found that difficult discharges occur in about 10% of all cases, with the majority of patients being over 65 years of age and required some form of assisted living. Most were general medicine patients with cancer or circulatory system disorders and are part of a healthcare program where hospitalization costs can be reimbursed. About 50% of the difficult discharge cases still had active medical conditions, while 70% no longer needed to be treated at a tertiary hospital. The factors contributed to anxiety for medical staff in dealing with these cases include the patient’s inability to care for themselves independently, and the fact that their families are not ready to care for the patient at home. For patients and their families, their concerns stem of a lack of confidence in their ability to care for the patient at home.
Part 3: The third part of the study focuses on the perspective of the patients, their families and society at large towards hospital stays and discharges. It was found that Thai society in general places high expectations on hospitals, with many holding the view that hospitals are able to treat and cure all ailments and is their primary healthcare provider. Subsequently, when faced with situations where medical conditions are not curable, patients and their families are not able to cope with the bad news. At the time of discharge, patients tend to disagree with the recommendations of the medical staff because of their dependency on hospital care. In addition, the Thai public lacks knowledge about palliative care and there is a general shortage facilities for alternative care such as nursing homes, hospices and chronic care facilities.
Part 4: The last part of the study was a knowledge exchange workshop on the issue of difficult discharges and potential solutions for tertiary hospitals in the Bangkok metropolitan area. The workshop was conducted with representatives from the hospitals and from the staff of 12 health districts under the Ministry of Public Health. Some of the major findings from the workshop was that: 1) the participation of family members in the patient’s treatment plan helped to make the discharge process easier, 2) hospital systems working in close cooperation in each health district resulted in a more efficient discharge and referral process and 3) for Bangkok, a major problem was the lack of secondary care institutions that were acceptable for patients and their families and the family not being ready to care for the patients at home.
Conclusion: The issue with difficult discharges from tertiary hospitals is widespread throughout large hospitals in Thailand. Many complex and overlapping factors contribute to the issue, including medical, patient, family, social and larger health care system factors. The solution to the problem needs coordinated steps that tackle all facets of the problem and requires further study to develop discharge protocols that can be practically applied by each hospital.
