Authors' objectives: Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to ‘winter pressures’. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care.

Authors' results and conclusions: The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified. Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting. The taxonomy consists of a total of 41 headings. These headings were further organised into the different contributions to the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was provided and this helped with identification of the evidence gaps. Within structural interventions for the hospital avoidance part of the patient pathway research gap were identified for same-day emergency care and research and implementation gaps for surgical hubs. The alternative delivery sites subsection is populated by systematic review evidence for the effectiveness of acute medical units, other specialist units developing using winter funding need to be fully evaluated. Models based on ‘discharge to assess’ (also ‘home first’ and others) within facilitated discharge are relatively well researched. Some taxonomy headings (e.g. ‘bed management’ and ‘discharge co-ordinators’) were often evaluated within a broader process of ‘discharge planning’. ‘Patient flow’ is another broad heading with some overlap with both bed management and discharge planning. The concept of patient flow is also broader than facilitated discharge, although its ultimate goal is ensuring safe discharge as soon as is clinically appropriate. The evidence base for initiatives defined as ‘cross-cutting’ varied widely and was characterised by case studies with a lack of research studies. Community provision initiatives and integrated care were heterogeneous and characterised by multiple diverse initiatives, largely unevaluated, and by involvement of multiple contributors and sectors. Overall, the evidence base is characterised by large numbers of case studies, often published online or presented at conferences, and relatively few peer-reviewed journal articles. Case studies are often accompanied by guidance to support implementation of changes to services. This distribution of evidence probably reflects the urgent need to develop and implement solutions to the ever increasing winter (and increasingly year round) pressures on the health and care system. The majority of evaluations report positive effects on important outcomes such as length of hospital stay but many are uncontrolled or based on small samples, meaning that they need to be interpreted with caution. Few initiatives identified were specifically implemented as a response to winter pressures. Hospital at home, as a heavily used intervention, was well-supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, few studies measure the impact of interventions over a long time; short-term results can appear promising but evidence for longer-term sustainability is notably absent. Hospital avoidance and delayed discharge requires a whole-system approach. It is imperative to consider the whole system to ensure that implementing an initiative in one setting does not just move the problem to another setting.

Authors' methods: We conducted a mapping review of United Kingdom evidence published 2018–22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King’s Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps. Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified. We conducted a mapping review of UK evidence published 2018–22. For the mapping review, we used a two-stage search process to search for the evidence. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King’s Fund Library to find relevant interventions. The search was broad for terms for winter pressures. Searches on Google Scholar (Google Inc., Mountain View, CA, USA), which searches the full text instead of just title and abstract, included terms for discharge and integrated care. Study screening and selection was undertaken in Microsoft Excel® (Microsoft Corporation, Redmond, WA, USA) by three reviewers who independently screened the title and abstracts of the 723 references that were retrieved by the search. Study eligibility was based on following aspects – population, exposure, comparative, outcome(s), study types: users of UK health and/or social care systems (population) winter pressures impacting on discharge, to social care and the community, and integrated care (exposure) other foreseeable, unusual or exceptional periods of demand (if appropriate) (comparison – may or may not be present) increased smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place), system effects, health and health service outcomes, effects on patients, carers and staff (outcomes) eligible types of study design (primary research study, evidence synthesis or research report) (study types). To classify within the broader thematic groups of interventions, we developed a taxonomy documenting the candidate interventions together with other relevant supporting literature. Our team started from categories developed by the Cochrane Effective Practice and Organisation of Care Group for their systematic reviews of discharge planning. These were further expanded using categories from a rapid review produced by the Centre for Clinical Effectiveness, Monash University. This process resulted in the following broad groupings: structural, changing staff behaviour, changing community provision, integrated care and targeting carers. The draft taxonomy was reviewed for parsimony (to minimise duplication of concepts) and comprehensiveness (to include all named interventions identified to date). However, published commentary has documented the non-exclusivity and lack of precision of existing labels. Following the production of the draft map using the taxonomy, we decided to further split the taxonomy headings to represent contributions to the patient pathway: hospital avoidance, alternate delivery site, facilitated discharge and cross-cutting. The modelling and workforce planning groupings were not considered as within scope because of their limited relevance to short-term alleviation of winter pressures and were therefore discarded. The second stage of searching consisted of searches for named candidate interventions from the literature and current practice on Google Scholar. The second stage was to identify where possible reviews, ideally systematic reviews, and these searches were broader than winter pressures but were limited to research published from 2012 to 2022. The second-stage searches helped in completing the intervention tables and identifying the evidence gaps. Research priorities were classified as high, moderate or low and further classified by the nature of the evidence gap(s) identified (research gap, synthesis gap and/or implementation gap). Time limitations for completing the review constrained the period available for additional searches with a focus on systematic reviews and high-profile studies. This carries implications for the variability of coverage and completeness of the evidence base identified.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR130588

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/KRWH4301

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: United Kingdom

DOI: 10.3310/KRWH4301

Organisation Name: NIHR Health and Social Care Delivery Program

Contact Name: Rhiannon Miller

Contact Email: rhiannon.m@prepress-projects.co.uk