Information Services Division
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Delayed Discharge Definitions and
National Reporting Requirements
Advice Note v1.0
Issued April 2019
INTRODUCTION
Until recently, the majority of Health Boards have used the delayed discharge data
management system, EDISON, to record and report on delayed discharges. As this system
is being retired, most areas are now collecting data through TRAK. The ‘shadow’ period in
running both systems during the transition, highlighted some issues around data collection.
ISD, along with the Scottish Government, held a series of workshops in late 2018 to
examine the recording of delayed discharges, and this advice note is the output of these
workshops.
This document should be read alongside the Delayed Discharge Definitions Manual (DM)
and the National Reporting Requirements (NDR) which remain the official guidelines on
collecting delayed discharge data.
The DM and NDR can be found at http://isdscotland.org/Health-Topics/Health-and-Social-
Community-Care/Delayed-Discharges/Guidelines/.
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Table of Contents INTRODUCTION .............................................................................................................................. 1
1. DEFINITIONAL CLARIFICATION ................................................................................................. 3
1.1. What do we count as a delayed discharge? ...................................................................... 3
1.2. Why do we count delayed discharges? ............................................................................. 4
1.3. When do we count delayed discharges? ........................................................................... 5
1.4. How do we count delayed discharge? ............................................................................... 6
2. DELAY REASONS ....................................................................................................................... 7
2.1 Assessment codes - 11A/11B ............................................................................................ 7
2.2 Awaiting Dementia Bed - 24F ............................................................................................ 7
2.3 Patient Choice ................................................................................................................... 7
2.4 Capacity ............................................................................................................................. 8
2.5 Code 9 ............................................................................................................................... 8
2.6 Code 100 ........................................................................................................................... 9
2.7 Mental Health delays ......................................................................................................... 9
2.8 Learning disability delays ................................................................................................. 10
2.9 Phased discharge ............................................................................................................ 10
2.10 Appeals .......................................................................................................................... 11
2.11 Change in patient circumstances ................................................................................... 11
3. INTERMEDIATE CARE .............................................................................................................. 12
3.1. What is Intermediate Care? ............................................................................................ 12
3.2. What is Bed Based Intermediate Care? .......................................................................... 12
3.3. What is NOT Bed Based Intermediate Care? .................................................................. 12
3.4. Intermediate Care and Delayed Discharges .................................................................... 13
4. OPERATIONAL PROCESSES ................................................................................................... 14
4.1 Using TRAK to record delays ........................................................................................... 14
4.2 Out of area delays ........................................................................................................... 14
4.3 Hospital transfers within the same Health board .............................................................. 14
4.4 Hospital transfers between Health boards ........................................................................ 14
4.5 Verification of information................................................................................................. 14
4.6 RDD date changes........................................................................................................... 14
5. OUTPUTS .................................................................................................................................. 15
5.1 Published information ...................................................................................................... 15
5.2 Freedom of Information requests (FOIs) .......................................................................... 15
6. CONTACTS ............................................................................................................................... 15
6.1 ISD .................................................................................................................................. 15
6.2 Scottish Government Policy Lead .................................................................................... 15
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1. DEFINITIONAL CLARIFICATION
The vast majority of patients will be discharged from the NHS without any involvement of
other agencies, such as social care or housing. However, in some cases patients will
require additional support or services after discharge, which can lead to a delay in that
discharge. This advice is concerned with that minority of patients that do suffer a delay in
their discharge from hospital.
1.1. What do we count as a delayed discharge?
Quite simply, a delayed discharge is a hospital inpatient who is clinically ready for discharge
from inpatient hospital care and who continues to occupy a hospital bed beyond the ready
for discharge date.
A patient who has completed treatment, and is now ready to leave the care of the NHS but
cannot, will be considered as a delayed discharge. Predominately, this will be patients
waiting to return home but in some cases it will be a move to a care home or supported
housing. It may also involve a transfer to an intermediate care facility for short-term
rehabilitative care.
Inter-hospital moves to continue treatment or recovery are not delayed discharges.
It is important to ensure that who and what we count as delayed discharges meets the
public perception. In many cases, we continue to count people who have become ill again
– you cannot be a delayed discharge if you are no longer clinically ready for discharge.
We suggest a simple test be applied – if everything was in place in the community,
could the patient be discharged today? If yes, then they are almost certainly a
delayed discharge, if no then they are very unlikely to be appropriately classified as a
delayed discharge.
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1.2. Why do we count delayed discharges?
The Delayed Discharge Expert Group report states:
“The correct data is the intelligence that partners need to solve the problem”.
The accuracy of the data depends on:
a) Starting the clock at the right time
b) Ensuring the local authority of residence (and the Health Board of residence if
different to that of treatment) is known and informed
c) Knowing and recording the principal reason for delay
d) Keeping this information updated until the actual point of discharge.
There are two key purposes to the collection of delayed discharge information:
- Accurate recording of data in order to manage the timely discharge of patients
- Public reporting of the number of delayed discharges in the system and the bed
days that are associated with these.
The latter is also, of course, vital in terms of the strategic planning of service provision.
Ministers will refer to, and be held to account for, the validated national data. It therefore
needs to be consistent with other data put in the public domain, such as Board reports,
Freedom of Information enquiries and press statements. Wherever possible, such
information provision should refer to the published national data and if not possible, must be
consistent with it.
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1.3. When do we count delayed discharges?
Basically, the clock starts at the first midnight after the patient has been agreed as clinically
ready for discharge. A patient should never be entered as a delayed discharge on TRAK
before the ready for discharge date (RDD).
The ready for discharge date is determined by the consultant/GP responsible for the
inpatient medical care and where a multi-disciplinary team, in consultation with all agencies
involved, agree that the individual’s care needs can be further assessed or properly met
outside a hospital setting.
It is good practice to set an Estimated Date of Discharge date (EDD) and ideally that will be
the same as the RDD.
- However, it should not be assumed these will be the same. If the actual date of
discharge should slip, then the delay period is between the RDD and the actual date of
discharge - the EDD becomes irrelevant.
- Equally, referral to social care should, where possible, be done ahead of actual
readiness for discharge. Again, the delay period starts at the RDD and not the referral
date.
People should only be discharged when they are medically fit and when it is safe and
appropriate to do so. Premature discharge is as bad for the individual as a delay and is
likely to lead to readmission.
It is now the case in some areas, that staff can simply ‘tick’ the ready for discharge box on
TRAK and the patient will be assumed as delayed (although other local processes may be
in place). It has always been that patients classed as delayed discharges are agreed by
both health and social care and not unilaterally. This remains the case, and partnerships
must put in place a simple but effective verification process
While the responsible clinician has ultimate responsibility for the decision to discharge, the
ready for discharge decision must focus on the needs of the individual and on achieving the
best outcome for that individual. The decision must be made through a multi-disciplinary
process in consultation with all agencies involved in planning that patient’s discharge.
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1.4. How do we count delayed discharge?
Information is collected and published by NHS Board of treatment and by local authority of
residence. It is then broken down by delay reason and duration.
The reason codes are split under three broad headings – ‘health and social care reasons’
which account for assessment delays, statutory funding, place availability or care
arrangements, ‘patient/carer/family related reasons’, where there are disagreements (other
than a medical appeal), legal issues or patients exercising right of choice, or ‘code 9
reasons’ where the timely discharge is out with the control of health and/or social care
authorities.
Information is also collected under ‘code 100’ but these are not considered delayed
discharges under the definition.
Further clarity on operational aspects of the recording of delayed discharges is available in
Section 4. The following section provides further advice on specific sections of the Data
Definitions Manual.
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2. DELAY REASONS
Areas are encouraged to use the full range of delay codes, choosing the best fit based on
the main reason for the delay at any given time.
Again, for strategic planning purposes it is vital that partnerships understand the reasons for
delay. If this is place availability, then one of those reasons should be used. However, if the
delay is due to securing funding for a place, then the code should be 23C; if it is patient
choice then code 71 should be used.
ISD and the SG are happy to provide advice, but the final decision must be made locally.
2.1 Assessment codes - 11A/11B
These should only be used for the period of assessment. Once this is complete, the reason
code must be updated to reflect the main reason for delay. Not knowing or agreeing a
reason should not default to codes 11A or 11B.
2.2 Awaiting Dementia Bed - 24F
In the same way that it is important to define whether a care home placement requires
nursing or is just residential, a need for specialist dementia or EMI beds should also be
highlighted using code 24F. This will feed into the national picture of demand for these
services as well as assisting local and regional planning.
2.3 Patient Choice
Not all choice delays are 71X – this should only be used if code 9 criteria is met. If the
person is not delayed due to a code 9 choice issue, then code 71 should be used. This is
still not recorded as a ‘health and social care’ reason.
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2.4 Capacity
The use of Section 13ZA is encouraged where possible and separate advice has issued on
this (https://hscscotland.scot/couch/uploads/file/planning-discharge-from-hospital-adults-with-
incapacity-march-2019.pdf ). However, if it becomes clear the patient lacks capacity code 51X
should be applied (e.g. following the decision of the case conference). If no case
conference is held, then apply the code 51X when the rules and responsibilities have been
set out and discharging using 13ZA has been ruled out.
For 51X cases, a new RDD should be set following completion of the guardianship process
(whether this was successful or not).
2.5 Code 9
Code 9 should be used for three broad categories:
Adults with Incapacity (AWI): to be used when someone is deemed as lacking
capacity, through the guardianship process, and until the end of that process (when
guardianship has been appointed or if the application is dismissed). The code is NOT
for people lacking capacity where section 13ZA can be used. It is for delays for
specific actions under the AWI Act.
Choice: Where an interim placement is not possible or reasonable, usually for
reasons of travel distance and transport difficulties (such as off-island placements or
very rural areas). In these cases it will have been agreed by the multidisciplinary
team that hospital is a better option.
Specialist care availability: where specialist provision is required but that provision
does not exist in the area. The guidance makes clear this is about a facility not
existing within the partnership area. It is not about a lack of availability in a specialist
facility that does exist.
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2.6 Code 100
Code 100 cases are not delayed discharges under the definition. They are patients
receiving appropriate care while they go through a complex and lengthy reprovisioning
exercise, so their discharge is on-going rather than delayed. This reprovisioning process
needs to be subject to an agreed, costed plan with set timescales.
Code 100 was introduced to capture the old ‘reprovisioning/commissioning’ exclusions that
were historically not counted at all. They will likely be longer-term patients, whose needs
have changed such that there is multi-disciplinary agreement that their needs could now be
better met in the community. There is no defined period of what ‘long-term’ might be but the
code should not automatically be assumed for those in hospital for long periods. Each case
should be assessed on its own merit.
It is accepted that commissioning such care can be a lengthy process. However, they
should be coded accordingly as code 100.
Note that code 100 should not be used for people inappropriately in a rehab and
assessment unit for a lengthy period. People with learning disabilities should be recorded
against the code which best describes the circumstances relating to their situation and care
needs at any given time Where this is the case, the guidance for each scenario should be
followed and the ready for discharge date recorded appropriately.
2.7 Mental Health delays
Patients detained under the Mental Health (Care and Treatment) (Scotland) Act 2003, who
cannot be discharged from hospital, should not be classified as delayed discharges.
If however, where there is MDT agreement that it is safe and reasonable for a patient to be
transferred to a more appropriate setting, and meets the criteria for being ready for
discharge, then such patients should be classified as a delayed discharge and coded
accordingly.
The Mental Welfare Commission receives information from the quarterly code 9
narratives & code 100 data for mental health specialties.
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2.8 Learning disability delays
It is essential that all delayed patients are recorded, including those with a learning disability
who may have particularly complex needs. It is possible that these patients will need to go
through a lengthy discharge planning process, involving a range of professionals.
When it has been agreed that a patient with a learning disability no longer requires hospital
treatment, and a ready for discharge date has been set, the patient should be recorded as a
delay and coded appropriately.
Learning disability patients in learning disability services should be considered as a
discharge once:
- the admission treatment objectives have been met
- all agreed specialist assessments have been undertaken (such as speech and
language therapy, occupational therapy, forensic opinion)
- an up to date risk assessment has been provided
- it is agreed that any ongoing assessment or treatment they require could be reasonably
provided within a community setting if an appropriate community setting was available.
Patients delayed awaiting a new placement, should be declared ready for discharge,
even if a specific placement is still to be identified or commissioned/developed.
2.9 Phased discharge
A small number of patients will have an agreed planned discharge date but require a
phased discharge involving trial periods of assessment and rehabilitation at home, with an
agreed planned discharge date and discharge plan.
These patients are not yet fully ready for discharge from hospital so should not be classified
as a delayed discharge. If there is no planned discharge date, discharge plan and agreed
discharge destination then such patients should still be recorded and an appropriate code
applied.
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2.10 Appeals
A patient has the right to appeal the medical decision to discharge by seeking a second
medical opinion which should be documented.
While this appeal is carried out (which should be done as fully but speedily as possible) the
patient should remain in hospital and is not considered to be ready for discharge (and
therefore not recorded as a delayed discharge).
Once the appeal has been concluded, the patient should either remain in hospital as an in-
patient (if the appeal is upheld) or discharged without delay (if the appeal is unsuccessful).
If this immediate discharge is not possible (and the patient is delayed past the next
midnight) then the patient is classed as a delayed discharge and recorded accordingly with
the RDD being the date the appeal concluded.
2.11 Change in patient circumstances
Should a patient become unwell after being declared ready for discharge, they should not
be recorded as a delay.
In terms of the level of ‘sickness’ that would decide whether a person was no longer ready
for discharge, it was agreed that this would be that the patient is so ill they must remain in
hospital. If an individual can be discharged safely to a more appropriate setting then they
should do so.
A ‘3-day rule’ was introduced previously (section 2.7, DM) to ease the burden of removing /
adding unwell patients on EDISON. This rule allowed people not fit for discharge to retain
their original RDD if their period of illness was 3 days or less. However, the definitions
manual states this is only applicable IF local systems cannot operate real-time recording.
With the move to TRAK, most areas should no longer need to apply this rule, and patients
should be added and removed accordingly, dependent of their health needs
Patients no longer fit for discharge should be recorded with the date they became unfit for
discharge and a discharge reason of 05 (Not fit for discharge) applied (see section 6.13 in
NDR). When the person is fit to be discharged again, a new delay episode should be
created.
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3. INTERMEDIATE CARE
3.1. What is Intermediate Care?
“Maximising Recovery, Promoting Independence’’: An Intermediate Care Framework for
Scotland describes intermediate care as a continuum of integrated community services for
assessment, treatment, rehabilitation and support for older people and adults with long term
conditions at times of transition in their health and support needs. These services offer
alternatives to emergency inpatient care, support timely discharge from hospital, promote
recovery and return to independence, and prevent premature admission to long-term
residential care. http://www.gov.scot/Publications/2012/07/1181
The National Audit of Intermediate Care describes Intermediate Care as follows: Intermediate care services are provided to patients, usually older people, after leaving hospital or when they
are at risk of being sent to hospital. The services offer a link between places such as hospitals and people’s
homes, and between different areas of the health and social care system – community services, hospitals,
GPs and social care. https://www.nhsbenchmarking.nhs.uk/naic/
3.2. What is Bed Based Intermediate Care?
Intermediate Care beds provide a time-limited episode of intermediate care commissioned
and supported by Integration Authorities and provided within a care home, housing with
care, or in a discrete step-down facility within a hospital site.
Step up-beds - admitted from home for assessment and rehabilitation as an alternative
to acute hospital admission
Step-down beds - transfer from acute hospital for further period of assessment and
rehabilitation.
3.3. What is NOT Bed Based Intermediate Care?
Intermediate Care beds are not:
Transitional care that does not involve active therapy or other interventions to maximize
independence, i.e. patients who are ready for discharge and are simply waiting for
longer-term care packages to be arranged.
Longer term rehabilitation or support services.
Rehabilitation that forms part of acute hospital care. However, these patients should
not be classed as delays, as they are receiving on-going treatment.
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3.4. Intermediate Care and Delayed Discharges
Intermediate care is a re-abling, rehabilitative, recovery process with a view to returning the
patient home.
What is the difference between intermediate care bed and a rehab bed?
The simple answer is probably not very much, albeit a hospital rehab ward is unlikely to
have the whole range of MDT support.
Someone receiving rehab will not be a delayed discharge wherever they are as they are still
getting treatment.
Reason code 27A should be used when the person is awaiting availability in an
intermediate care facility.
A person is not a delayed discharge if they are receiving Intermediate Care and
then wait for another service.
It has been suggested all community hospital beds are intermediate care – this is not the
case. Community hospitals will provide a range of diagnostics and treatments, many will
provide surgical procedures.
It is not the intention to reclassify beds, wards or facilities as intermediate care and then
merely move people to wait for another service.
For the purposes of delayed discharge recording, intermediate care beds are
deemed as being in the community. They cannot be in an acute hospital.
Step up-beds -admitted from home for assessment and reablement as an alternative to acute hospital admission.
Transitional care that does not involve active therapy or other interventions to maximize independence, i.e. patients who are ready for discharge and are simply waiting for longer-term care packages to be arranged.
Longer term rehabilitation or support services.
Rehabilitation that forms part of acute hospital care. However, these patients
are not classed as delays, as they are receiving on-going treatment.
Step-down beds - transfer from acute hospital for further period of assessment and reablement.
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4. OPERATIONAL PROCESSES
4.1 Using TRAK to record delays
Operational verification of patients delayed is essential.
Oversight of use by ward staff indicating a person is ready for discharge – this is a multi
disciplinary decision.
Data ‘sense’ check prior to submission of nationally required information is essential
Delayed Discharge Date / Delayed Discharge Reason refers to the date/reason the
delay episode ended, and are distinct from those used on TRAK.
4.2 Out of area delays
The Health & Social Care Partnership of residence MUST be notified of a delayed
patient. This does not happen automatically via TRAK.
4.3 Hospital transfers within the same Health board
If a patient is transferred to another hospital during their delay, the original admission
date should be submitted.
Note that inter-hospital transfers should not be classified as delayed discharges.
4.4 Hospital transfers between Health boards
If a delayed discharge patient is transferred to a hospital in another health board, the
original delay episode should have a discharge reason and date added.
The receiving health board should record a new delay episode, with the date of
admission to their care, and a revised ready for discharge date, according to their
assessment of the patient.
This will avoid the receiving health board being held accountable for delayed bed days
occurring elsewhere.
4.5 Verification of information
All data submitted to ISD on a monthly basis should be verified prior to submission.
Details of the data quality checks undertaken by ISD are available: https://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-
Discharges/Guidelines/docs/Delayed-Discharge-Data-Quality-Checks-v1.0-April-2019.pdf
4.6 RDD date changes
The ready for discharge date should only be reset in the following scenarios:
Patient is unfit for discharge, and fit again at a later date
Guardianship process completed (51X) or no longer required (eg use of Section 13ZA).
! For the national monthly data submission ISD would expect to see 2 rows of data
per patient in these cases.
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5. OUTPUTS
5.1 Published information
ISD published monthly and annual delayed discharge information which can be found:
http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Delayed-
Discharges/
5.2 Freedom of Information requests (FOIs)
Media reaction to FOI responses, highlight the importance of accurate information,
as Ministers will be approached for political justification.
Refer to published data where possible.
ISD / SG can offer general advice, but not respond on behalf of Boards/Partnerships
6. CONTACTS
6.1 ISD
For queries regarding the national data set and definitions, please contact:
Lisa Reedie
Principal Information Analyst
NHS National Services Scotland
Information Services Division (ISD)
Phone: 0131 275 6117
Email: [email protected]
6.2 Scottish Government Policy Lead
For queries regarding policy, please contact:
Brian Slater
Delayed Discharge Policy Manager
Scottish Government
Phone: 0131 244 3635
Email: [email protected]