Discharge planning in Saudi Arabia following limb injury

Aim The aim of this study is to explore the adequacy and appropriateness of approaches to discharge planning for patients with non-major limb injury (NMLI) in Saudi Arabia (SA) hospitals, and identify factors that could lower the number of patients making unplanned returns to Emergency Departments (ED), exploring how they fit together in a system, to determine which models or systems or philosophies fit well with the Saudi context. Background Trauma is the leading cause of morbidity, mortality and long term disability in SA and is associated with the highest number of hospitalizations, ED presentations and out-patient visits. Patients with NMLI in particular may be unable to stand or walk or complete other activities of daily living (ADLs) independently, when discharged. One of the most important outcomes of discharge planning for those with limb injury is the patient’s access to adequate and appropriate information as a resource for making health related decisions. Research indicates that one possible pathway to a discharge without adverse events would be through systematic and evidence-based practice of the discharge process. Design A mixed method sequential explanatory design was utilized for the study. In Phase One, a convenience sample of 302 participants with NMLI were invited to complete an anonymous questionnaire when they presented to EDs and Out Patients Departments (OPD) in four SA hospitals. Phase Two involved face-to-face semi-structured interviews with 10 Orthopedic nurses at the same participating hospitals. Results The most common cause of limb injury in this study was falls (n= 139) 46% followed by pedestrians injured during Road Traffic Accidents (RTA) (n=78) 25.8%. Almost half (n=139) 46% of participants had unplanned returns to ED. The causes behind returning vary; however, cast complications (n= 105) 34.5% and pain (n= 24) 8% were the most common causes for those patients re-presenting. Frequencies increased as age increased, and decreased as discharge preparation increased (P < 0.001). A similar pattern was observed between clarity of instructions and unplanned ED return. Patients who received verbal instructions in their primary language and from nurses and doctors (multidisciplinary team) rated the discharge preparation significantly higher compared to the other types of instructions (P < 0.001). those with lower limb injury and the elderly have less self-care ability compared to young and those with upper limb injury, which was not surprising. Nurses in Phase Two reported navigating patients through the discharge process, providing them with follow up appointments and discharge needs for home through an often complicated process of separate discharge from different specialists and care providers. Instructions were typically given both in writing and verbally, and the following discharge instructions were problematic causing complications and return visitation. However, this can be avoided with clear instructions. Patient’s misinterpretation of fatalism, the failure to use reasoning and escape responsibility results in putting their life in danger. Conclusion This study is likely to inform a new understanding of discharge planning arising from the experiences of the participant nurses and patients. The integration results together enabled the forming a model to describe the factors that were felt by participants to positively impact patient discharge outcomes.