Synopsis
Coordinate medical recovery, mobility, daily function, medicines, equipment and community support around patient-defined goals so discharge is timely, safe and continues rehabilitation rather than ending it.
- Begin discharge planning at admission by recording baseline residence, mobility, cognition, self-care, carers, stairs, equipment and what outcome matters to the patient.
- Set specific goals across medical stability, transfers, walking, stairs, washing, dressing, toileting, nutrition, cognition, pain, wound and self-management.
- The team needs shared information: surgeon defines structural and weight-bearing limits; physician manages physiology; therapists test function and environment; nursing observes twenty-four-hour performance; pharmacy reconciles medicines; social care and community services deliver support.
- After hip fracture, offer physiotherapy assessment and mobilisation on the day after surgery unless contraindicated, then mobilisation at least daily with regular review.
- Early supported discharge after hip fracture is appropriate only when medically stable, mentally able to participate, able to transfer and mobilise short distances and still able to benefit, with the Hip Fracture Programme team remaining involved.
- First-line discharge decision tests real tasks with the prescribed aid and weight-bearing status; bed exercises or one corridor walk cannot prove home safety.
- Complete medicines reconciliation, VTE course, analgesia and bowel plan, wound and suture care, equipment, transport, contact numbers and booked follow-up before transfer.
- Use teach-back and an accessible written plan that states restrictions, warning symptoms, who to contact and which team owns each next action.
Key red flags
New chest pain, hypoxia, syncope, tachycardia or unilateral leg swelling during rehabilitation requires urgent cardiopulmonary and VTE assessment.
Fever, wound drainage, spreading erythema, escalating joint pain or sudden inability to bear weight suggests infection, dislocation or fixation failure.
Acute fluctuating attention, withdrawal or agitation requires delirium assessment and cause treatment before judging rehabilitation potential.
New focal weakness, speech change, severe headache or loss of coordination requires an acute neurological pathway.
An unsafe home, absent essential care, coercion, neglect or inability to access food and medicines creates a safeguarding and discharge barrier.
Discharge without a reconciled high-risk medicine, anticoagulant stop date or opioid plan can cause preventable bleeding, withdrawal, toxicity or readmission.
Investigation priorities
Measure transfers, walking, stairs, balance, cognition and daily activities against the destination's actual demands.
Management branches
An orthopaedic patient enters acute care with likely rehabilitation needs.
- Record pre-event residence, mobility, cognition, self-care, carers, environment and personally important goals.
- Identify anticipated structural restrictions, medical risks and likely equipment or community-service needs.
- Set shared measurable goals and begin referrals early rather than after the discharge date is chosen.
- Nominate a coordinator and update the patient and carers in an accessible format.