A discharge delay is when a patient remains in hospital beyond the date agreed by the multidisciplinary team and beyond the time when they are medically fit to be discharged. Occasionally the discharge process may not proceed as planned; a discharge may be delayed for a number of reasons and a system should be in place to record this. For every patient who is ‘delayed’, NHS trusts are required to report the delay to their commissioners. It is the responsibility of the health authorities, in collaboration with local authorities, to monitor and address any issues that result in delays in the transfer of patients from an acute bed to their home or a community bed, such as a care home bed or rehabilitation bed. Trusts closely monitor bed activity and reporting varies from weekly to daily in the winter months.

Patients may take their own discharge against medical advice and this should be documented accordingly using the hospital's appropriate form (Box 3.2). When patients are assessed as requiring care or equipment but decline these, this does not negate the nurse's duty to ensure a discharge is safe. A discussion should take place with the patient, and their carer if applicable, to assess how they intend to manage without the required care and/or equipment in place. It is crucial that the appropriate community services are made aware of assessed needs that are not being met through patient choice or lack of resources. It is critical that the community teams who will be supporting the patient when they return home are notified; where possible, this should be in writing, enclosing a copy of any form documenting discharge against medical advice.

Premature discharge or discharging the patient to an environment that does not meet their needs may result in them being readmitted to hospital (Alper et al. [2]). Evidence demonstrates that tailored discharge planning can reduce readmission rates and length of stay but that a significant proportion of patients return to hospital within a month due to complications or unplanned care (Teodorczuk [48]). Readmissions are costly and put patients at a higher risk of acquiring infections, of medication errors and of deconditioning, and their impact is therefore negative for both patients’ quality of life and the healthcare system (Sheridan et al. [47]). Addressing readmissions by ensuring patients have well‐planned and co‐ordinated discharge is therefore essential.

The elderly are particularly at risk of readmission following discharge (Lees‐Deutsch [23]). Research commissioned by the Royal Voluntary Service ([46]) estimated that people aged 75 and older are more than twice as likely as those younger to be readmitted to hospital, if they are not given enough support on discharge. This is particularly true for those who live alone or have long‐term healthcare needs. Patients with dementia similarly have higher readmission rates possibly due to the fact that they are less likely to benefit from discharge education, self‐care instructions or to report symptoms (Teodorczuk [48]). NICE ([37]) guidelines consider referral back to relevant community‐based care practitioners and a call or visit from a community‐based nurse or GP within 72 hours of discharge to mitigate the possibility of readmission for those at high risk. It is essential that nurses understand the negative impact of readmission in order to ensure timely and safe discharge with maximum continuity of care.