Transformation Directorate

Rapid improvement guide to expected date of discharge and clinical criteria for discharge

Expected date of discharge (EDD) and clinical criteria for discharge (CCD) are essential care co-ordination tools mandated by:

  • The Royal College of Physicians
  • The Royal College of Surgeons
  • The Enhanced Recovery Programme
  • The Keogh Review
  • The Seven Day Programme

EDD and CCD must be clearly defined and used consistently if they are to be effective. They should be set using simple rules as part of clearly constructed clinical case management plans.

Their aim is to align the whole multidisciplinary team to specific objectives for every inpatient stay. EDD and CCD help identify and flush out constraints or waits (both internal and external), and then their proactive management helps reduce length of stay.

The process

Clinical criteria for discharge

  1. The CCD is the minimum physiological, therapeutic and functional status the patient needs to achieve before discharge. They should be agreed with the patient and carers where necessary.
  2. The CCD should never be described as ‘back to baseline’. For example, the British Thoracic Society (BTS)/ Scottish Intercollegiate Guidelines Network (SIGN) guidance 2014 states that no one physiological parameter defines when a patient should be discharged. A patient admitted with acute severe asthma but who normally runs a peak expiratory flow rate (PEFR) of 90–95% may not need to achieve this level at the point of discharge, but does need to achieve a PEFR >75% with <25% variability due to their higher risk of relapse.
  3. For patients with frailty or impaired activities of daily living, the CCD should include functional factors. For example, a patient with dementia and reduced mobility who has a normal exercise tolerance of 25 yards may well be fit for discharge if they are mobile with a frame, their toilet is only five yards from their bedroom and they have the supervision of one person for this distance. It is important to anticipate that patients will continue to recover at home with or without support.
  4. For a proportion of patients, the CCD can be used to trigger discharge if this is agreed with the patient and well communicated across the team. For other patients, the CCD are a guide, and sign off for discharge by a senior clinician may still be required.
  5. The CCD can be a short list of objectives. They should be kept to maintain team focus.

Expected date of discharge

  1. The patient’s EDD should be set at the first consultant review and no later than the first consultant post-take ward round the next morning. If a patient is to be transferred to a ward-based specialty team, then the EDD and CCD should be set by the team who will be responsible for their discharge. Crucially, the sooner the patient is identified as in need of sub-specialty care and that sub-specialty team reviews and sets the EDD and CCD, the sooner their care will be progressed.
  2. For patients with an expected length of stay of two days or less, an expected time of discharge should be set.
  3. It is important to assume an ideal recovery pathway, one unaffected by internal or external waits, when setting a patient’s EDD. If it is set based on anticipated waits and delays in the system (eg waits for clinical decisions, diagnostics, inter-specialty referrals and social care decisions), then these waits become hidden and thus will not be resolved.
  4. The EDD and CCD are clinical, not managerial, tools. Together with a comprehensive clinical care and discharge management plan, they describe the objective for a patient’s admission. They can be used to co-ordinate care and minimise unnecessary waits in the patient’s journey. The system’s managerial capacity should focus on tackling unnecessary waits to support the clinical team. In most circumstances, waits within the acute hospital cause the most delays.
  5. If a patient’s stay goes beyond their EDD, best practice is to highlight this as EDD +1, +2, etc and identify what is causing the delay (eg delays in critical inter-specialty referral responses).
  6. The use of Red/Green bed days at board rounds and the implementation of the SAFER patient flow bundle help teams identify and manage constraints on delivering EDDs.