From Ward to Home: A Nurse-Led Guide to Safe Hospital Discharge for Complex Patients

Bringing a loved one home from hospital is emotional. When their needs are complex – ventilator support, a tracheostomy, PEG feeding, spinal or brain injury, advanced neurological disease – it can also feel frightening.

With the right plan and the right team, home can still be the safest and most dignified place. This nurse-led guide explains how to plan a safe hospital discharge for complex patients.

What do we mean by “complex”?

Healthcare professionals use “complex” for people who may have:

• Ventilation or a tracheostomy

• PEG / PEJ / NG feeding

• Serious heart or lung disease

• Spinal cord or brain injury, advanced MS, Parkinson’s or stroke

• Multiple conditions and medicines that interact

• High risk of sudden deterioration

These needs don’t automatically mean a care home. But they do mean discharge must be well coordinated.

1. Join the discharge planning process early

Don’t wait to be told, “You’re going home next week.” Ask the ward team:

• Who is the discharge coordinator?

• When will there be a discharge planning meeting?

• Which professionals will attend?

  • Ward doctor and nurse

  • Discharge coordinator

  • Therapists

  • Community / ICB / CHC nurse

  • (Ideally) a complex care provider such as Aeon Nursing

Take a notebook and ask:

• “What are the biggest risks if we go home?”

• “What support are you assuming will be in place?”

• “What would make you confident this discharge is safe?”

Aeon Nursing can join or advise on discharge planning meetings to make sure the right questions are asked.

2. Clarify medications and clinical tasks at home

Before you go home, you should understand:

Medications

• Names, doses, timings and what each medicine is for

• Which drugs are time-critical

• What to do if a dose is missed or thrown up

Clinical tasks

• Observations (blood pressure, pulse, oxygen saturations, respirations, blood sugars)

• Procedures (suctioning, tracheostomy care, PEG feeds, catheter care, repositioning)

For each task, ask:

• Who will do this at home – family, nurse or trained carer?

• What training will be given before discharge?

• What written instructions and charts will we take home?

A nurse-led complex care provider like Aeon Nursing builds all of this into a clear care plan and trains staff and families properly.

3. Check equipment is ordered, delivered and installed

For complex care at home, the right equipment is essential. Typical items include:

• Hospital bed and pressure-relieving mattress

• Hoists and slings

• Wheelchair and seating

• Suction machine, oxygen, ventilator

• Feeding pump and giving sets

• Catheters, dressings, syringes, gloves and other consumables

You should know before discharge:

• What has been ordered and by whom

• When it will arrive and who will install it

• Where it will go in the house – including safe access and power sockets

If a key item isn’t ready, it is reasonable to say:

“We don’t feel safe going home until this equipment is in place.”

4. Agree a written care plan and escalation plan

A safe discharge for a complex patient must include:

A nurse-led care plan that covers:

• Diagnoses and key risks

• Day and night routines

• Medications and clinical tasks

• Equipment in use

• Manual handling and falls plans

An escalation plan that explains:

• Red-flag symptoms to look out for

• Who to call first if you’re worried (care provider, community nurse, GP)

• When to call 999

• What information to have ready (observations, recent changes, medicines)

At Aeon Nursing, every complex care package includes a detailed care plan and clear escalation pathway, with 24/7 clinical support.

5. Talk honestly about family wellbeing

Discharge planning often focuses only on the patient. Your wellbeing matters too.

It’s normal to feel:

• Relieved to be leaving hospital

• Scared of “getting it wrong”

• Guilty if you can’t do everything yourself

• Exhausted and overwhelmed

Be clear about your limits:

• “We need night support – we can’t stay awake 24 hours.”

• “We need regular respite so we can keep going long term.”

• “We want time to be family, not just carers.”

Any complex care provider should treat family resilience as part of the care plan.

How Aeon Nursing supports safe hospital discharge

As a doctor- and nurse-led complex care provider, Aeon Nursing can:

• Join or support hospital discharge planning

• Carry out a detailed pre-discharge assessment

• Design a nurse-led care package tailored to your relative

• Work with NHS teams and funders, including CHC and ICBs

• Offer intensive support in the first days and weeks at home

You don’t have to navigate discharge alone.

Next steps

• Download our Hospital to Home Discharge Checklist to use in your meetings

• Contact Aeon Nursing for a free, no-obligation conversation about your discharge plan

Important information

This article is for general guidance only and is not a substitute for medical advice. All care provided by Aeon Nursing is subject to clinical assessment, risk assessment and service availability in your area. Information about NHS Continuing Healthcare and other funding is general and may change; decisions are made by NHS bodies, not Aeon Nursing. Our downloadable checklist is a planning aid and does not create any contract for care.

Author & Content Writer: Dr Naeem Aslam