Participant characteristics.

Hospital discharge is a pivotal point in healthcare delivery, impacting patient outcomes and resource utilisation. Ineffective discharge processes contribute to unplanned hospital readmissions. This study explored hospital discharge process from the perspectives of patients, caregivers, and healthcare staff. Qualitative data were collected through semi-structured interviews with adult patients being discharged home from a medical ward, their caregivers, and healthcare staff at an Australian hospital. Thematic analysis followed established guidelines for qualitative research. A total of 65 interviews and 21 structured observations were completed. There were three themes: i) Communication, ii) System Pressure, and iii) Continuing Care. The theme ‘Communication’ highlighted challenges and inconsistencies in notifying patients, caregivers, and staff about discharge plans, leading to patient stress and frustration. Information overload during discharge hindered patient comprehension and satisfaction. Staff identified communication gaps between teams, resulting in uncertainty regarding discharge logistics. The theme ‘System Pressure’ referred to pressure to discharge patients quickly to free hospital capacity occasionally, even in the face of inadequate service provision on weekends and out-of-hours. The ‘Continuing Care’ theme drew attention to gaps in patient understanding of follow-up appointments, underscoring the need for clearer post-discharge instructions. The lack of structured systems for tracking referrals and post-discharge care coordination was also highlighted, potentially leading to fragmented care. The findings resonate with international literature and the current emphasis in Australia on improving communication during care transitions. Furthermore, the study highlights the tension between patient-centred care and health service pressure for bed availability, resulting in perceptions of premature discharges and unplanned readmissions. It underscores the need for strengthening community-based support and systems for tracking referrals to improve care continuity. These findings have implications for patient experience and safety and suggest the need for targeted interventions to optimise the discharge process.

医院出院（hospital discharge）是医疗服务供给中的关键节点，对患者结局与资源利用效率均产生重要影响。低效的出院流程会导致非计划性医院再入院。本研究从患者、照顾者与医护人员的视角出发，对医院出院流程展开探究。研究通过半结构化访谈（semi-structured interview），收集了澳大利亚某医院内科病房出院回家的成年患者、其照顾者以及医护人员的定性数据，并采用遵循定性研究既定规范的主题分析法（thematic analysis）开展分析。最终共完成65次访谈与21次结构化观察。研究共提炼出三大主题：① 沟通（Communication）、② 系统压力（System Pressure）与③ 延续性照护（Continuing Care）。“沟通”主题揭示了在告知患者、照顾者及医护人员出院计划时存在的挑战与不一致性，进而引发患者的焦虑与挫败感；出院阶段的信息过载会阻碍患者对信息的理解，并降低其满意度；医护人员同时指出团队间存在沟通缺口，导致出院后勤工作存在不确定性。“系统压力”主题指的是，即便在周末及非工作时段服务供给不足的情况下，仍时常存在快速安排患者出院以腾出医院床位的压力。“延续性照护”主题关注到患者对随访预约的认知存在缺口，凸显了制定更清晰出院后指导方案的必要性；研究同时指出，缺乏用于追踪转诊及出院后照护协调的结构化系统，可能会造成照护碎片化。本研究结果与国际相关文献以及澳大利亚当前对改善照护过渡阶段沟通的重视程度相契合。此外，本研究揭示了以患者为中心的照护与医疗服务机构为保障床位可用而承受的压力之间的矛盾，这一矛盾使得患者认为出院时机过早，并最终导致非计划性再入院。研究强调，需强化社区支持体系与转诊追踪系统，以提升照护的连续性。本研究结果对患者体验与患者安全均具有参考价值，同时表明需开展针对性干预措施以优化出院流程。