When is a patient discharged from hospital? The Brass index and scale

Brass index and scale in hospital discharge: the discharge of a patient from hospital to the territory, to the home, to other facilities, but also in the transition from one ward to another represents a critical step in the pathway of any person

Preparing the patient for discharge is therefore a caring responsibility, as well as a right of the patient and his or her family, who must be involved and accompanied throughout the care pathway.

The contexts of hospitalisation and home care are so different that they result in huge differences in the assessment carried out.

One of the biggest problems that emerges in hospital/territory communication with regard to protected discharges, and therefore to continuity of care, is precisely linked to this aspect of difficulty in grasping the entire complexity of the person, during and after the illness event.


Discharge planning is a care intervention aimed at ensuring continuity of care; it consists of a series of steps in which the person’s problems should be analysed one by one.

To do this, it is possible to use an assessment tool, the BRASS index (Blaylock Risk Assessment Screening) (Blaylock and Cason, 1992), which can be adopted from the moment of admission to the ward and which makes it possible to identify patients at risk of prolonged hospitalisation or difficult discharge.


The BRASS index was developed as a discharge planning tool especially for patients over 65 years of age.

The authors (Blaylock and Cason, 1992) in their review of the literature, and their experience in geriatrics and gerontology care, identified the following factors:

  • age, functional status,
  • cognitive status,
  • social support and living conditions,
  • number of previous hospitalisations/accesses to emergency rooms
  • number of active clinical problems.

They also included: behavioural pattern, mobility, sensory deficits and number of medications taken because, although these are not elements of functional or cognitive status, they are relevant for the elderly.

The BRASS index is an instrument used to identify patients at risk of prolonged hospitalisation or difficult discharge

Data are collected by filling in the scale, interviewing relatives or carers. The BRASS index investigates 10 dimensions (mentioned above):

  • age
  • living situation
  • social support
  • functional status
  • cognitive status
  • behavioural pattern
  • sensory deficits
  • previous admissions/accesses to the emergency room
  • active clinical problems
  • number of medications taken.

Scoring on the Brass scale :

The assessment is made on the basis of information provided by a family member or person who knows the patient well.

Three risk classes are identified: low (0-10) medium (11-19) high (20-40).

Duration: the scale is simple, quick (about 15 minutes) and requires minimal training.

Limitations of the Brass Index

The BRASS index is easy to compile and provides good indications for predictive validity (specificity) with regard to patient discharge problems: high-risk patients are frequently not discharged home (Mistiaen et al., 1999).

However, the studies carried out (Mistiaen et al., 1999; Chaboyer et al., 2002) show that the index is not very sensitive in identifying those patients who could present problems after discharge, probably because, by carrying out the survey at the time of hospital admission, those elderly people who worsen their condition due to hospitalisation, especially if it is prolonged, are not correctly identified.

The BRASS, administered as part of the hospital admission assessment, makes it possible to identify those who are at risk of prolonged hospitalisation and difficult discharge: in particular, those patients who will need the activation of services (or care resources, including family care) for out-of-hospital care.

Nurses can use the information BRASS provides to plan educational interventions to be implemented during hospitalisation and home care programmes.

Further studies on its application are necessary in order to better specify risk levels, as the balance between specificity and sensitivity can be achieved by choosing different cut-off levels in the index score (Mistiaen et al., 1999).

The critical aspects highlighted can be limited by repeated evaluations during hospitalisation, especially if prolonged, precisely because the elderly can change their functional status during hospitalisation because ‘evaluation, especially if rigorous – even when it seems difficult or hopeless – is a guarantee of respect for each individual person and an indication of optimism about the elderly person’s potential and their chances of responding meaningfully to a care project (Trabucchi, 2003)’.

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