Implementing systems for dynamic discharge practice (simple discharge)

1. Implementing systems for dynamic discharge practice (simple discharge) Liz Lees Consultant Nurse (Acute Medicine) Liz.lees@heartofengland.nhs.uk

2. Today's presentation • Defining a simple discharge • CNST requirements • Local Interpretation: measurement • Estimating dates for discharge • Discharge training and accreditation • Changing culture and thinking on the shop floor • 3 Case studies • Tips for sustaining progress.

3. Defining a simple discharge • Department of Health discharge 'toolkit' (2004) defines simple discharges as those patients who will usually be discharged to their own homes and have simple ongoing care needs which do not require complex planning and delivery • Make up at least 80% of all discharges and are the norm in patients where a self-limiting condition has responded to treatment. Defining principles: • Has a ‘clear’ and often linear process • Co-ordinated and ‘owned’ at ward MDT level • LEAN principles and delegation (transport) • Patient choice involvement (time of discharge) • Up to 7 components in the process (Simple bundle)

4. Discharge bundle concept (7 + 7) • Decision (+/-) • Patient informed/involved in planning • Time of discharge agreed • Clothes • GP letter • Transport arranged (by patient or staff) • Medications (or advice) 1. (+/-) Sick notes (Schemes Employer/BHF/BUPA) 2. (+/-) Dressings 3. (+/-) Investigations as Outpatient 4. (+/-) Follow up as Outpatient (referral to specialist) 5. (+/-) Simple items of equipment (nebulisers, mobility aids) 6. (+/-) Mobility and site assessments (stair assessments/ walking aids - Crutches) 7. (+/-) Re-start of existing care services/arrangements The specialist v complex discharge debate (+/-) Lifestyle changes (Management of; Insulin, Oxygen, Stoma) My view – if it is your core business in your area – it is NOT complex

5. The pace of simple discharges Theory of car racing Faster the pace, the further ahead you need to look Activities Theory of constraints Speed of process, speed of slowest step Hours Days 1 2 3 4 5

6. National policy requirements Achieving timely, simple discharge from Hospital (Dh, 2004) Implementing processes to encourage patient involvement, patient choice, patient information, nurse facilitated discharge and embed systems for estimated dates of discharge……… Recipe for care not a single ingredient (Dh, 2006) Using intermediate care facilities to promote faster recovery from illness, while reducing unnecessary admissions, supporting timely simple discharge and maximising independence…..

7. CNST and Trust standard CNST: • Unified set of records with evidence of a discharge plan, • named person responsible for discharge • Clear audit trail of discharge (discharge checklist) Trust standard:estimated date of discharge Measures: • a completed discharge checklist (in notes) • patient information (evidenced from PAS) • evidence of patient involvement (ask patient) • Documented plan (in notes)

8. Estimating dates for discharge Review: • Individual systems: above beds – abstain • lack of understanding • Study: Lees, L., Holmes, K., (2005) Estimating a date of discharge at ward level: a pilot study, Vol. 19, No. 17, pp 40 – 43. Nursing Standard. www.nursing-standard.co.uk • EDD what does it really mean for patients • Proformas

9. The Front of the Notes

10. Facilitating Discharge • Post Admission (Acute Medical Unit) • Post take WR standardised proforma • Nurses attending post take WR • Standardised Discharge Criteria e.g. Community Acquired Pneumonia, BTS 2004

11. The White Board

13. Current situation (2008) • Centralised system ward consensus – Disparity from degree of variability between different practitioners entering a date. • Not about a date - Length of stay, activities and commitment to dates • Initiating process and reviewing progress • Good nursing handovers • Excellent communication • Research underway: Abstract / Empirical continuum • Paternalistic model Most of all what do you want it to achieve?!

14. EDD – back to basics “to introduce a simple sustainable process, that every one would understand their contribution and participate in” EDD process Management plan With patient Ward round Bed management Nurse handovers Ward maps

15. Discharge training Top 5 Training needs- For all wards • Starting from where staff are at • Training needs analysis • Induction • Study day • Pre, post and masters level module – discharge planning (Birmingham City University) • E-learning • Discharge competency framework (Dh, 2004)

16. Discharge training needs analysis tool

17. Levels of competency(framework in toolkit, Dh, 2004) • Advanced practitioners (Expert)

18. Case study 1 Not simple, not complex Incomprehensible!

19. On Presentation • 74 yr old male • Ref: District nurses to A&E • PC: Constipation • PMH: Dementia, Alcohol abuse, Diabetic, leg ulcers, poor vision. • SH: large multi-agency care package, DN involved • 48 hour stay on admissions ward, enemas • Discharge instructions – home with Senna What happened next?

20. Active discharge phase • Staff arranged transfer by 2 man ambulance • Nurses organised TTO (cupboard on ward) • Doctor wrote discharge letter. • Ambulance staff arrived What happened next?

21. Active discharge phase • Ambulance collected him from ward (18:00) • Call from carers at 21:00 (put to bed service) He is not at home What happened next?

22. Salvage operation • Nurse phones ambulance service and established patient had been safely dropped off….. Bit worried but thinks carers must have got it wrong….. Nothing documented in notes • What happened next? • At 22:00 call to ward: carers at a Nursing home had been putting residents to bed and noticed they had a new (extra) resident….. But no bed….. He was quite content and had enjoyed a good supper! • Nurses note address is 2 doors away from his home….. And she phones carers • What happened next? • By now carers have gone home, so he is brought back to A&E, where he spent the night and following morning before services could be recommenced

23. What could we improve? • Follow a transparent discharge process • Clear on who is involved in patients care • Communicate the plan • Involve carers • Use discharge checklist (again) • Try a follow up call • Discharge education at ward level

24. Case study 2 Simple discharge??

25. OnPresentation • 76 yr old female, by ambulance • Ref: Emergency GP referral • Imp: Urinary tract infection • PMH: Hip replacement (96), depression • SH: Lives alone, Cat, None smoker, Daughter ---------------------------------------------- • Req: Urine dipstick, chest x-ray, bloods, ECG • Decision: After 3 hours medically fit for discharge What happened next?

26. Active discharge phase • Nurses arranged discharge • s/w family (daughter, by phone) • Ordered medications • Waited for GP letter • Arranged transport (external taxi) ------------------------------------------ What happened next?

27. And there is more! • Taxi arrived at emergency dept • Another nurse (not involved in care) discharged patient • An hour later daughter called department ‘mom had not arrived home’ ------------------------------------------- What happened next?

28. Oh dear! • Passers by had noticed lady could not cross road and appeared lost • Shop keepers contacted the Police • A&E department referred a lady brought into department by Police • Wandering in town centre…….. • Identified by wristband………. • Established facts with Taxi Company and eventually the driver:- • He was not given a full address by his Taxi company • It was common place for him to rely on the patient to know where they lived • “said she had lived in Solihull, but en route changed her mind about where she lived. She asked me to leave her in town, she wanted to do some shopping”

29. What could we have done better? • O/E: missed dementia screening (MMSE = 4/10) • Nurses: assess risk – vulnerable persons policy • Intermediate Care will arrange escort service, via Red Cross • Did we ever ask the daughter to collect?! • Process: Discharge checklist (address) • Ensure responsibility and named person discharging patient • The usual:- documentation!

30. Case study 3 So near and yet, so far.

31. OnPresentation • 41yr old male, by ambulance • Ref: Self referral to A&E • PC: Painful bruised toes – both feet • Imp: Cellulitis and Sepsis • PMH: Alcohol abuse, Depression. • SH: No fixed abode ---------------------------------------------- • Req: Bloods & cultures, CXR, Swabs, ECG • In-patient stay: 2 weeks (surgery amputation, IV Abx, dressings, Physio • Plan: transfer to Intermediate Care What happened next?

32. Active discharge phase • Nurses arranged intermediate care assessment • Accepted for I/C and paperwork completed • Ordered transfer medications • Notified Social workers • Arranged Hospital transport (internal ambulance) ------------------------------------------ What happened next?

33. A catalogue of disasters • He waited patiently for the ambulance • By 6pm (5 hours after assessment) • Told by Bed Co-ordinator “he can’t go today” • Senior Sister – why?!.... (1) The weather had been particularly bad that day….I’m afraid the doors have blown off the ambulance…. (that day a total of 3 patients were not able to be transferred). He was eventually transferred at 10pm by WMAS. (2) The service refused to take his Zimmer frame and he was unable to mobilise. This was eventually delivered by Taxi. (3) The next day he was found not have any dressings or transfer of care instructions for the wound…. He was also found to need IV antibiotics…..(not detected as Cannulae had been removed ……to be replaced) A combination of situations meant he was transferred back to the AMU. (4) In the middle of a chaotically busy shift the Nurse could not locate the man – he was presumed to have self discharged from the department

34. What could we have done better? • Bad luck with transport (& weather) • Assessment: communicating the whole plan • Process: Discharge checklist (dressings) • Ensure responsibility and named person discharging patient • The usual:- documentation!

35. Top tips • Multi-professional Discharge concerns “admission and discharge” (CNO, 2000) • Know the process and know how to execute process • Inextricable links between good communications and estimating dates for discharge or length of stay (in Hospital or on the service) • Requires new knowledge, skills and levels of competency • Standardisation of all processes (PGD’s, Checklists, management plans, handover plans, patient information) • Requires ward leadership and continued strategic support • Start small and build – evaluating success • Requires governance for sustainability (CNST & local standard)

36. Barriers and challenges We are like inhabitants of little islands, all in the same part of the ocean. Each has evolved a different culture, different ways of doing things and a different language to talk about what they do. Occasionally the inhabitants on one island may spot their neighbours jumping up and down and issuing strange cries about some new discovery but it makes no sense to them …………so they ignore it (Charlton, et al 1980 p. 15).