Emergency and acute medical care Chapter 35 Discharge planning 6 Study design Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified. The process for improvement used proactive discharge planning based on the common failure reasons for patients staying beyond 2 h: medication, consults and physician delays. The hospital discharge department exists to assist with discharge planning, and it is the hospital’s responsibility to see to it that the discharge is a safe one. Provided that the clinical management Ready to Go - No Delays, one of the High Impact Actions (NHS Institute for Innovation and Improvement, 2009), offers a 10-step process for planning the discharge or transfer of patients. Each clinical area needs to decide a structure for the future that takes into account decision makers, regardless of profession. This article emphasises why discharge planning is important and lists the essential principles that should be addressed to ensure that patients leave at an optimum time, feeling confident and safe to do so. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital. The Scottish Intercollegiate... Read Summary Effective discharge planning is crucial to care continuity. The table below details 10 key steps to safe and timely discharge (*adapted from: Ready to go, DH 2010). The National Integrated Care Guidance begins by outlining and explaining the nine key steps required for effective discharge planning and transfer from the acute hospital setting (see figure 1). Ultimately a management plan should engage and focus the whole team with patients to plan the aspects of care that are needed leading up to the point of discharge. The discharge policy must also support the process; a wise step may be to reconsider the elements within your discharge policy – does the policy include the 10 steps? As with any health policy, Ready to Go? Coordinate the discharge or transfer of care process through effective leadership and handover of responsibilities at ward level. From the outset of a patient’s admission, the multidisciplinary team leading their care, plus the patient, their family and carers, all need to have a clear expectation of what is going to happen during their stay. In some areas with early supported discharge schemes, Saturday working is becoming more commonplace. 2. Key stakeholder buy-in and shared ownership, with clarification of roles and responsibilities. Simple discharge (inpatient or day case) 1. A plethora of outreach services (such as intravenous therapy at home) and rapid access clinics that work with acute medicine and surgical admission units also increase the pace of discharge or transfer. 1.2 National/local context and evidence base The commissioning intentions set out in this specification have been informed by the NHS Dorset Strategic Plan for a Healthier Dorset 2010- 2014 which set out the key priorities for health care in Dorset. New health and social care policies during 2009 were prolific, perhaps demonstrating the complexity and challenges faced by the health service and social care in developing services fit for patients with dementia while accommodating safe discharge and transfer (DH, 2009a; 2009b). This is where the greatest improvement could be made in the whole process of setting an estimated date of discharge. Background: Discharge planning is a routine feature of health systems in many countries. suitcase. Lees L (2010) Exploring the principles of best practice discharge to ensure patient involvement. 8. From the outset of a patient’s admission, the multidisciplinary team leading their care, plus the patient, their family and carers, all need to have a clear expectation of what is going to happen during their stay. The purpose of the study was to describe the ability of an evidence-based discharge planning decision support tool to identify and prioritize patients appropriate for early discharge planning intervention. A new policy to guide the discharge or transfer of patients from hospital and intermediate care was published earlier this year (Department of Health, 2010). It is intended to smooth the transition from facility care to a home setting, or alternate facility. It includes a ten step plan for successful discharge planning, but no literature was found that The aim is not to replicate information but to ensure that vital aspects of planning are not missed amid the increased activity before discharge. The impact of discharge planning on mortality, health outcomes and cost rem … Discharge planning from hospital to home Cochrane Database Syst Rev. There is also a play on words evident in practice areas: predicted date of discharge and length of stay, estimated length of stay and estimated date of discharge (Lees, 2008). It requires that nurses not only deliver care with the team but also act as patient advocates and understand their 4.4 Action steps 40 4.5 Practical examples 40 4.6 References 42 Appendices 4.1 Carer’s assessment checklist 43 4.2 Carer’s assessment and care plan 44 4.3 Patient’s and carer’s leaflet 45 Contents. Develop a clinical management plan for every patient within 24 hours of admission. If we can consider and start to conquer these problems in individual wards, policies supporting organisational safety, patient satisfaction and reduced length of stay should start to become integrated within practice. 2 Discharge from hospital: pathway, process and practice, DH (2003) 3 Hospital Admission and Discharge: People who are homeless or living in temporary or insecure accommodation, DH, CLG, Homeless Link and London Network of Midwives and Nurses, (2006) 4 Homeless Link 2010. The steps are based on good practice previously identified, used and evaluated by service providers Search results Jump to search results . Having considered discharge and transfer in the context of current issues in the health service, the 10 steps can be more easily considered in practice (Box 1). Information exchange and collaboration between care providers are essential, but deficits are common. The clarity of the 10 steps enables specific areas of the discharge process to be audited in order to create a focus for where work needs to be undertaken on specific points in the pathway. Without doubt, “out of hours” services and “winter pressures” are vastly outdated concepts in discharge planning and accommodating capacity over seven days. Although the simplicity and clarity of the new DH policy is refreshing, it is important that nurses are not lulled into a false sense of security about its implementation. Not yetestablished Plans inplace Established Mature Exemplary The 10 steps of discharge planning. “step up/step down” community bed based services. the end of December 2010. 1.2.1. New guidance outlines a systematic approach to patient discharge. For example, discharge and transfer for patients with dementia may require a new type of healthcare worker and new support services that encompass the whole care pathway for a society growing older and living longer with increasing frailty (DH, 2009a). • Ensure the person and their family receive clear information about their . Discharge planning is complicated, particularly in those who are frail, elderly or have complex care needs. This step applies to all patients who are admitted for care in a facility, including a short-term care hospital, inpatient rehabilitation facility, long … by estimating length of stay, the aim is to focus on carefully planning time and accounting for possible variance (except for an unexpected deterioration in patient condition). This review gives an introduction to, and taster of, our newly launched Nursing Times Learning unit on discharge planning The key principles of effective discharge planning discharge plaNNiNg learNiNg objecTives This learning unit is free to subscribers and £10 + VAT to non-subcribers at For example, adding to the process may be acceptable but missing elements from it will delay discharges. Information exchange and collaboration between care providers are essential, but deficits are common. This raises a whole new debate in the area of discharge planning, which is concerned with the reduction of junior doctors’ working hours – and changing roles and responsibilities across a team to support that change (RCP, 2007). The pace of discharge and transfer is such that most clinical areas have developed systems where they have a dedicated coordinator. 1: Start planning for discharge on admission. Ready to Go - No Delays, one of the High Impact Actions (NHS Institute for Innovation and Improvement, 2009), offers a 10-step process for planning the discharge or transfer of patients. The aim of this step is to identify the likely patient pathway from or before admission. Advance statement: find out what an advance statement is, and how you can create one to let people know your wishes. For simple discharges carried out at ward level, the process should be standardised throughout an entire hospital. For simple discharges carried out at ward level, the process should be standardised throughout an entire hospital. 9. use a discharge checklist 24-48 hours before transfer. A brief overview of the 10 key principles of effective discharge planning from a nursing perspective. Discharge planning is a care process that aims to secure the transfer of care for the patient at transition from home to the hospital and back home. Further supportive materials and examples of good practice are available from the linked website. The latest review in 2010 suggested that a structured discharge plan tailored to the individual patient probably brings about small reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. 9. Funding issues, change of residence or increased care needs that need to be negotiated between health and social care make discharge complex. The End of Life Care Strategy: Rationa In elective care, planning should begin before admission. Chapter 35 Discharge planning 5 35 Discharge planning 35.1 Introduction Planning for a patient’s discharge from hospital is a key aspect of effective care. required for effective discharge planning and transfer from the acute hospital setting (see figure 1). For simple discharges carried out at ward level, the process should be standard-ised throughout an entire hospital. plan was started on admission of the patient, reviews with them should be a relatively straightforward process. Recent guidance features 10 practical steps to improve the process of patient discharge and transfer – one of the eight high impact actions for nursing and midwifery. The key messages are: check it out, ask the patient and make it happen. ‘If you read one thing today, make sure it’s Vicky Neville’s open letter’, 28 June, 2010 10. Communication, ensuring multidisciplinary teamworking and assessment are three key roles for discharge coordinators (Rose et al, 2009), as well as the transfer of information that may otherwise be missed (Helleso, 2006). Discharge planning started at pre-admission for elective patients or within 24 hours of , and recorded on discharge planning tool throughout hospital stay Likelihood that discharge plans will be complex assessed within 24hrs of admission Complex or unmet care need Yes No Referrals sent for assessment and/or provision, e.g. Nursing Times; 106: 25, 10-14. A brief overview of the 10 key principles of effective discharge planning from a nursing perspective. Clinical management plans do not have to be prescriptive – they should serve as a guide and be revisited if/when patients move through the continuum of care (Lees and Delpino, 2007). Step 2: Discuss the pros and cons of discharge to a skilled nursing home versus home and any other issues specific to your situation with the hospital discharge planner. 2: Identify whether the patient has simple or complex discharge needs, involving the patient and carer in your decision. Source: department of Health (2010) Box 1. Its title – Ready to Go? The judgment concluded that the courts have no general power to monitor the discharge of the Local Authority's functions, but that a Local Authority that failed in its duties to a child could be challenged under the Human Rights Act 1998. 3. Robust systems to gather patient information have to be in place – this information must then be shared with the multidisciplinary team to ensure early engagement in the discharge process. The process used on each ward must be the same, underpinned by specialist aspects of discharge planning relating to the individual area. 1 35.3 Clinical evidence 2 Ten studies (11 papers) were included in the review8,16,23,32,33,36,42,52,53,59,64; these are summarised in 3 Table 2 below. Liz Lees, MSc, BSc, DipHSM, DipN, RGN, is consultant nurse, acute medicine, Heart of England Foundation Trust, Birmingham. Plan discharges and transfers to take place over seven days to deliver continuity of care for the patient. This document focuses specifically on aspects of diabetes care that should be considered at discharge . Furthermore, a whole new vocabulary on patient discharge and transfer has developed, such as “capacity”, “flow”, “predictability” and “breaches”. Review, action, progress (RAP) is the process that has been suggested for this (NLIAH, 2008). Time can be translated into money and, The following documents are available: Integrated Care Guidance a practical guide to discharge 9 step checklist (March 2014) Integrated Care Guidance, a practical guide to discharge and transfer from hospital (March 2014) This study is a 3-staged process to develop, pretest and pilot a framework for an effective discharge planning system in Hong Kong. Moreover, general awareness must be increased and dementia care must become mainstream in acute and intermediate care settings, not perhaps viewed forever as the domain of “specialists” (DH, 2009b). If we consider elective care first, this step can be started before admission in the preoperative admission phase and may take the form of a screening tool, risk assessment or care pathway. The 10 Steps – „Ready to Go‟ (DH 2010) 23 Appendix B Extract from report, ‘Strategy for Improving Integration of Care Pathways to support discharge from hospital’, presented to the Discharge from Hospital Review meeting on 30/5/13 24 & 25 . “Discharge” and “transfer” are presented as synonymous, and “hospital and intermediate care” are presented as a part of planned discharge pathways, functioning through a series of 10 coordinated steps in the process of planning patients’ discharge or transfer. The 10 steps of discharge planning Ready to Go – No Delays, one of the High Impact Actions (NHS Institute for Innova-tion and Improvement, 2009), offers a 10-step process for planning the discharge or transfer of patients. Effective discharge has also been a priority area in Australia since 1998. To ensure effective and efficient discharge practice, clinical staff and managers have to understand the interactive dynamics of new terminology, new services and new process steps not only in the context of their clinical area but also across the hospital and community. The 10 steps of discharge practice are: 2 1. The steps necessary to appeal a hospital discharge decision or to file a complaint about the quality of care. For example, in general therapists only work Monday to Friday, which means that the therapy plans in place must continue on a weekend with nursing staff support. • Ask questions so that you understand different types of discharge support. Published by Scottish Intercollegiate Guidelines Network (SIGN), 01 June 2010 (2014) Guideline 118: Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning - Full guideline. This article examines the current policy context surrounding discharge in the health service, and gives practical advice on implementing the 10 steps. The 10 steps of discharge planning. The discharge process at all levels is important to trusts’ efficiency and effectiveness and is well worth a comprehensive review – using the 10 step approach. Discharge planning involves a coordinated effort between the patient/resident, caregiving professionals, family members, and community supports. Discharge planning is a routine feature of health systems in many countries. ... 2010). The principle is to anticipate potential delays and to respond by managing those proactively. For example, if there is no clinical management plan, this alone may cause staff to dismiss the process and “do it their own way”. Increased attention is Order Essence of Care 2010 online from the TSO Bookshop; To order by telephone: Please call +44 (0)870 243 0123 Textphone +44 (0)870 243 3701. 4. Multidisciplinary teamworking over seven days in hospital settings also requires service provision in primary and social care at the same time to speed up patient discharges. If used appropriately, they can help to prevent complaints about the discharge process and aid compliance with the standard for discharges within the clinical negligence scheme for trusts. Patient involvement is about genuine and meaningful engagement with patients throughout the entire discharge planning process. Step 2: Identify intervention outcomes, performance objectives and change objectives. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from … They act as an integral part of the handover between clinical settings extending to nursing homes, intermediate care and GPs, and should prevent delays or lack of clarity about what has or has not been completed. Regardless of what we choose to call it, if the estimated date of discharge is to have any meaningful application in practice, its underpinning principles must be understood at three levels: Patient engagement is often absent from the process or conducted on a very superficial level (Sargent et al, 2007). This guide to better discharge planning can help reduce length of stay and ensure patients are ready to leave hospital, thereby reducing unnecessary readmissions Strategically – to predict overall hospital capacity; Operationally – to assess progress and outcomes of clinical plans; Individually – for patients to understand the expectations, limitations and engagement required from them in the process of planning discharge (Lees and Holmes, 2005; DH, 2004). Plan the date and time of discharge early Department of Health Publisher: Great Britain. Although it will never replace the role of the multidisciplinary Members of the multidisciplinary team need to act as advocates to enable patients to make choices, and must have the skills and knowledge to navigate through available and appropriate services with patients (Birmingham, 2009). These documents are extremely relevant to the new policy on discharge. Quality, Service Improvement and Redesign Tools: Discharge planning Figure 2 The detail below focuses on the key elements of planning for elective discharge for simple discharges, but the approach is similar for day case and simple emergency admissions. The advantage of this differentiation is that it should enable discharge planners to recognise when simple becomes complex. Start planning for discharge or transfer before or on admission. In some cases, it is likely that the plan will form part of a multidisciplinary team meeting or will be used in one, depending on their frequency. Steps 6 and 7 depend on step 3 being in place. Discharge planning is a care process that aims to secure the transfer of care for the patient at transition from home to the hospital and back home. own barriers to enabling truly shared decision making (Milton-Wildey and O’Brien, 2010). Personalised care and support planning is a process in which the person with a long-term condition is an active and equal partner. Most patients admitted by junior medical staff will have an outline (initial) management plan. Although the principle of a checklist is not new (Lees, 2006), the concept of using the same one across a trust/organisation and making sure it is developed in collaboration with the primary care trust and social care is new. Discharge checklists have proven to be a difficult area of practice to sustain. Many pieces of work on safety and service development suggest consultants’ decisions are critical to this (RCP, 2007). A wide range of initiatives to improve the discharge planning process have been developed and implemented for the past three decades. These steps include identifying whether the person has simple or complex discharge needs, setting an expected date of discharge/ transfer and reviewing treatment plan with the person on a daily basis. 4. Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care, Living Well with Dementia: a National Dementia Strategy Implementation Plan, Joint Commissioning Framework for Dementia, Achieving Simple Timely Discharge from Hospital: A Multidisciplinary Toolkit, Code of Practice for Integrated Discharge Planning, Facilitating an effective discharge from hospital, Using post-take ward rounds to facilitate simple discharge, High Impact Actions for Nursing and Midwifery, Passing the Baton – A Practical Guide to Effective Discharge Planning, Making effective use of predicted discharge dates to reduce the length of stay in hospital, 100629Exploring the principles of best practice discharge to ensure patient involvement, Winners of the Nursing Times Workforce Awards 2020 unveiled, Don’t miss your latest monthly issue of Nursing Times, Announcing our Student Nursing Times editors for 2020-21, New blended learning nursing degree offers real flexibility, Expert nurses share their knowledge of pressure ulcers in free-to-watch videos, Matron ‘honoured’ to administer first Covid-19 vaccine in UK, Scotland’s nurses to get £500 bonus as Covid-19 ‘thank you’ payment, Tributes to Bristol nurse and mentor following death with Covid-19, PHE updates green book with chapter on new Covid-19 vaccines, Nurses faced with ‘rotten and insect-ridden’ PPE during first wave, Nurse’s cardiac arrest inspires community’s quest for defibrillators, England deputy CNO to become new RCN director for Scotland, Pay lost by striking Northern Ireland nurses to be reimbursed, Healthcare workers ‘seven times as likely to have severe Covid-19’, This content is for health professionals only, This article has been double-blind peer reviewed. Integrated Discharge Planning Documents. Simple discharge can be executed at ward level with the multidisciplinary team. The high impact actions for nursing and midwifery (NHS Institute for Innovation and Improvement, 2009) are also crucial, incorporating a standard that focuses on discharge, entitled “ready to go – no delays”. Use a discharge checklist 24-48 hours before transfer. 1. For example, admissions after 5pm will be reviewed by the whole team the next day on ward rounds; these therefore become inextricably linked to management plans (Lees et al, 2006). Which of the 10 steps may be missing in their discharge process; Where implementation might fail through lack of support or where it has already failed; Where there may be resistance to any of the 10 steps. Hospital Discharge Planning www.nextstepincare.org ©2011 United Hospital Fund 2 Many people start discharge planning with unrealistic expectations because they have inaccurate information about what insurance will pay for and for how long. The discharge process in the NHS now encompasses a huge breadth of viable alternatives to hospital, ultimately aimed at speeding up patients’ discharge and frequently entailing new – and sometimes innovative – steps for assessment and referral. The impact of discharge planning on mortality, health outcomes, and cost remains uncertain 42. ment of Health outlines 10 key steps to improve discharge (DH, 2010b), one of which describes using nurse or midwife-led discharge (Box 1). 5. Conversely, in emergency care, advance planning is not possible. The Department of Health's guidance for England also said that discharge planning from a hospital is a process, instead of an isolated event, which should start at the earliest opportunity [17, 18]. 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