Transcript Slide 1

Implementing systems for
dynamic discharge
practice (simple discharge)
Liz Lees
Consultant Nurse (Acute Medicine)
[email protected]
Today's
presentation
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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.
Defining a simple discharge
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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)
Discharge bundle concept
(7 + 7)
1.
2.
3.
4.
5.
6.
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
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
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…..
CNST and Trust standard
CNST:
1.
Unified set of records with evidence of a discharge plan,
2.
named person responsible for discharge
3.
Clear audit trail of discharge (discharge checklist)
Trust standard: estimated date of discharge
Measures:
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a completed discharge checklist (in notes)
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patient information (evidenced from PAS)
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evidence of patient involvement (ask patient)
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Documented plan (in notes)
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.nursingstandard.co.uk
 EDD what does it really mean for
patients
 Proformas
The Front of the Notes
Facilitating Discharge
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Post Admission
(Acute Medical Unit)
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Post take WR
standardised proforma
Nurses attending post
take WR
Standardised Discharge
Criteria e.g. Community
Acquired Pneumonia,
BTS 2004
Date &
Time
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Patient Name:
PID:
Post take ward round:
Patient Management Plan
Consultant:
Discussion with patient (additional history, advice given, etc.)
Examination:
Temp _______ o C
MEW S if >2________
O 2 Sats______% on _____l/min
Impression (differential diagnosis)
Management Plan (treatments, investigations, physio/OT/SW input, etc.)
Criteria for Discharge (include specific results, level of independence, etc.)
Estimated Length of stay: 1-2D
SIGNED:
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3-4D
 4-5D 
DATED:
5-6D
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7days +
BLEEP:________
The White Board
13 POINTS FOR 13.00h DISCHARGE
Suggested best practice is outlined and must be incorporated into each on-call G(I)M practice.
They include:
On Admission
1.
2.
Information given to pt & relatives regarding discharge arrangements
Information from patient regarding discharge transport arrangements
documented in notes
Discharge Planning
3.
4.
Expected date of discharge documented in notes
24 hour advance warning given to family and patient, and check
transport arrangements
a)
relative pick-up by 13.00
5. Early bird senior medical ward round confirms discharge early in the
day
6. Conventional ward rounds review likely discharges first
7. Ward staff book transport early:
a)
Advance booking
b)
Hospital car – avoid ambulances where possible
Discharge Processes
8. TTOs written by 09.30 at the latest
9. Pharmacy receives TTOs between 09.00 – 11.00
10. Confirm pick up time with relative by 09.30
11. Nominated member of staff to deliver discharge
12. Patient in ward discharge area (bed space cleared)
Performance
13. Monitor / feedback / incentives
Current situation (2008)
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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?!
EDD – back to basics
“to introduce a simple sustainable process, that every one
would understand their contribution and participate in”
EDD process
Ward round
Management
plan
With patient
Bed
management
Nurse
handovers
Ward maps
Discharge training
Top 5 Training needs- For all wards
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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)
Discharge training needs analysis tool
NAME……………………………………..
Corporate Aspects
GRADE………..
WARD……………..
Have you
received
training?
If yes, was
training
adequate for
your needs?
Do you feel
require any
further training?
Are you
competent to
train others?
Yes
Yes
Yes
Yes
No
No
No
Awareness of Trust discharge policy
1
1
1
Accessing Discharge Lounge
2
2
2
Understand how to access Bed Managers
3
3
3
Understand how to report bed availability on
ward
4
4
4
Ability to predict possible bed availability on
ward
5
5
5
Understand use of Traffic light system on
ward
6
6
6
Reporting Delayed discharges on ward
7
7
7
Completing Section 2 and Section 5
8
8
8
Participate in repatriation of patients to base
wards
9
9
9
No
Levels of competency
(framework in toolkit, Dh, 2004)
Estimating expected date of discharge
Undertake a full and holistic assessment of
patient
3. Advanced
practitioners Demonstrate excellent knowledge of the
clinical condition and likely interventions and
(Expert)
process required & communicate this with the
family, carers and MDT
Review and revise the EDD based on further
assessments & evidence
Estimate LOS needed to complete treatment
to a level where patient is clinically fit for
discharge
Case study 1
Not simple, not
complex
Incomprehensible!
On Presentation
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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?
Active discharge phase
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Staff arranged transfer by 2 man ambulance
Nurses organised TTO (cupboard on ward)
Doctor wrote discharge letter.
Ambulance staff arrived
What happened next?
Active discharge phase
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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?
Salvage operation
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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
What could we improve?
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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
Case study 2
Simple
discharge??
On Presentation
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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?
Active discharge phase
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Nurses arranged discharge
s/w family (daughter, by phone)
Ordered medications
Waited for GP letter
Arranged transport (external taxi)
-----------------------------------------What happened next?
And there is more!
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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?
Oh dear!
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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”
What could we have done
better?
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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!
Case study 3
So near and yet,
so far.
On Presentation
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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?
Active discharge phase
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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?
A catalogue of disasters
He waited patiently for the ambulance
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By 6pm (5 hours after assessment)
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Told by Bed Co-ordinator “he can’t go today”
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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
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What could we have done
better?
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Bad luck with transport (& weather)
Assessment: communicating the whole plan
Process: Discharge checklist (dressings)
Ensure responsibility and named person
discharging patient
The usual:- documentation!
Top tips
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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)
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).