Nurse-led discharge planning improves quality of care

Traditionally, patients who undergo major surgery such as a hysterectomy have been admitted to hospital for five to seven days, even though many would like to return home earlier to recover in familiar surroundings.

The gynaecological unit at Castle Hill Hospital in Cottingham, where all types of gynaecological operations are carried out, has 18 major operation beds and six day-case beds.

Three years ago the unit moved to a smaller building and the number of beds was reduced. This prompted a re-evaluation of discharge procedures to optimise bed occupancy without reducing the quality of care or increasing the risk of postoperative complications for patients.

Nurses have long recognised the significance of discharge planning in helping patients to make a smooth and safe transition from hospital to home and know it is fundamental to good patient care (Farren, 1991). The re-evaluation included discussion of the benefits of nurse-led discharge planning and, as a result, the decision was made to implement it (Box 1).

Discharge planning begins at, on or before the day of admission. This ensures that the support the patient will need from other agencies after discharge can be arranged in good time. Without the appropriate procedures patients would have to remain in hospital much longer and would leave without adequate support, increasing the risk of deterioration and readmission (Henwood, 1994).

Discharge changes
The pilot study began by allowing E, F and G-grade nurses to organise patient discharge.

The medical team is involved in key decision-making for the 48 hours after surgery. When the patient is stable and the medical assessment has been completed, key decision-making on patient care - up to and including discharge - is made by nurses. Assessments are based on nurses' professional judgement and clinical experience (Earl-Slater, 1999; Colyer and Kamath, 1999).

Nurse-led discharge was piloted at the hospital and assessed, enabling criteria for early discharge to be established (Box 2).

Pilot study results
The results showed a reduction in length of stay and hospital-acquired infections. All first-level nurses now undertake nurse-led discharge planning in cases where patients meet the eligibility criteria.

Before nurse-led discharge planning was implemented in 1997 patients experienced delays, which are now generally avoided through prompt referral. The length of stay has been cut from an average of 2.2 days to 1.7 days. Patients having major surgery spend 3.95 days (1999-2000) in hospital compared with 4.51 days in 1997.

The audit department is satisfied with the service, which has a low readmission rate. Despite a reduction in bed capacity, waiting times have been reduced from eight weeks to less than four.

Conclusion
Early discharge calls for effective organisation and liaison between health care professionals, a view supported by the Nuffield Institute for Health (Godfrey and More, 1996).

Nurse-led discharge meets service demands, improves the quality of care, provides a more efficient pathway for discharge planning and increases patient satisfaction. However, successful nurse-led discharge must be backed up with a concise and regularly updated policy.

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