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Improving team meetings to support discharge planning.

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Delays in hospital discharge have a significant impact on patients, their carers and the NHS. Prolonged and unnecessary hospital stays can (National Audit Office (NAO), 2003):

Abstract

VOL: 102, ISSUE: 26, PAGE NO: 32

Maggie Tarling, MSc, BSc, RGN, is lecturer in nursing, Florence Nightingale School of Nursing and Midwifery, King’s College London

Hassam Jauffur, RGN, is clinical site coordinator, Queen Elizabeth Hospital NHS Trust, London

Delays in hospital discharge have a significant impact on patients, their carers and the NHS. Prolonged and unnecessary hospital stays can (National Audit Office (NAO), 2003):

- Increase dependency;

 - Increase the risk of developing complications such as healthcare-associated infection;

- Have an adverse effect on the use of resources in the NHS, such as lost bed days resulting in other patients having to wait longer for treatment;

 - Increase the stress experienced by staff.

Effective discharge planning can reduce delayed discharges and therefore support the achievement of The NHS Plan (Department of Health, 2000).

The project

A practice development project was established at Queen Elizabeth Hospital NHS Trust, London, to improve multidisciplinary team (MDT) meetings and support effective hospital discharge.

A multiprofessional and interagency discharge working group was established in order to improve discharge planning.

The group held a series of focus group meetings with clinical staff from all professional groups across the organisation to establish the areas of discharge planning that were a cause for concern. Many areas were highlighted as having potential for improvement. The results of this approach indicated that the most common method of coordination between professional disciplines within the trust was in the form of MDT meetings held on a weekly basis in most adult clinical areas. 

The following concerns were identified relating to MDT meetings in the organisation:

- There were discrepancies and variations in relation to the purpose of MDT meetings across the organisation;

- There were poor MDT working practices in some areas with variations in the timing and frequency of meetings. Some MDT meetings were not decision-focused and had no standard format. This implied that there was no clear structure and agenda for these meetings. There were some concerns expressed about the lack of leadership during some of these meetings;

- There was poor documentation of decisions following these meetings and therefore it was difficult to keep track of priorities and actions that followed meetings.

Following the results from the focus groups, an action plan was developed to address the issues that emerged from this initial work. A practice development project was established to observe MDT working practice across the trust and identify areas of good practice and develop guidance for the conduct of MDT meetings.

The objective was to agree best practice, provide consistency, enable staff to enhance their knowledge and skills in discharge planning, support training and education of staff, and provide a benchmark to evaluate practice.

Methods

It was decided to use a qualitative approach to identify the various practices that were in place within the trust and highlight areas for improvement and development.

The methods used in the assessment of practice were as follows:

- Observation: A total of 12 wards were included from both medical and surgical adult areas. An independent observer studied the MDT discharge meetings over a period of 12 weeks, looking at style of leadership, the structure and process of meetings, and documentation.

- Semi-structured interview: A series of semi-structured interviews were conducted with various professionals. A total of 42 staff were interviewed, comprising 18 nurses, three doctors, seven occupational therapists, five physiotherapists, six care managers, and three discharge coordinators. These interviews ranged in length from 20 to 30 minutes.

Findings

Following observations of MDT meetings in all 12 clinical areas it was found that 80% had regular weekly MDT discharge meetings.

Leadership of MDT meetings

Three styles of leadership were observed and related to the person who led the meeting - medic-led, nurse-led and allied professional-led. There were no observed MDT meetings led by social services. Each of these professionals had their own particular style of leadership which influenced the structure and focus of the meeting. Table 1 shows the observed strengths and weakness of the professional style of leadership observed. Medic-led MDT meetings provided information about clinical progress and decisions on expected date of discharge (EDD). However, there was less emphasis on some social issues relevant to discharge planning. The nurse-led MDT meetings provided a social focus but leadership skills could sometimes be weak and clinical decisions relating to EDD were not addressed.

Structure of MDT meetings

Various patterns of MDT meeting organisation were observed across clinical areas. Some ward areas gave the meetings a high profile, with a clear structure and regular attendance by all professionals. Others had unclear leadership, poor focus upon decision-making and no standard format. Overall, 62% of clinical areas did not have a clear structure to their meetings. There was also a lack of clearly defined roles and responsibilities around the management of discharge. Although each professional interviewed was able to state their role and contribution to MDT meetings, approximately 60% of clinical areas were unclear about roles and responsibilities for actions following meetings. 

Documentation

It was found that the documentation used by nursing staff on the admission of patients into clinical areas was often not completed fully. Therefore accurate information about the patients’ pre-morbid condition and social circumstances was not effectively communicated in meetings. A total of 45% of all nursing documentation reviewed was incomplete. Each clinical area had identified problems with documentation and had produced its own documents to overcome these issues. Therefore there was no consistency in the documentation used and the information collected for each patient. 

Various practices in the documentation of the discussions and agreed actions of the MDT meeting were observed. A total of 46% of meetings had no documentation of actions and decisions following the meeting with no clear responsibility documented for the follow-up of identified actions. It was observed that each professional attending the meeting kept their own documentation and there was no common summary of the discussion.

Guidance for meetings

Guidance was produced, following the results of the project. It was important to clarify issues about decision-making and to clearly define certain aspects of discharge planning to ensure clarity and clear professional boundaries. It was agreed that the decision to discharge rests with the patient’s consultant or authorised doctor to ensure that the patient is clinically fit for discharge. The concepts of medical stability and safe to transfer have been embedded in the Community Care (Delayed Discharges etc) Act (2003). 

The patient who is ‘fit for discharge’ no longer requires the services of acute or specialist staff within a secondary care setting, and where:

- Review of the patient’s condition can be shared with the GP including any adjustments to medication;

- Ongoing general, nursing and rehabilitation needs can be met in another setting at home or through primary/community/intermediate/social care services;

- Care setting, additional tests and interventions can be carried out in an outpatient or ambulatory setting (DH, 2004).

The decision to discharge must weigh the risks of remaining in the hospital environment against those of being elsewhere. The role of the multidisciplinary team is to take all factors into consideration when planning safe and effective discharge or transfer of a patient.

The process

The objective of an MDT meeting is to discuss all patients needing multidisciplinary input and focus on patients for whom an action plan can be set for their discharge because they are no longer acutely ill, are improving or are medically more stable.

The aim should incorporate who is going to implement the action plan and when it has to be carried out. It is important therefore that every member of the team is prepared before each meeting. It is recommended that the following information is required before each meeting:

- A working knowledge of the patient’s medical condition, nursing, therapy and social needs;

- Completed patient assessment with the patient’s pre-morbid state;

- Idea of social situation and needs;

- Communication from the patient and family;

- Progress made from last meeting.

Structure

It should be clear who is expected to attend each MDT meeting. Generally the attendees should include nurses caring for the patient or ward manager, consultants, junior doctors, discharge coordinator, care managers, occupational therapist, physiotherapist and other therapists such as speech and language therapists if relevant to the patient’s needs. It is important to have a clear agenda for each meeting to provide a structure and ensure that time in the meeting is effectively managed. 

The following structure is recommended:

- Discuss patients needing multidisciplinary input;

- Give short summary of the patient’s name, diagnosis, predicted length of stay, expected date of discharge, care plan and action plan so far;

- Discuss whether the patient is medically fit or stable enough for transfer or discharge, according to the above definition;

- Decide an action plan as appropriate to the patient’s needs;

- Summarise the action plan and the responsibilities for follow-up.

Decisions and agreed actions must be clearly documented and include the following:

- Summary of action plan, proposed discharge date, and whether or not the patient is medically stable;

- A clear note of each discipline’s responsibility for driving the discharge plan;

- Decision as to the professional responsible for providing feedback on the outcome of the meeting to the patient and/or carer. 

Roles and responsibilities

There should be an identified chairperson for each MDT meeting who has the appropriate experience and will do the following:

- Lead and take control of the meeting, ensuring that it keeps to time;

- Make sure that all relevant patients are discussed appropriately; 

- Make sure that there is a summary of the MDT discussion and the agreed goals, discharge plan/date actions in the patient’s record along with clear lines of responsibility and time frames for needed actions;

- If there are disputes between carer and patients, disciplines or others that cannot be resolved at the MDT meeting, ensure a case conference is organised as soon as possible.

It is important that each MDT meeting agrees where shared information is documented and that a nominated member takes responsibility for the following:

- Making notes throughout the meeting in the appropriate documentation;

- Ensuring a summary of discussions and outcomes in terms of goals, discharge planning and planned/predicted discharge date;

- Documenting action plans with identified responsibility for actions and follow-up.

It is important that professionals attending the MDT meeting have a clear understanding of their role, responsibilities and contribution to the meeting (Box 1).

Discussion

The results of the observation across the adult clinical areas in the trust supported the initial concerns raised from focus groups. However, there were some areas of good practice and this formed the basis for the development of good practice guidance.

Observations of the leadership style of each professional taking this role was interesting and reflected the prime focus for each professional’s care and treatment of patients. This result reflects a previous study by Healy et al (2002) in which different professional configurations of multidisciplinary teams influenced the type of referrals made and was also seen in the semi-structured interview results.

It has been argued that for collaboration to be effective between professionals, a clear understanding of all different roles is needed. This understanding will contribute to a recognition and respect for others’ opinions and contributions (Adler et al, 1995).

It is hoped that the guidance developed from this work will provide different professionals within the multidisciplinary team with an opportunity to recognise and understand others’ contribution to patient care and outcome. 

Fostering understanding between professionals has been found to promote professional behaviour and accountability and improve the referral process between them (Halm et at, 2003).

The results indicated that the documentation of discussions in the MDT meeting and agreements of any actions were generally poor. It was not in the scope of this particular project to develop specific discharge planning documentation.

Previous research has discovered that the use of integrated care pathways (Sulch et al, 2002) and the use of MDT discharge pro formas can improve MDT care and documentation (Monaghan et al, 2005). However, it was felt that it was important to ensure that fundamental understanding about role and responsibilities was established before the standardisation of documentation could be fully addressed.

Conclusion

There are significant development implications for nurses arising from this practice development project. Nurses are actively involved in running and participating in MDT discharge meetings. It is important for the improvement of these meetings that all professionals are aware of their role and their contribution.

Nurses need to be clear about and understand different professionals’ roles and responsibilities in order to improve professional behaviour and accountability. It is hoped that the resulting guidance will provide a framework and act as a benchmark of good practice, and will open discussion and promote understanding among the professionals involved in MDT discharge meetings.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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