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Call for nurse-led patient discharge to improve care

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Worsening hospital performance on discharging patients has prompted calls for nurses to be handed control over transfers of care.

The annual health check, published last week by the Care Quality Commission, has revealed the proportion of hospitals failing to hit a target to reduce delayed transfers has increased by 12 per cent in the past two years.

Nearly a quarter of trusts (24 per cent) failed to meet the required standard for delayed transfer of care, up from 21 per cent in 2006-07.

The annual assessment ratings also showed fewer hospitals have been complying with patient experience indicators – 11.1 per cent failed in 2008-09, compared with 8.2 per cent the previous year.

The scores have led to a call to action for nurses to take a more prominent role in patient discharge.

NHS Institute for Innovation and Improvement head of innovation Lynne Maher, a nurse by background, said modern nurse training, with its emphasis on evidence-based skills and care pathways, meant the profession was better placed than ever before to take on responsibility for discharging patients.

She said: “It’s about understanding what the patients’ anxieties are, for example transport to take them home or being able to get prescriptions from a local pharmacy. Nurses are more able than ever before to be supporting and sometimes making these important decisions around patient discharge.”

But Ms Maher acknowledged it would be difficult to persuade doctors of this. She said nurses could show it was in the best interests of patients by presenting the available evidence and acting as role models.

The few nurse-led discharge schemes currently in operation have provided evidence of their success.

At Luton and Dunstable Hospital Foundation Trust, responsibility for discharges is already nurse-led in many areas. It is rotated between ward nurses for six month periods, freeing up colleagues to treat patients.

The trust’s medical ward discharge coordinator Julie Pilley said: “This creates a single point of contact for all the different agencies involved and helps with patient flow and bed management.”

The system puts one nurse in charge of dealing with social workers, paperwork, relatives, physiotherapists and prescriptions. They also take part in twice weekly teleconferences with local authorities and primary care trusts.

During a six month pilot period, the number of failed discharges fell from 156 to 39. Senior nurse Anne Prime said: “It gives us time for the relatives. Before, we were all busy on the ward but now we can talk at more length about their concerns.”

Other trusts where nurses have been given a stronger role in the discharge process have reported similar successes. For example a project at Barts and the London Trust reduced patients’ length of stay and saved £2m in a year.

Additionally nurse facilitated discharge is currently ranked third most popular idea among the  submissions to chief nursing officer for England Dame Christine Beasley’s call for top ten “high impact actions” to improve NHS efficiency.

But, while delayed discharges appear to be increasing, a number of improvements identified by the CQC’s annual health check are being seen as a success story for nurses.

For example, 79 per cent of trusts hit local MRSA targets in 2008-09, compared with 52 per cent in 2007-08. Rates of Clostridium difficile have also fallen, with only 1.7 per cent of organisations failing to reduce infections by the required amount, compared with 3.5 per cent last year.

The perceived influence of nursing in gaining the upper hand in the battle over HCAIs was one of the reasons that sparked the Prime Minister’s Commission on the Future of Nursing and Midwifery (10 March p3). As Nursing Times reported, sources close to the prime minster identified discharge as another area that nurses could potentially be handed control over.

Department of Health MRSA/cleaner hospital programme director Janice Stevens, a former nurse, said: “Success has been a multidisciplinary process but without doubt the nursing profession has led the way in getting this on everyone’s agenda and driving a lot of improvements.”

In particular, she pointed to improvements in hand hygiene, aseptic techniques and care with IV lines and catheters.

But she added: “The journey’s not over. For the future the nursing leadership will continue to be important, they have to keep thinking about how they keep the momentum going, making sure those basics are absolutely integral to quality and safety.”


Annual health check, good and bad:
Indicators showing declining performance:
- Patient experience: The proportion of trusts failing this indicator has risen from 8.23 per cent in 2006-07 to 11.17 per cent in 2008-09
- Delayed transfers for care: In 2006-07 21.1 per cent of trusts returning data failed on delayed transfers, rising to 23.6 per cent in 2008-09 *
Indicators that have improved:
- MRSA: 47.9 per cent of trusts failed to hit the target in 2007-08, compared with 21.1 per cent in 2008-09
- Clostridium difficile: 1.7 per cent of trusts failed in 2008-09, compared with 3.5 per cent in 2007-08
*Delayed discharge data is unavailable for acute trusts in 2007-08


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