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Evaluating the development of a nurse-led discharge scheme.

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Hospitals need to consider new and different ways of hitting national targets for waiting times and cutting delays in transfers of care. Winchester and Eastleigh Healthcare NHS Trust is based in central Hampshire and serves a quarter of a million people. It has over 600 beds and comprises: the Royal Hampshire County Hospital, providing general hospital services; Andover War Memorial hospital, providing clinics, rehabilitation and minor injuries services; and The Mount Hospital, providing adult rehabilitation services.

Abstract

VOL: 101, ISSUE: 06, PAGE NO: 36

Linda Flower, BSc, RGN, is sister at Royal Hampshire County Hospital, Winchester

Hospitals need to consider new and different ways of hitting national targets for waiting times and cutting delays in transfers of care. Winchester and Eastleigh Healthcare NHS Trust is based in central Hampshire and serves a quarter of a million people. It has over 600 beds and comprises: the Royal Hampshire County Hospital, providing general hospital services; Andover War Memorial hospital, providing clinics, rehabilitation and minor injuries services; and The Mount Hospital, providing adult rehabilitation services. Nurse-led discharge involves senior nurses experienced in their area of practice making the decision to discharge individual patients (with previous agreement of the medical team) rather than wait for the daily medical ward round. It is hoped this will speed up discharge by a few hours or possibly a night or two, depending on the clinical area involved. A review of current practice in the trust showed patients were discharged from hospital by the medical team. Although a couple of areas in the trust indicated nurses discharged a few of their patients, this seemed to be an informal arrangement with the medical team with no obvious controls or protocols in place. In principle, discharge from hospital is a medical decision but as such can be delegated to another health care professional provided the necessary safeguards are in place, including: - The person given the task is willing to undertake it; - They have appropriate professional training and the competence to undertake the task; - There is an accepted recording system to enable the task to be recorded in the patient’s notes; - There is a record of staff training and competence to demonstrate that the role is subject to an audit of training and procedures; - Legal and professional responsibilities are adhered to using the Code of Professional Conduct (NMC, 2002) and local policies, protocols and guidelines. Drivers for change
The trust is developing proposals for a major service review and workforce redesign, reflecting the themes from local reviews, national strategies and guidance relating to the NHS modernisation. Linking with this overall plan, nurses taking responsibility for discharge may result in a more efficient process and shorter hospital stays. Nurses are encouraged to expand and develop their roles and skills for the benefit of patients (Department of Health, 2000; 1999) in order to deliver a more patient-focused service. The NHS Plan (DoH, 2000) identifies that nurses need to maximise their skills and talents to improve patient care. The chief nursing officer for England identified 10 key roles for nurses, one of which is admission and discharge of patients for specified conditions and within agreed protocols (DoH, 2002; 2000). Methodology
The Workforce Development Confederation funded a small project to explore the role of the nurse in leading and taking accountability for discharge. The funding was required to second and support a senior nurse for a limited time to coordinate the project. All areas within the trust were canvassed about their current practice and the possibility of developing nurse-led discharge in their area. Initially, nine areas - including surgery, orthopaedics, medicine and elderly care, gynaecology and rehabilitation - were found to be keen to develop nurse-led discharge. Early progress was slow because getting appointments to see all the ward leaders, gaining agreement from all the consultants and dealing with their varied and individual concerns proved impractical. It soon became obvious that waiting for all the health care staff involved to move forward at the same time would jeopardise the project’s development. In November 2003 we decided that developing nurse-led discharge would be restricted to an upper gastrointestinal, breast and general surgery ward and a lower gastrointestinal, vascular and general surgery ward. Both wards indicated they were keen to develop the process and all the general surgeons showed an interest in exploring and developing the idea. The audit A short audit in a typical week - involving all patients being discharged from the two wards - was undertaken using a questionnaire distributed to the ward staff. This was done to find out if there were any delays in discharge, the reasons for these delays and to provide a benchmark to allow a repeat audit to see if improvements had been made once the nurse-led discharge process had been developed. A literature search was carried out. There appears to be no published literature on nurse-led discharge despite considerable anecdotal evidence it is being developed in other trusts. A site visit to the Wirral Hospital Trust was made in August 2003 as staff there had presented a paper on nurse-led discharge earlier in the year at an RCN conference. The Hampshire project draws heavily on the advice and documentation shared on this visit. Information was sought from other hospitals. Some areas sent their procedure or protocol documents for developing nurse-led discharge in their trusts. Results
The results of the audit of surgical discharges - carried out before the development of the nurse-led discharge process - showed there were delays in a significant number of discharges (Figs 1-2). The data also showed that 47 per cent of patients had the potential for an earlier discharge. In three particular cases staff felt patients could have been discharged days before. Discussion with nurses and medical staff identified the preferred process and documentation to allow for nurse-led discharge: - Medical staff will indicate in either the perioperative form or medical notes that a patient has reached the stage when they are suitable for the nurse-led discharge protocol; - All senior nurses have had their competency assessed and documented, and are ready to discharge suitable patients; - A general criteria for discharge has been agreed and all patients must reach this before discharge; - ‘Condition specific’ criteria for discharge relating to breast patients has been developed and will be kept with the general criteria on the breast ward. Any specific criteria for other patients will be written in the medical notes as required. For those proving to be common it will be possible to write further ‘condition specific’ criteria so that this does not need to be repeated in every patient’s notes in the future; - Nurses who discharge patients will be writing their name instead of the doctor’s name as the person authorising the discharge on the hospital information system. This required a minor alteration to the system and will allow tracing of decision-making and possible audit in the future. All the above documentation is being held at ward level for easy reference and future audit and evaluation. A protocol for nurse-led discharge was written and agreed for the development period (Box 1). This has been followed by a policy, which is currently being ratified by the trust’s nursing policy group. This will provide the framework for developing nurse-led discharge throughout the trust in all divisions. Nurse-led discharge is starting on the two pilot wards and all surgical conditions are being included if the individual patient’s condition allows. Nurse-led discharge in action
An example of the process in practice was seen in the first week when two patients from the afternoon operating list had recovered well by 8pm and 9pm respectively - long after their medical teams had gone home. In the past these patients would have waited on the ward until the following morning to see their medical team before being discharged, but in these two cases they were discharged with their agreement by the nurse in the late evening. Another success was highlighted by a patient who was unfit for discharge on a Friday and who might otherwise have remained in hospital until the following Monday as the team were not on duty over the weekend. The patient was fit for discharge by Sunday and was discharged by the nurse, saving the patient another night in hospital and freeing up a bed on the ward. While it could be argued that all these patients could have been discharged by the on-call team, in practice this team is often busy in casualty or theatre and cannot see the patient. Challenges Few early problems have been identified at this stage. The medical staff have needed frequent reminding about the process and their need to document if a patient is suitable for nurse-led discharge. As a result some patients have been lost to the project. It is early days and with their continued commitment this should improve. We are also looking into preprinted stickers to authorise nurse-led discharge making it easy and quick to indicate in medical notes in future. The issue of take-home drugs not being prescribed early enough has not been fully resolved. However, nurses are trying to ensure medical staff prescribe these as soon as patients are identified as suitable for the protocol, if not before. Senior staff nurses and higher grades are the only nurses currently authorised under the protocol to discharge patients, and at times we have had only more junior but experienced staff on duty. We will be looking to gain the medical consultants’ agreement to include some junior staff nurses, who have experience in their area of practice and are deemed competent, to be included in the protocol. The future
This project will be presented to the trust’s Nurses and Midwifery Advisory Board to publicise this development and raise interest in other areas of the trust. The intention is to gain agreement from senior nurses from all areas to support and facilitate further development in their clinical areas. While the project has so far involved only a small number of patients, it is clear some of these could be discharged earlier. If we can shorten the length of stay of a few patients in all areas, including medicine and orthopaedics, there will be a significant overall improvement in the trust’s bed capacity. This will improve the experience for these patients and also help meet national targets such as A&E waiting times. Once the process has been tried and proven to work it should be fairly straightforward to roll out to other areas in the trust. The final policy, once agreed by the trust policy group, will form the framework for individual ward and department development. The trust is planning to open a new short-stay ward in its new treatment centre and this is an obvious area where nurse-led discharge will improve the efficient running of the ward. If introduced at the start other areas such as orthopaedics and ENT will be exposed to the process. This may prove a useful way for medical consultants in these areas to gain more confidence in nurse-led discharge and add their support to its development in longer-stay wards. The possibility that all health care professionals could contribute to and write discharge information, which would be included in a single final discharge summary, should be explored so that the new system provides more comprehensive and detailed discharge information for GPs. This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net

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