Abstract Lees, L., Delpino, R. (2007) Facilitating timely discharge from hospital. www.nursingtimes.net
VOL: 103, ISSUE: 29, PAGE NO: 30-31
Liz Lees, RGN, DipN, BSc, Dip HSM, MSc; Rebecca Delpino, RGN, DipN
Liz Lees is consultant nurse, acute medicine, emergency assessment area, Heartlands Hospital; Rebecca Delpino is sister (and discharge project leader), Solihull Hospital; both at Heart of England Foundation Trust, Birmingham.
Abstract Lees, L., Delpino, R. (2007) Facilitating timely discharge from hospital. www.nursingtimes.net
During January 2007, a discharge project was established to improve multidisciplinary team communication and coordination of the patient’s progress through the discharge process. The project involved a local agreement to adjust the information displayed on the ward central patient location board to include relevant patient discharge information. Ward staff agreed to participate actively in the project for a month; the work that commenced during the project has continued to date. This article describes the development of the board, early results and discusses the implications for practice in the clinical setting. The work described will be of use to nurses who are keen to develop and empower others in the principles of leading/facilitating simple, effective and safe patient discharge from hospital.
Commonly used to display basic patient details, patient location boards are usually situated at the entrance to a ward or to sub areas within a ward, such as patient bays or outside side rooms. However, the type of patient information displayed varies significantly from one ward area to another. For this project, information on and usage of boards has been compared across 15 wards within the Heart of England NHS Foundation Trust (HoEFT). This comparison has demonstrated that only two pieces of basic patient information are displayed routinely throughout their stay: the patient’s name and the name of the consultant in charge of their care. Through discussion, nurses representing the 15 wards have revealed that up to 12 different pieces of information may be noted on ward patient location boards. The lack of clarity surrounding what should be included on the boards provided an ideal starting point for reconsidering their use in relation to the discharge planning process.
Linking patient boards and discharge planning
Some wards have not been displaying any information about the patient’s discharge on patient location boards, while others display imminent actions. These include patient transport requirements and whether patients are awaiting tablets to take home (TTOs). However, this information is usually included on an ad hoc basis, normally on the day of the patient’s discharge or transfer. Further exploration has revealed that the difference in the amount and type of information displayed on the boards was not influenced by the types of nursing care being delivered, the complexity of the discharge elements involved or whether the patient’s length of stay was relatively short (<2 days) or long (>5 days). The organisational culture of a ward appears to determine the extent to which patient boards are used for communicating key aspects of patient care (Lees and Holmes, 2005). The ability to see the discharge facets ‘at a glance’ has helped the multidisciplinary team to avoid misunderstandings about the likely discharge pathway. Furthermore, to ensure the use of boards becomes commonplace (DH, 2006), clinical leadership on the ward is required to enthuse and stimulate the integration of the patient’s progress through the discharge process.
Meeting the operational demand for beds
One of the HoEFT’s key performance indicators is to promote patient discharge by 1pm. Models used to determine bed capacity management and short-stay emergency care indicate that, if a patient’s discharge is facilitated by 1pm, the hospital has sufficient capacity to carry out elective work and accommodate patients admitted as an emergency without breaching the four-hour emergency target (DH, 2004; NHS Institute for Innovation and Improvement, 2006). To realise and sustain this discharge performance indicator at ward level, nurses are encouraged to take individual responsibility and ownership. Feedback is reported through a series of organisational performance measures in place at management level. Nurse-facilitated admission and discharge principles should underpin the achievement of this target (DH, 2000; DH, 2004). Simple discharges are regarded as within the nurse’s remit to coordinate and expedite. But in order to move practice forward, many aspects of ward organisation and communication must work together to ensure safe patient discharge. Patient boards could help by simply noting whether the patient’s discharge is due to take place in the morning or afternoon. Some trusts have included traffic-light bed management systems on their boards to indicate estimated length of patient stay (DH, Greater Manchester Case Study, 2006). The HoEFT’s bed managers were in support of this view; they explained that visible, accessible information regarding the patient’s discharge plan undoubtedly helps to determine where they can/should place patients. Such information regarding time of discharge is hugely important, enabling them to manage the potential bed capacity effectively throughout the day. Equally, evidence suggests that patients are also likely to be better informed by nurses if they can see the course of events being planned (DH, 2006). In the context of the whole hospital system, good communication processes at ward level will influence positively the likelihood of achieving the four-hour emergency care target (DH, 2007; NHS Institute for Innovation and Improvement, 2006). Furthermore, good communication and information sharing at ward level assists the integrated planning of care between different agencies and stages of care pathways (DH, 2003).
Over the past two years the NHS has been adopting and promoting Lean thinking principles (NHS Institute for Innovation and Improvement, 2007). Much of what is advocated is regarded as common sense, yet it is a challenge to achieve in practice. For example, Lean advocates standardisation of processes in relation to discharge planning as this is something that takes place on every hospital ward (NHS Institute for Innovation and Improvement, 2007). Responsibility for simple discharges is owned and executed at ward level without the involvement of multiple agencies (Lees, 2007). In addition to the medical management plan, discharge information is gathered from the point of admission, a process that usually commences on the ward round (Salter, 2001). It is also likely that this is when the date of discharge will be discussed (Lees and Holmes, 2005). If nurses are present on the ward round they are clinically empowered with information that will help determine the volume, nature and pace of activities being organised for the patient’s discharge(Lees et al, 2006; Chatterjee, 2004). Key actions arising from both the information gathering and ward round could be transferred and communicated through one central point, namely the ward patient board.
The patient discharge project took place on a 33-bed elective orthopaedic ward. The ward is divided into five bays and several side wards. The discharge project was implemented to promote improved communication and coordination of discharge practice. In particular, the project sought to empower nurses to take charge of leading/facilitating simple discharges and encourage other staff involved in patients’ discharge to make proactive use of the patient information boards (Chatterjee, 2004). The nurses organise care of patients proactively throughout their stay according to their nursing dependency (needs); from high-dependency/high-visibility areas to low-dependency care before discharge to home. For example, a patient’s stay may involve up to four bed moves; if these moves are not coordinated efficiently confusion may occur surrounding the discharge process and date of discharge. Moreover, multiple moves or transfers can result in the wrong information being communicated to the patient and relatives, potentially delaying a patient’s discharge. Conversely, good communication and coordination contributes to a well-managed discharge and may prevent potential delays, ensuring the effective use of bed days (Salter, 2001).
The project was launched for one month from 1 February 2007. The aim was to improve the discharge process by refocusing and standardising discharge information written on ward/patient boards. It was communicated in advance to multidisciplinary team members to engage their support and ensure clear project objectives for those directly involved in patient discharge activities. The objectives were:
- To promote transparency of the discharge process and progress to the discharge plan for all involved;
- To incorporate the estimated date of discharge or approximate length of stay as part of the information included on the boards;
- Demonstrate clearly which elements of the discharge process are actively underway;
- To improve overall communication of the discharge process for the patient/family/relatives;
- To improve the flow of patients through increased awareness of the possible constraints;
- To enable and empower nurses to make progress chasing the components of the discharge plan (nurse-led discharges).
For the purposes of the project, it was agreed to display eight items of patient and discharge information (Box 1). This was based on the nature of the ward (orthopaedic) and the usual discharge process/pathway for such patients.
Box 1. Discharge information
The layout of patient information is illustrated below (Fig 1) - each card was laminated and individual details were added or wiped off. All cards were displayed on one central ward board.
The project was evaluated across the whole multidisciplinary team involved using individual questionnaires with eight focused questions to assess the staff feelings towards the change in practice. The patient board has remained in use since the project period finished. Although the ward does encompass specialist areas of practice involving outreach and early discharge teams, there is nothing to preclude these additional elements being displayed. Staff feel it has enabled them to work more collaboratively towards effective and efficient patient discharges. At the very least it was felt to be more user-friendly and professionally presented.
Summary of results
All (100%) staff preferred the new information boards but some indicated that the light reflecting on the board made it difficult to read from a distance. Ninety-one per cent of staff felt the information on the new patient name cards was appropriate, and 58% felt that no further information needed to be included. A third (33%) of staff had not made use of the OT, physio and SOOT tick boxes, although it was suggested that a social work box could be included. Some 83% of staff were happy to seek advice about estimating a patient’s date of discharge if they were unsure themselves. Half (50%) of staff were happy to include a patient’s estimated date of discharge on the board.
Good-quality, multi-professional record-keeping has a pivotal role in the discharge planning process. Nonetheless, discharge information is usually kept in a multitude of places both on and off the ward, such as in nursing records, medical notes and in the individual files of the different members of the multidisciplinary team contributing to the patient’s care. Invariably information relating to the discharge process is not easy to locate and progress to a discharge plan thereby difficult to determine. This is compounded by the fast turnover of inpatients under constant review, facilitated by frequent consultant reviews and an organisational impetus to reduce length of stay. Estimating the date of a patient’s discharge begins with the multidisciplinary team committing to a possible discharge date and then communicating this to the patient and family (DH, 2006). The ward staff involved in the project felt this was a reasonable undertaking when it was realised that the date is not static and can be guided by the patient’s progression through the care pathway (Lees and Holmes, 2005). It is unfortunate that a drive to improve patient confidentiality has relegated most patient name boards to the history archives of nursing practice. Notwithstanding, this project endorsed a pragmatic balance; visible discharge information is required for all involved and remains critical to keep the discharge process moving forwards.
Implications for practice
This project is transferable to a multitude of other wards and departments. The benefits have been divided into three phases: before, during and after discharge from hospital.
- A clear discharge plan helps to improve communication with the multidisciplinary team;
- Visibility of the patient’s discharge plan helps to avoid misunderstandings with the patient and family regarding the discharge pathway.
During the active discharge planning phase:
- An estimated date of discharge or a system that will allow staff to see ‘the parts of the process that need to be completed in the predicted timescale’ should be included on ward boards. This should help to reduce the variance in length of stay;
- When the new system has been introduced it must be promoted and reinforced continually, especially to new staff joining the ward team and rotating junior doctors new to the area.
- This system facilitates open communication with the multidisciplinary team, patient and family. Questions that are likely to be stimulated through the transparency of discharge information on the patient board will probably reduce the volume of patient complaints after discharge;
- The impact of good communication and planning should improve satisfaction in the care experienced.
The integration of discharge planning information on the patient boards has enabled the MDT to work more closely to benefit the patient through a more effective and efficient discharge process. Use of the boards promotes openness about discharge elements with the patient and family/carers to make the discharge happen. The patient boards provide a summary of key discharge actions that are in progress. Although there will be concerns regarding the amount of information that should be displayed on patient boards, the discharge process includes the same fundamental elements and principles of practice regardless of the ward environment. In particular, it should be reemphasised that an estimated discharge date on a patient board ‘is not fixed’ but does aid planning, the benefits of which should be demonstrable. This should be communicated to the patient on admission (or soon after) and, with this principle in mind, the discharge process cannot be regarded as highly confidential. Nevertheless, to ensure the boards do not become a tick-box exercise requires increased understanding of the fundamental principles of discharge planning. Including estimated dates for discharge would also help to link the admission and discharge processes, improving the patient experience of discharge from admission to hospital. It is hoped that this project could be considered in other hospitals as a means of examining the strengths and weaknesses of current practice.
Acknowledgements to: Karen Bowley (ward manager), the multidisciplinary team members and nursing staff on ward 15, Solihull Hospital.
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