VOL: 97, ISSUE: 34, PAGE NO: 32
Mave Salter, MSc, RN, DNCert, DipCouns, CertEd, is a clinical nurse specialist, community liaison, The Royal Marsden Hospital, London
A well-managed discharge benefits not only patients and their families or carers, but also health care professionals. It prevents delayed discharges and inappropriate readmissions, ensuring the cost-effective use of beds.
Ideally, discharge planning should start before or on admission to ensure the timely provision of appropriate services. The aim is to assess, plan, coordinate and evaluate patient-focused, evidence-based and cost-effective care for patients leaving the hospital.
With staff shortages and a high turnover of patients, discharge planning takes on particular relevance. Ineffective communication between hospital and community staff is not new, as research has shown (Skeet, 1970; Nixon et al, 1998; Waters, 1987). To avoid misunderstandings, close contact with the multidisciplinary and primary health care teams should be maintained.
Discharge planning in practice
Discharge planning at The Royal Marsden Hospital is carried out by clinical nurse specialists for community liaison. They aim to provide a holistic service that meets the needs of patients with cancer in both the hospital and the community.
The extensive treatment that many oncology patients receive often makes them quite ill and they may need a ‘trial’ discharge to assess whether they can manage at home. Patients and carers are consulted throughout the discharge planning process. Carers may require a needs assessment for themselves, as set out in the Carers (Recognition and Services) Act 1995.
Community liaison nurses (CLNs) aim to support patients and their carers physically, socially and psychologically when planning a discharge. Each patient’s beliefs and culture are taken into consideration. Where available, ‘hospital at home’ or ‘enhanced recovery’ projects or schemes are used. Case conferences and family meetings are arranged, where necessary, and community staff are invited to attend.
The role of the CLN includes:
- Being an educator and resource in all discharge planning;
- Promoting safe and effective discharge;
- Evaluating the effectiveness of the discharge plan;
- Preventing discharge delays and inappropriate readmissions;
- Ensuring clinical governance through audit/research;
- Providing written and visual tools to aid discharge planning;
- Networking with the multidisciplinary team.
Weekly multidisciplinary meetings are held on each ward. The CLN is a resource for simple discharges and may act as coordinator/facilitator in more complex discharges. Complex discharges are defined as follows:
- Where the patient requires a high level of nursing care or a large package of care involving different agencies;
- Where the patient’s needs have changed since admission so that several different services need to be coordinated;
- Where the family/carer requires intensive input into discharge planning considerations.
Safe discharge working group
With the aim of improving discharge planning and to meet the criteria of the clinical negligence scheme for trusts, core members of The Royal Marsden’s clinical practice forum set up the safe discharge working group. Its main objectives were to reduce the risk of poor discharge planning and share current practice on different wards to determine best practice, developing hospital-wide, systematic documentation and referral systems.
The initial remit of the group was to:
- Redesign the community care referral form for community nurses in a tick-box format;
- Standardise all documentation sent to the primary health care team;
- Identify the equipment requirements of patients and how to obtain these supplies;
- Set up in-service and outreach educational programmes.
Redesigning the referral form
The previous community care referral form for patients discharged from The Royal Marsden Hospital was time-consuming for ward nurses to complete. It was decided, therefore, to redesign the form in a tick-box format (Fig 1).
Most patients require referral to community nurses and/or local social services at some stage in their illness, so the form was revised to improve and accelerate the process of nurse-to-nurse referral. This does not take the place of but complements verbal contact between the hospital and community nurses, which is particularly important when equipment needs to be in place before the patient is discharged. Where possible, community staff are also invited to attend family meetings and case conferences. The form contains instructions for it to be faxed to the community nurses after initial contact by telephone.
All health care professionals involved in discharge planning were consulted and given a chance to discuss the project at every stage, both in the hospital’s multidisciplinary team and the primary health care team (Box 1).
Guidelines on completing the form (Fig 2), together with checklists for equipment (Fig 3) and information to be given on discharge, were collated into folders for ward and outpatient department use. The information was also displayed on the hospital’s intranet.
Before implementation, the form was piloted across the trust and forwarded for comment to district nurses and community palliative care teams. Revisions were made where appropriate. Positive feedback was obtained from all health care professionals (Box 2).
The remit of the group included planning a comprehensive teaching programme aimed at both ward and community nurses to ensure the success of both the new form and the accompanying information.
Education needs to be ongoing for sustainable change to occur, so pocket-sized guidelines were produced as a further memory aid for nurses and doctors.
A rolling programme of education to introduce the pack was instituted across the hospital, with the provision of one-to-one and group sessions for those who requested them.
This project has followed The Royal Marsden Hospital’s strategy for nursing, which includes:
- The promotion of person-focused care;
- Clinical effectiveness via evidence-based practice;
- The sharing of best practice;
- The documentation of care.
Quality discharge should not be a matter of chance (Department of Health, 1994). Communication networks between hospitals and the community are improving, especially with the government’s commitment to a primary-care led NHS.
The focus on developing patient-centred care and services closer to where people live will depend on primary, secondary and tertiary centres working effectively together. Discharge planning is a key example of where this kind of team work is crucial.
- The author would like to acknowledge the help and support of Miriam Wood, informatics/project nurse and The Royal Marsden Hospital