Patients who are waiting to go home can become frustrated by delays. Nurses should develop systems to ensure patients receive a smooth and timely discharge
Liz Ward, RGN, is associate, high impact team, NHS Institute for Innovation and Improvement; Katherine Fenton, MA, RCNT, RM, RGN, is chief nurse and director of clinical standards and workforce, NHS South Central; Lynne Maher, DProf, MBA, RGN, is interim director for innovation, NHS Institute for Innovation and Improvement.
Ward L et al (2010) The high impact actions 8. Ready to go – no delays. Nursing Times; 106; 34, early online publication.
In recent years, discharge initiatives which aim to free up hospital beds have become commonplace. However, new systems such as bed management have left many nurses feeling disengaged from the management of patient admission and discharge. Nurses feel pressurised into speeding up discharge by the increasing focus on bed capacity and patient turnover. This can make them feel distanced from their primary role of caring for patients.
While new roles and initiatives can be valuable, changing the way nurses engage with discharge is key. Ensuring that discharge is nurse-led will lead to faster discharge and less frustration for patients who are waiting to go home.
This article, the last in our series on the high impact actions for nursing and midwifery, looks at how nursing staff can respond to the issue of discharge planning.
Keywords: High impact actions, Discharge planning, Bed management
There is a common misconception in the NHS that delays in discharging patients from hospital are unavoidable as certain processes cannot be speeded up. Sometimes, effective discharge is regarded as being less important than speedy admission. Nurse-led discharge may be perceived as risky, or discharge may be regarded as wholly the responsibility of one group of healthcare professionals. In many cases, hospitals believe that clinical management makes estimating discharge dates impossible.
It is not just the frustration and inconvenience caused to patients that makes timely discharge a pressing issue - the average patient on a surgical ward costs up to £400 per day (Webber-Maybank and Luton, 2009), so there are financial benefits too. A reduction in the length of stay by 2-6 days per patient could save NHS trusts an estimated £15.5-£46.5m a year (NAO; 2000). For the NHS as a whole, the House of Commons Health Select Committee (2002) calculated that beds being occupied by patients who could be discharged represented an annual cost of £720m.
What can nurses do?
Nurses can take a lead by developing clear systems and processes to ensure smooth and timely patient discharge. Nurse-led discharge enables hospitals to offer a discharge that is better planned and has fewer delays. This leads to a more positive patient experience, with a lower risk of healthcare-associated infections.
While implementing nurse-led discharge does not necessarily require additional roles and investment, it should be recognised as an extended role. It should be voluntary and come with training, backed by clear guidance and policy.
To make nurse-led discharge work, the whole discharge process needs to be evaluated. The best place to start is by reflecting on your organisation’s effectiveness. The Department of Health’s (2010) Ready to Go? – Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care will enable you to evaluate your own practices and identify where changes are needed. Discharge planning should begin at the admission stage.
The Essential Collection (NHS Institute for Innovation and Improvement, 2010) includes four case studies from different settings. In each case the healthcare organisation has succeeded in addressing the issue of patient discharge.
Case study 1: Discharge and extended neonatal outreach
Cambridge University Hospitals Foundation Trust’s neonatal unit developed discharge and extended outreach services to get babies home safely and in a timely manner.
The unit takes babies from 23 weeks old and has 33 cots, including 17 equipped for those needing intensive care. It cares for 950 babies each year.
With more preterm babies now surviving and one in eight babies needing some form of neonatal input, there is increasing demand on services. However, staff were facing bottlenecks and length of stay was increasing.
There was a lack of clarity surrounding transitional care and staff needed to make savings through the capacity improvement programme. The unit introduced a discharge coordinator whose role is to get babies home. It also invested in an extended outreach team to support babies with nasogastric (NG) feeding tubes.
Impact of the initiative
Babies are now being discharged earlier. There is better planning and preparation as everyone is aware of the discharge date. Documentation is being revised so that parents can take greater control. The team now identifies teenage mothers for extra support and works with the local hospice to improve end of life care.
Staff are working towards greater standardisation by aligning the criteria for outreach tertiary referrals. It is estimated that this frees up 1.4 cots per day in the unit, at a cost of £450 per day. The team is generating money by delivering a national training course and the outreach team is helping to prevent readmissions by reinserting NG tubes in the home.
Case study 2: Paediatric nurses discharging patients
At the same hospital, children were facing long waits for consultant discharge, which usually happened at the end of the day. Some parents wanted to leave without seeing the doctor, resulting in a note of “left without medical advice” in children’s notes. A retrospective audit of 646 patients, carried out in 2007, found that 39% of discharges were delayed by more than four hours, 21% by more than six hours and 11% by more than eight hours.
The trust introduced a pilot scheme to provide nurse-led discharge. A project group was established, giving all medical colleagues the opportunity to comment, and an education programme was developed to provide training and supportive documentation. In May 2008, the nurse-facilitated discharge policy and procedures were ratified.
Impact of the initiative
Of the 588 discharges that took place on the children’s wards between April and September 2009, 410 were nurse-led. The experience for children and parents has improved, as the nurses who looked after them during their stay are responsible for discharging them. Nurse-facilitated discharge is now being introduced on a number of adult wards. A pro forma has been developed to allow nurse-led post-surgery wound review to take place on the ward. The team has also developed a patient group directive to allow nurses to administer an oral sedative to children undergoing scans on the ward.
Case study 3: New discharge facilitator roles
NHS North Staffordshire Community Healthcare has 180 beds across three community hospitals. It handles GP admissions and provides rehabilitation and end of life care. Many patients were being admitted for continuing care and had an average length of stay of six weeks. The trust identified delayed discharge as a problem; one hospital site was being used as a nursing home, with some patients staying for up to five years. There were waiting lists in acute trusts for transitional care, and the number of acute beds was to be cut by 300 across the local health economy.
The trust developed services to provide sub-acute and acute rehabilitation. It appointed a discharge planning lead and, under the new system, an estimated discharge date is established within 48 hours of a patient’s admission to hospital. Documentation has been revised and all ward managers now receive training in discharge planning. Patients undergo an assessment by occupational therapists within 24 hours of admission.
Impact of the initiative
Sixty per cent of patients now leave hospital on their estimated date of discharge. The trust has reduced length of stay from six weeks to four and achieved 98% bed occupancy. Individual hospitals manage their own waiting lists. Readmissions for patients with chronic obstructive pulmonary disease have been cut from eight or nine a year to just two or three.
Case study 4: An urgent help service for adolescents
Sussex Partnership Foundation Trust set up a community outreach team eight years ago. In 2009, it opened a new purpose-built adolescent unit catering for 12-18-year olds, which takes around 60 admissions a year, half of whom have eating disorders. The average length of stay was 2-3 months. Consultant-led admissions meant that patients required assessment in clinic, which resulted in waiting lists.
The trust redesigned its outreach team in conjunction with key stakeholders. It developed an urgent care service, led by mental health practitioners, to provide intensive support to patients. The service supports weekend leave for patients needing to be discharged. Speeding up discharge has been part of an overall approach to reducing hospital admissions.
Impact of the initiative
Urgent care teams respond to all urgent referrals within four hours. The teams are exceeding their targets of 15 contacts per clinician per week. The trust now has a more streamlined referral service, supporting 80 families. Length of hospital stay has reduced from 2-3 months to 6-8 weeks.
Box with HIA logo] The Essential Collection, plus literature reviews for each HIA, can be downloaded from the NHS Institute website. This also contains an opportunity estimator so that you can calculate potential savings, and a range of tools and resources. Go to: institute.nhs.uk/hia
What are the best sources of information?
- Department of Health. Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care.
- Department of Health. Achieving timely ‘simple’ discharge from hospital. A toolkit for the | multidisciplinary team.
- Community Care (Delayed Discharges etc.) Act 2003.;Explanatory notes
- NHS Institute. The Productives Series Admission and Discharge modules
- National Audit Office: Ensuring the effective discharge of older patients from NHS acute hospitals.
Webber-Maybank, M., Luton, H. (2009) Making effective use of predicted discharge dates to reduce the length of stay in hospital. Nursing Times; 105: 15, 12-13.
National Audit Office (2000) Hip Replacements: Getting It Right First Time. London: NAO.
The Select Committee of Health (2002) Health – Third Report: chapter 1. London: Stationery Office.