VOL: 102, ISSUE: 18, PAGE NO: 28
Liz Lees, MSc, BSc, DipN, DipHSM, RGN, is consultant nurse (acute medicine)
Gaynor Allen, RGN, is senior sister, emergency admissions ward; Diane O'Brien, RGN, EN, ONC, is senior sister, emergency admissions ward; all at Heart of England NHS Foundation Trust, BirminghamLiz Lees, MSc, BSc, DipN, DipHSM, RGN, is consultant nurse (acute medicine)
During 2004 'discharge instruction labels' were implemented as part of the post-take ward round and discharge process on a 48-bed emergency admissions ward, the medical admissions unit (MAU) at the Heart of England Foundation Trust, Birmingham. On admission to the MAU, a distinctive red-edged label was inserted into patients' documentation to record an outline of their discharge parameters. The team conducting the post-take ward round were asked to tick boxes to document discharge or transfer destination and to estimate a date or approximate length of stay, taking into account when a patient might be fit for discharge.
An audit of the labels demonstrated that they were rarely completed fully. The best compliance was achieved for the transfer destination. The area least likely to be completed was estimating the length of stay (date of discharge).
Nevertheless, discussions with the ward clinical coordinators revealed that they unanimously believed the labels positively influenced the coordination of discharges and transfers. The labels also provided a starting point to improve the clarity of simple discharge instructions beyond the scope of the doctor.
The labels have been supported from the outset by the discharge action team. This was set up specifically to progress simple discharges from the MAU.
A ward clinical coordinator role was introduced in the emergency admissions ward to assist the flow of patients from admission to discharge or transfer (O'Brien and Lees, 2005).
Coordinators are involved in numerous interactions, liaising between patients, clinical teams and departments. A fundamental aspect of the role is to support the numerous medical teams, therapists, other health professionals and patients during and after the post-take ward round to ensure actions, such as investigation results and discharge decisions are dealt with efficiently. While patient management decisions take place at the point of the post-take ward round, the responsibility for fulfilling the actions often rests with the ward coordinators and nursing team, long after the post-take ward round has finished.
The clarity of instructions arising from the post-take ward round is imperative, especially to facilitate simple discharges (Department of Health, 2004). Even minor delays in the process can inconvenience the patient and also potentially limit capacity to admit new patients within the time parameters of the emergency care pathway (DH, 2004).
Management plans in context
Post-take ward rounds on MAUs are a hugely important point in patient care for reviewing the initial patient history, examination and early investigation results (Thompson et al, 2004). However, experience suggests not all the information discussed or decisions made are always passed on to wards or consultants receiving patients (Coni, 1998). Pro formas and management plans are not new ideas and have been implemented successfully to document the decisions made on a post-take ward round (Thompson et al, 2004).
While patient review by a consultant or senior doctor is a crucial role of the post-take ward round, medical management is not the sole function or only plan that arises from this. The participation and contribution of nurses acting as the patient's advocate and conveying up-to-date patient information is also essential (Busby and Gilchrist, 1992).
More recently approaches to discharge and capacity planning require clinical practitioners to estimate a patient's length of stay (DH, 2003). Introduction of processes to facilitate this have not been without problems and it has proved a relatively contentious area of practice (Lees and Temple, 2005).
Consequently, the post-take ward round and subsequent management of patient care arising from it is multifaceted. It can be divided into four phases:
- Engaging the medical and multidisciplinary team in the post-take ward round discussions and decisions that arise;
- Listening to and involving patients in decisions about their care;
- Using a pro forma that clearly documents discussions including discharge/further placement plans and predicted length of stay or estimated date of discharge;
- Empowerment of the nursing team and multidisciplinary team to carry out actions and problem solve, after the ward round is finished.
The label was designed to provide a focus on simple discharge or transfer decisions at the point of a post-take ward round. Patients are admitted to the MAU from the A&E department.
There can be up 16 consultants conducting ward rounds at one time. With numerous consultant teams working on the MAU, not surprisingly problems such as a lack of information in the plan and inconsistent (poor) standards of documentation had been encountered following post-take ward rounds.
The label was purposely kept simple, distinctive and small (Fig 1). It was piloted for a month, after which an audit was conducted to seek the views of the different teams who had used it.
We sampled 50 of the first 400 labels from the medical management plans. The date, time and consultant were provided on all 50 labels and the categories (1-4) were all completed.
The sections 'Investigations required' and 'Referrals required', were not consistently indicated as actions required following transfer. The most commonly requested investigation was a repeat ECG and referrals were frequently made to the discharge action team. The section 'Estimating a date for discharge or length of stay' was relatively new and it was only completed on six of the 50 labels. The section on 'Follow-up required' was completed in two out of 50 labels.
The label was adjusted to take account of feedback received and incorporated different categories and the patient identification number (Fig 2).
It was felt that using numbers gave rise to confusion between the ward number and transfer destination when placed next to a patient's name. Two other more subtle changes were made on the more practical aspects of the plan:
- Indicate whether tablets to take out (TTO) (discharge medications) are required;
- Rather than trying to indicate a date of discharge, indicate a predicted length of stay in days.
The early 'selling points' of the new label were that: l It did not demand any extra time to complete as it used tick boxes (based on the categories most relevant to an admissions ward);
- It did not replicate information already collated as part of the admission process;
- It provided an opportunity for clinical input to decisions regarding the placement of patients and to assist bed management.
Audit at 12 months
In a survey conducted after the first 12 months benefits were identified by the coordinators and other staff using the label. These included that the label was:
- Quick to complete;
- Relatively easy to implement;
- Distinctively recognisable;
- Standardised information was provided;
- Discharge medication requirements can be predicted so appropriate supply is more likely;
- Helps to discriminate between patients requiring therapy input and those most suitable for discharge;
- Perfectly transferable to other directorates by changing the categories.
If this idea were to be replicated elsewhere, further aspects would need to be considered:
- Time available for nurses to join the post-take ward round;
- Acting upon decisions made after the post-take ward round;
- Promoting the role of the ward nurse to join the ward round;
- Engaging the medical profession for input about length-of-stay decisions.
During early 2005 discharge labels were abandoned in preference to discharge information as part of a new post-take ward round management plan.
The new approach was adopted to improve the quality of information included in the overall patient management plan. The plans have been produced on yellow paper to ensure their profile and purpose remains distinctive.
Although there was some early resistance from junior doctors, the forms are now routinely requested by the admitting teams on their post-take rounds. Doctors were concerned that the post-take ward round forms would take longer to complete and require unnecessary information. Several amended versions of the post-take ward round form have been developed following discussion with junior doctors at their admitting forum meeting and significant support from the associate clinical director (acute medicine).
Despite the initial scepticism the forms have been adopted on the elderly care admissions unit in a slightly different format. For example, they incorporate a frailty scoring system.
Initial feedback suggests the information provided on the forms has been clearer for members of the multidisciplinary team to follow, especially if they are unable to join the post-take ward round. Discharge decisions are ultimately multidisciplinary and not exclusively the doctors' role, hence nurses who join the post-take ward round must also encourage and prompt the recording of length of stay (Lees and Temple, 2005).
Nevertheless, documenting a length of stay should not become a tick-box exercise. To become truly successful it must be shared with the patient/relatives and be embedded into bed management processes.
Furthermore, it has been widely acknowledged that focusing on length of stay requires a complete change in organisational culture with the responsibility shared from the outset and during induction to the trust.
Discharge planning at the post-take ward round needs to be recognised as a fundamental role, especially in determining features of potential patients likely to be suitable for discharge or transfer.
The discharge labels were a useful place to highlight discharge decisions and estimate a patient's length of stay. It is possible that without these labels the development and implementation of the post-take ward round management form may have been impossible to achieve (Box 1).
This said, a piece of paper forming a plan cannot make discharge happen or ensure results are moved forwards. The input of the multidisciplinary team and a nurse representing patients on the ward round are also needed. A crucial part of this process is to achieve support from senior doctors to promote and embed the post-take ward round management plan. Beyond the plan must be a process that achieves best practice as part of what is expected in the organisation, rather than an optional extra.
- This article has been double-blind peer-reviewed.
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