Chapter 15 Preparation for discharge
This chapter will describe:
• the importance of discharge planning and impact of perioperative scheduling
• key policy drivers for early discharge
• the challenges in active discharge planning process
• developing effective discharge bundles
• managing complex discharges
• coordinating discharge with multi-agencies.
This chapter will explore the optimal discharge process for patients undergoing surgical procedures and provide an in-depth analysis of discharge planning, including the contemporary perspectives of the nurse’s role in facilitating patient discharge from hospital. It is also acknowledged that nurses facilitate the process of discharge from many other healthcare settings, and the principles of practice discussed are transferable across many areas.
The chapter begins by discussing the potential challenges when discharging surgical patients. It offers a detailed overview of the governmental policies creating the impetus to modernise discharge processes. Perspectives such as change management, bed management and team working, which influence the process of discharging patients from hospital, are discussed. Moreover, leadership, responsibility and accountability will be explored in relation to expanding the nurse’s discharge planning role. A distinction will be drawn between nurse-led and nurse-facilitated discharge from hospital. This distinction will be supported by principles of good practice, including protocols that should enable the discharge process to operate in a timely manner. Furthermore, competency and educational development and supplementary approaches will also be explored. Throughout the chapter, examples will be used to identify some of the systems and processes that need to be in place, if we are to assist nurses in their role as a focal point for discharge planning.
Core elements supporting best practice in discharging patients include:
• hospital policy guidance
• change management processes
• proactive discharge planning
• excellent multi-disciplinary team working
• information technology: transparency and information sharing
• excellent pharmacy support
• nursing leadership skills
• ward coordination: role and functions
• good skills in patient assessment
• discharge training: sustained
• competency development
• timely patient information.
The challenges for discharging surgical patients
Surgery is often referred to as planned activity constituting the ‘bread and butter’ of a hospital’s core business. Consequently it must be supported by processes and practices at a strategic level which control the flow and overall patient capacity.1 Conversely, the business of medicine is generally unplanned activity and the patient demand/flow is relatively unpredictable, making it impossible to include a preadmission phase. Notwithstanding, surgical patients do present as emergencies and these patients can be more challenging, with the added complexity of recovery from invasive procedures, and emergency presentation precludes any preparation for discharge. To ensure such emergency patients are expedited efficiently from hospital, systems must be in place to act quickly and ensure consistency with ‘normal’ preadmission processes, postadmission.
While the complexity of the discharge process may be regarded as simpler for young and relatively independent patients requiring surgical interventions, one miscommunication or error can be just as catastrophic for the patient and organisation, such as forgetting to prescribe or administer bowel preparation preoperatively. A miscommunication with letters (especially if the patient has moved address or GP) may result in cancelled surgical procedures and operations. From experience it is often a misplaced laissez faire attitude to the ‘simple discharge’ which may result in a failed discharge, poor patient experience or readmission.
The discharge process must be actively managed to reduce and control the number of variables, which will in turn increase the likely positive outcome for the patient. Moreover, greater collaboration is required to share best practice in caring for patients with complex discharge needs. Furthermore, care of patients should involve appropriate practitioners at the outset of care regardless of professional base; for example, a patient having had surgery may need specialist mental health and elderly care support. To address discharge planning challenges in detail requires a thorough understanding of each stage in the discharge process, namely:
• point of referral (emergency or elective)
• preoperative management
• admission (likely investigations and recovery time)
• rehabilitation and enablement (early involvement of the multi-disciplinary team)
• predischarge preparations (bespoke details to individualise plans)
• day of discharge
• follow-up care.
There are many policy documents driving different perspectives of care; those that specifically address the surgical component are briefly outlined below.
Spotlight on surgery
The NHS Plan (2000) stated that 75% of all surgical interventions will be carried out as day cases1. The drive towards shorter lengths of stay widely advocates access, booking and choice at the centre of care planning for surgical patients.2 Following this, a specific guide detailing patient condition groups and operational guidance for their management was published.3 In the move towards redesigning surgical services, four main considerations were suggested, which could easily be applied to discharge planning, namely, increasing the volume of patients whose care is managed in primary care, use of care protocols, commissioning of services and carrying out minor procedures in primary settings. It also states that moving towards more day surgery ‘should not impact upon the work of GPs and primary care’.3 While it offers brief guidance on discharge planning it somewhat oversimplifies the whole process. A key aspect that must be addressed when embracing such policy is to ensure sufficient supply of primary care and social services to support aftercare, following discharge. For example, we have an ageing population, whose needs may be overlooked without the involvement of experienced practitioners who understand the ‘simply risky’ elements to discharge planning that cannot always be anticipated and thereby managed in advance of surgical procedures. The multifaceted elements associated with ageing may mean such patients are not managed consistently, for example, with different processes for inpatients and day surgery.
Discharge policy: key changes
The principles underpinning discharge planning remain largely unchanged despite large-scale organisational NHS changes since its inception. Perhaps the core challenges affecting the discharge process arise from: rising numbers of emergency admissions, changing patterns for patient referrals, shorter lengths of patient stay and the acuity of patients admitted to hospital. In addition, the gradual and sustained advances in new roles have played a large part in adapting the nursing response to changing clinical practices, including discharge planning. For example, discharge planners and coordinators are now commonplace. However, the changing NHS has altered patient/carer needs and expectations, and thus the commissioning of services, stimulating further changes in discharge planning practice.4,5,6 Therefore policy documents are placing more emphasis on changes required in specific areas of discharge practice and, in particular, the nurse’s contribution to those.7 Some of the key areas are discussed below.
Chief Nursing Officer’s ten key roles for nurses
From a nursing perspective, the Chief Nursing Officer of England responded to the NHS Plan with the ten key roles.1 This creates new opportunities for some and increased responsibilities for others, depending on the extent to which nurses are proactively involved in discharge planning and implementation of discharge. This change process will stimulate development of new organisational policies, protocols and training, which will serve to protect both the employing organisation and individual practitioner in expanding their role and taking on new practices.8 It will also promote the development of new teams and instigate innovative ways of working to benefit the patient. Finally, the scale of change will elicit integrated working practices outside the hospital in different organisations that deliver health and social care.
In most cases policy stimulates new ways of working; in others it may provide additional support to a change already being practised by nurses. Yet the case of discharge planning policy appeared to revive interest in the focus of the nurse’s role, most notably after the announcement of the Chief Nursing Officer’s ten key roles for nursing.1 The inclusion of the key role ‘admitting and discharging patients’ has elevated discharge practices from arguably an everyday matter to a high–profile part of patient care. The journey to achieving this key role in practice is dependent upon many different organisational facets impacting upon many professional groups, and adjusting responsibility for discharge planning.
Single Assessment Process
The concept of the Single Assessment Process (SAP) was introduced after the National Service Framework for Older People was published in 2001.9,10 It is aimed at all clinical areas where the care of older patients is taking place. While the process of implementation was initially arduous, its intention to simplify and integrate assessments formed the precursor for new ways of working between health and social care. Best Practice documents raised the profile of health and social care working together, requiring a step outside the nurse’s traditional role in hospital, to integrate not only professional practices but organisational systems, to guide the patient’s discharge.11 Concurrently, changes in the funding aspects of patients delayed in hospital, while waiting for social care arrangements to be put in place, brought about another process known as recharging.12 While this requires nursing responsibility to instigate, through its inextricable links with the discharge process, arguably it has been seen as a separate or parallel process. Enquiries in the surgical setting have revealed that the SAP is seen to sit outside ‘usual discharge practice’. The advantages of completing the SAP are therefore outweighed by its lack of integration within hospital information technology systems and a lack of understanding of the overall benefits it could bring to patients. One key area of consideration should be to ensure that information technology systems interface and information can be exchanged between systems without the need for duplication of data entry. The biggest impact of the SAP is slowly but surely being realised through the action of estimating dates of medical fitness to discharge and perhaps estimating the length of stay or discharge date itself.
Key named discharge planners
A noteworthy, inspiring guidance document, namely Freedom to Practise, combined emergency care policy with case examples of patient care from the point of referral to the point of discharge; it included mechanisms to facilitate nurse leadership in the discharge processes.13 Its radical approach placed tangible support behind traditionally bureaucratic processes, which often seem distanced from the reality of everyday clinical practice. A second area of policy focus, reiterated in several policy documents, recommends the practice of developing key named persons to act as discharge coordinators at ward level. This suggestion was meant to provide members of the multi-disciplinary team and other agencies with a named person to liaise with, who would coordinate the discharge plan.14
Discharge policy was further refined by its specific focus on ‘discharge checklists’ as part of the process. Once more the policy guidance was virtually ‘directive’, reinforced at hospital board level through its inclusion as a measurable facet of Trust performance in the Clinical Negligence Scheme for Trusts.15 The CNST stipulates a named person in the discharge plan and the use of a checklist providing a quantifiable audit trail, to determine the components of discharge that have taken place.
Reasserting the nurse’s role – nurse-facilitated discharge
Finally, another toolkit was introduced, which would reassert and embrace the nurse’s role in facilitating timely discharge from hospital.16 This aspect is addressed in detail later in the chapter; timely discharge combines the concept of estimating dates for discharge, nurse led or facilitated discharge, and improving all processes (by removing blocks) relating to a simple discharge. Almost all hospitals have adopted some parts of the redesign suggested, yet standardisation and lean approaches continue to rely on innovative practitioners rather than strategically resourced approaches. Inevitably, national evidence of published projects reveals disparate practice is rife, ranging from well-developed highly innovative local policy and protocols to small-scale projects with little strategic support to sustain good practice. Organisational readiness is imperative in order to support nurses, who alone cannot achieve the scale of change required to embrace the concept of nurse-facilitated discharges. It is the inextricable links with other practitioners that are vital in balancing policy, understanding and embracing this concept.
The sustainable introduction of new or innovative ways of delivering discharge practice rests firmly with systematic introduction of new processes. This impacts directly on the nursing profession, though nurses may perceive this to be dominated by new paperwork and systems of collecting data.
A few words about change
Despite this positive perspective, ‘change’ is quite a frightening prospect for some professionals and not necessarily readily adopted in the area of discharge practice. In health care, professions may attempt to maintain control by keeping the status quo as well as through professional protectionism. This is often reinforced by oppressive strategies deliberately used to slow down the pace of change, especially if the change is seen to adversely impact upon role development.17 If a method of facilitating this change is not used, often it is easy to misinterpret the implications, giving rise to tension. To counterbalance possible misapprehension and fragmented practices (reactive to proactive discharge planning) organisations should try to develop a culture of sustaining new practices, rather than adopting a ‘must do by the end of’ mentality, which may only serve to constrain development or shorten the shelf life of the change. Therefore, change must be managed effectively and preparation, planning and discussion are crucial to ensure success. This is particularly important when change is occurring because of wider agendas and priorities which may not seem apparent at practice level.
Processes which directly impact upon discharge planning
Bed management is not a new concept; indeed it is a fundamental aspect of every hospital’s working day.18 So why is it perhaps seen as a separate role from that of clinical professionals? Posts of this nature were originally appointed to relieve pressure on the nurse’s role, yet they most certainly require nursing input. The root of managing beds started in nursing, but perhaps the migration of this role into a separate management post mitigates against promoting clinical perspectives of care which proactively manage the process of patient admission and discharge. There are many texts written which explore capacity management and large organisational systems, yet perhaps because of their remoteness from clinical practice they tend to be seen as of little relevance. It could be argued that lack of bed capacity and intensive turnover of patients with a higher acuity creates untoward clinical pressure and is potentially at odds with ‘caring for patients’, creating a culture of counting patient throughput (in time) rather than measuring quality of care. A constructive way forward may be determined by asking what it is we want these roles to achieve. What approach should be used? Is a universal role the answer? This said, a variety of bed management models can be seen throughout the country, such as: non-clinical bed coordinators, strategic bed managers, computerised data entry systems (only as reliable as the person entering the data). I firmly believe that decision making based on clinical expertise is at the centre of managing beds.
An ideal model embraces the nurse’s unique knowledge of the patient, with knowledge of systems and process, as part of a problem-solving approach. One model developed at the Heart of England NHS Foundation Trust in the UK involves a clinical coordinator. This serves to focus responsibility for the discharge and effect clinical coordination of patient’s needs and to free the hospital bed earlier in the day. However, this approach is not without its problems. For example, all areas need to adopt a uniform approach to such roles to achieve a uniform degree of momentum across the organisation, placing as much pressure on the internal transfer of patients as on discharge. Cost-effectiveness needs to be explored, aligned with freed bed capacity while considering patient satisfaction and patient-centred care; without all this, discharge coordinators may be regarded as an expensive luxury, once again ‘here today and gone tomorrow’.
Team work may be in a state of demise with a huge aspect of the nurse’s role centred around coordinating a ‘group’ of staff rather than a ‘team’ of staff working together on a shift.19 Understanding the difference between ‘group’ and ‘team’ is important if nurses are to begin to appreciate the root of some discharge planning problems. For example, a ward team can be defined as being made up of consistent staff members with clearly defined roles20 belonging to that ward. In addition, a team will have a shared or common purpose,19 such as achieving the discharge plan within a defined timescale. This is hugely important from the patient’s perspective along what may be quite a complex route to discharge from hospital.21 Perhaps the systems that are established to manage services lie at the roots of the demise of team work. Invariably, staff are moved to ensure safe staffing levels; agency and bank nurses, while crucially needed, are often used to ‘top up levels of staff’ to established levels per shift. Moreover, temporary wards with flexible capacity are often opened to serve times of additional pressure, with skeleton staffing and agency or bank nurses, who do not know each other’s strengths or specialist knowledge base. Furthermore, such wards are often closed at relatively short notice, having a catastrophic effect on the essential communication and handover of the process of patient discharge plans. Effectively pulling together a discharge plan is a multi-professional and coordinated activity, but is more often than not facilitated by nurses. Organisational practices of this nature will constrain the development of nurses’ knowledge, extend patient lengths of stay through fragmented communication and perhaps promote a lack of ownership of discharge planning.22 The notion of a team involves accepting responsibility and growth in knowledge and skills.19 It must be remembered that the team also includes allied health professionals and doctors. Hence, it could be argued that reducing junior doctors working hours and the shift away from ward-based teams of doctors has also fragmented our concept of a team. The final element of this disjointed picture is completed when patients are also selected as suitable for moving to ‘flexible capacity wards’ (often at short notice) where the continuum of care may also become fragmented, resulting in processes being missed altogether or duplicated. Nonetheless, it has moved responsibility to nurses who have the greatest patient contact spread over 24 hours a day, seven days a week. Perhaps nurses are in a position to assert some control by stating what it is they need (tools, resources) and how they need to work.23 Without doubt, to achieve nursefacilitated discharges effectively will require strong leadership from nursing.
Developing the culture: perspectives on leadership
‘Passion, drive and commitment’ are three essential aspects of developing a culture of nurse leadership irrespective of the particular subject being explored.19 Passion about discharge planning may arise from an intimate knowledge of the subject and the desire to carry out the role. The drive may be helped by understanding the organisational goals; this will help nurses have a sense of ownership of the fundamental principles of proactively being involved in patient discharge. Drive and commitment go hand in hand, particularly regarding discharge planning, where ownership of the problem or issue, by tracking its progress until it is resolved, is crucial. For example, rather than leaving an issue to chance, handing it over to others or disowning the issue altogether, it will require follow-through, regardless of shift pattern or which professional it was handed to. Conversely, the patient acuity and complexity of care makes it notoriously difficult to keep track of ‘who did what’, ‘what the result was’, and ‘its implications for patient care’, ultimately impacting on the discharge plan and length of stay (see Box 15.1).
Box 15.1 Case example: what plan?
Junior doctors on an acute medical ward made a physiotherapy request for an oxygen saturation assessment and mobility assessment, only to discover that the physiotherapist had in fact already discharged the patient from her care earlier in the week. In this case the central facets of the discharge plan were not stated at the outset of care; while individual therapy referrals had been made, the notion of waiting in a queue for a series of single unconnected events to take place was evident, leaving the outcome, or desired outcome, uncertain/open-ended.
Hence, it requires a significant commitment from the nurse to take and accept responsibility, focusing upon creating discharge plans as a priority, amongst the many other aspects of nursing care that have to be delivered. Leading the plan requires sustained commitment to regularly review the patient’s progress and to assert control. The change to leadership mentality demands that nurses question the way they organise themselves to deliver care.
Nurses assert that they feel overwhelmed with activities and tasks, but organisation and leadership help to create valuable time. For example, in the case of discharge planning and the busy acute hospital environment, perhaps we are too tied up in the individual task, rather than understanding where we are in the process and thereby which tasks will achieve the biggest impact in the time we have. There is an overwhelming need to be able to clarify with all professionals involved the patient’s individual needs, over approximately what indicated time scale, in a discharge plan.24,25,23 This must be supported by principles regarding the process and outcome desired (see Box 15.2). All of these contribute to the estimated date of discharge.
Evidence from the case notes from patients who have had reasonably short lengths of stay
Box 15.2 The fundamental principales of discharge planning
1. Knowledge of disease process or condition
2. Estimating how long recovery might take, or if recovery is a realistic outcome
3. Involving the patient and family and carers in the plan
4. Proactively dealing with issues and difficulties that may arise
5. Communicating and documenting the plan to the team or group of staff
6. Making appropriate referrals and following through outcomes
7. Coordinating and owning the discharge information
8. Being decisive and carrying out activities
9. Reviewing and updating the progress of the plan
10. Disseminating accurate information to all involved