Discharge Planning and Practice
News and updates from today’s conference looking at effective discharge planning and practice to improve transfer of care
Hospital to Home: Changing the way discharge planning works to achieve 0% of overstaying older people
Dr David Evans, Chief Executive, Northumbria Healthcare NHS Trust
Dr Evans comments:
"Common sense check list - It's about getting it into peoples minds what they need in place to get home.
Patients given a 24 hour call number so they can speak to the ward in an emergency.
It doens't always have to be a Consultant that discharges a patient - Nurses, Pharmacists, Therapists, OTs.
For elective care, pre-assesmnet pays dividends in getting home after proceedure.
It's the patient that important, not our system.
With no admission there will be no discharge - Admission avoidance: Short term community team, Marie Curie, Consultant/GP helpline, Ambulance support, 'Airedale lite' & frailty support. Right care, PACS vanguard, Community clinical pharmacists."
Monitoring progress against the NICE Guideline on Transition between inpatient hospital settings and community or care home settings for adults with social care needs
Dr Olivier Gaillemin, Member, Guideline Development Group, Transition between inpatient hospital settings and community or care home settings for adults with social care needs, NICE, and Consultant Physician in Acute Medicine, Salford Royal NHS Foundation Trust
It is to be celebrated that more people are living longer. With that comes a change in requirements for those needing to access health and social care, particularly those with unplanned admissions to secondary care. Current systems are not optimised to meet the needs of those with multi-comorbidity, possibly living with frailty and who may be requiring social as well as healthcare. As a result systems are failing themselves and those they profess to support. It is not hard to find numbers to reflect this, from failed Emergency Department Standards, to numbers of people trapped in hospital badged as “Delayed Transfers of Care”. Human stories from multiple sources – AgeUK / healthwatch / the Parliamentary and Health Service Ombudsman - give meaning to the numbers.
How to improve?
A person-centred approach will often give us the answers. Multiple sources of good examples to locally driven, person-centred, “joined-up” approaches to services exist. Much of the recommendations made and services developed feel “intuitively right”/“common sense”. Is there evidence to back this up?
NICE (National Institute for Health and Clinical Excellence) and SCIE (Social Care Institute for Excellence) collaborated to bring us the evidenced guideline (NG27) and quality standard (QS136): Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
A few points to highlight:
1. A focus on Person-centred care: Both see people receiving care as an equal partner who can make choices about their own care and involve families and carers in discussions about the care being given or proposed (if the person gives their consent).
2. Communication and information sharing: A focus to ensure that the person, their carers and all health and social care practitioners involved in someone’s move between hospital and home are in regular contact with one another. This will require building communication protocols.
The Quality Statements identified in QS 136 are a good place to focus efforts initially, probably having identified those areas where the biggest gains can be had.
As an example we in Salford developed a Frailty Unit embedded within the Acute Medical Unit which allows us to deliver Comprehensive Geriatric Assessment at the point of admission to secondary care. The outcomes for patients and the system have been positive and maintained.
The process of developing the unit has been an iterative one using Quality Improvement methodology, PDSA cycles and regular QI meetings. We see this as the key to delivering on much of the recommendations made in the NICE guidance with every locality and service having different strengths and requirements. Giving staff the tools and time to work to develop their service at times, guided by patient experience, can pay great dividends.
The solutions are multiple and where people have had time to explore them and implement them, the examples of excellent practice equally abound. Learning from these and closing the variation gap – Getting It Right First Time – will be positive for all.
Dr Gaillemin comments:
"A discharge co-ordinator is there to minimise duplication, they are a point of contact. It can be someone different each day appointed at the start of the day"
"We're obsessed by complexity and we forget to do the simple things like talking to someone"
A collaborative approach to improving safety at discharge and transfer of care
Eva-Maria Carman, Research Associate, Human Factors in Complex Systems Research Group, Loughborough Design School, Loughborough University
The discharge process has been identified as a potential area of risk for patient safety and as a possible area for cost containment. Despite numerous case studies being undertaken to develop interventions to improve the efficiency and safety of this process, an effective intervention is not yet at hand. Patient safety experts have agreed that the most effective solutions to improve hand-over communication and the discharge process will require a systems approach.
This project was initiated to undertake human factors and ergonomics analysis of the discharge process with the aims of developing a better understanding of the system regarding patient discharge. This required the identification of risks, influencing factors, potential reasons for delays and failures in this process. The project consisted of three phases, namely a database analysis phase, a pre-discharge analysis phase and a post-discharge analysis phase. The methods adopted in this project included incident report analysis, observation and focus groups. Both staff from acute care and community care that were involved in the discharge process were included. The results were derived from the analysis of 348 incident reports, observation of five Target Action Group meetings with hospital staff, three focus groups with a total of 14 participants conducted with hospital staff, and six focus groups with a total of 39 participants conducted with community staff.
This explorative study investigated not only the types of things that can go wrong with the discharge process, but also the aspects the work well and promote patient safety from both community and hospital perspective. The elements explored included defining a good discharge, potential errors, influencing factors, signals for preventing a failed discharge, learning opportunities, and elements that assisted in achieving a successful discharge. Key areas of risk identified included the transfer of information, communication and the lack of understanding and trust between services. Key findings included identifying person-, task-, and organisation-related elements that promote a good discharge. Elements associated with aiding the discharge process that were identified included promoting good collaborative professional-patient work by educating and involving the patient and their family; information sharing and good documentation; and organisational aspects such as good communication and good teamwork.
This project, which highlights the risks and assets of the discharge process, has provided a solid foundation for improvement strategies and the development of an intervention. Based on the evidence compiled, a plan for the development of informed solutions to improve safety, efficacy and efficiency of the discharge process with the aim to reduce discharge-related patient safety incidents was proposed. By including both community and acute care staff in this project the aim is that this basis will allow for the development of an intervention that will be acceptable to all users in the discharge process.
Future events of interest:
Setting up and running Virtual Clinics
Hospital at Night Summit: Delivering a 24/7 Hospital
Developing the Role of the Physician Associate
Emergency Day Surgery Summit
National PROMs Summit 2017
10 July 2017