Discharge Toolkit Complex and Delayed transfers of Care (DToC)
Contents Item
Page
Overview
3
pDD SOP
4
pDD Guidance
5
LOS Guidance (extract)
6
MDT SOP
9
MDT Audit form
11
Case Conference SOP
12
Case Conference Audit form
14
Board Round SOP
15
Patient Passport SOP
16
Action Plans
17
Appendix 1 – Newsletter example
18
Appendix 2 - Discharge checklist
19
Toolkit Overview Aims The toolkit aims to provide information to staff to support Complex Patients to a safe and timely discharge that is viewed as a continuum of care between hospital community and other care environments. A complex patient is defined as any patient that has multiple care needs and requires increased input to facilitate discharge. A DToC patient - the Department of Health defined a delayed transfer of care as "Occurring when a patient is ready for transfer from a general and acute hospital bed, but is still occupying such a bed. A patient is ready for transfer when: (1) a clinical decision has been made that the patient is ready for transfer; (2) a multidisciplinary team decision has been made that the patient is ready for transfer; and (3) the patient is safe to discharge/transfer" Objectives The Complex discharge toolkit will provide information regards: • Support patients and family in a safe and timely discharge • Provide patient and family members with information and support related to the discharge plan • Enhance the patient pathway and outcomes and minimise delays • Aid communication between hospital staff, community and other care environments • Ensure planning for discharge happens daily • Ensure safe and efficient use of resources
How to use the toolkit The toolkit provides guidance around five elements of the complex patients discharge planning process: 1. MDT predicting a date for discharge 2. Holding a MDT meeting 3. Holding a Case Conference 4. Holding a Board Round 5. Using the Patient Passport You will be responsible for taking principles and integrating them onto your ward/s. We would suggest that your team work together to understand the principles outlined within this toolkit and to then apply them to your area. By putting them into practise, you will experience improvements to discharge planning on your ward.
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Standard Operating Procedure (SOP) for Predicting a Date for Discharge (pDD) Complex Patients Aim This SOP will inform ward staff regarding their role and responsibilities when predicting a date for discharge for complex patients. Objectives All patients categorised as a complex discharge will be given a pDD once plan of care confirmed or when medically stable. This date will be identified by the Multidisciplinary Team (MDT) either at the Board reviews or MDT meeting. How to identify pDD 1. Once plan of care identified for the patient the MDT members at the board round can identify a pDD for complex patients or 2. Once complex patients become medically stable, MDT in weekly meeting to set pDD (see MDT SOP) The pDD can be identified using one of the 2 options above depending on the complex needs of the patient the date should be displayed on the whiteboard. Responsibilities • It is the responsibility of the Nursing team to ensure that the pDD is clearly identified on the whiteboard. • This pDD will be used to plan for a safe and timely discharge. • It is the responsibility of both the Clinical, Nursing and MDT team to ensure that the patient and their relatives or carers are kept informed of their discharge plans or a change in their predicted date. If you require any further information or clarification about this SOP please contact the Clinical Improvement Unit, Lincoln County Hospital ext 2073.
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Predicting a Date for Discharge Guidance Length of Stay (LOS) The Trust has published guidance to support the identification of pDDs. This booklet is available on the Trust Intranet front page and details the top 20 conditions/ procedures for each specifically and their average length of stay from Dr Foster. The figures used are intended to provide guidance for both clinical and nursing staff. The date that is chosen as a predicted date of discharge is based upon the patients clinical need. The guidance can be used to predict an interim date which can then be reviewed either by medical team or MDT and confirmed/ updated. It will be the ward managers decision on how to use these LOS figures. Other wards have found it helpful to print the guidance relevant to your specialty, laminate and display in a prominent position/ hand out e.g. to members of the team who are new to the specialty.
How to use LOS document
Open Intranet Homepage
Click on Length of Stay link in the yellow popular box Open pdf Length of Stay document (right hand corner) Print relevant pages
Laminate
V4 VNB 080310
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Extract from ULHT LOS Guidance
Cardiology LOS Guidance
No.
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20
Diagnosis group
ULHT LOS
National LOS
Acute myocardial infarction Coronary atherosclerosis and other heart disease
8.8
7.7
3
4
Cardiac dysrhythmias Congestive heart failure, nonhypertensive
3.2
3.4
12.9
11.6
Conduction disorders
3.4
3.9
Nonspecific chest pain
1.9
1.4
Syncope Peri-, endo-, and myocarditis, cardiomyopathy
3.6
3.5
12.1
9.7
6.9
12
Heart valve disorders Rehabilitation care, fitting of prostheses, and adjustment of devices Cardiac arrest and ventricular fibrillation
1.2
5.6
3.1
9
Pulmonary heart disease
7.7
8.6
Acute cerebrovascular disease
53.6
21.4
Other connective tissue disease
2.7
2.4
Pneumonia
11.7
11.4
Other circulatory disease Complication of device, implant or graft Pleurisy, pneumothorax, pulmonary collapse Complications of surgical procedures or medical care
9.8
8.7
8.4
14.1
7
6.1
9.8
5.5
1.8
5.4
Deficiency and other anaemia
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General Surgery LOS Guidance (By procedure) No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Diagnosis group
ULHT LOS
National LOS
No procedure
3.7
4.7
Diagnostic imaging (except heart)
9.7
7
Laparascopic cholecystectomy
1.9
2.1
Excision of colon and/or rectum
17.3
9.8
Excision of breast
3
3
Appendicectomy
4.4
3.3
Inguinal hernia Transluminal operations on femoral artery Diagnostic endoscopic procedures on lower GI tract
2.2
1.8
3.8
6.1
5
5.9
Rest of Lower GI Therapeutic endoscopic procedures on biliary tract
4
4.3
3.9
5
Rest of Soft tissue
9.2
6.5
Drainage of lesion of skin
2.3
3.4
Varicose vein stripping or ligation
1.1
1.3
6
3.3
3.5
2.5
Repair of umbilical hernia
3
3.8
Pilonidal sinus operations
1.7
1.9
Primary repair of incisional hernia Therapeutic operations on jejunum and ileum
7.5
3.8
15.4
8.2
Other excision of gall bladder Drainage through perineal region
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General Surgery LOS Guidance
No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Diagnosis group
ULHT LOS
National LOS
Abdominal pain
2.6
2
Biliary tract disease
3.6
3.9
Abdominal hernia
3.5
3.1
Cancer of breast
2.9
3.1
Other gastrointestinal disorders Appendicitis and other appendiceal conditions
5.4
5.4
4.6
3.8
2.9
2.8
2.9
2.9
Anal and rectal conditions Skin and subcutaneous tissue infections Cancer of colon Peripheral and visceral atherosclerosis
15
10.6
7.9
7.9
Superficial injury, contusion
2.7
3
Gastrointestinal haemorrhage
5.2
5.6
Diverticulosis and diverticulitis Complications of surgical procedures or medical care Pancreatic disorders (not diabetes) Intestinal obstruction without hernia
8.9
8.1
6.2
6.7
7.2
8.6
10.1
11.1
Cancer of rectum and anus
13.8
10.9
Haemorrhoids
1.6
1.5
Urinary tract infections
4.2
5.8
Other circulatory disease
4.6
5
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Standard Operating Procedure (SOP) for weekly MDT meeting This SOP will inform staff regarding their roles and responsibilities in relation to a weekly multi-disciplinary meeting. Our Aim The aim of the Weekly MDT is: • To discuss any complex patients that are currently an inpatient on your Ward (a complex patient is defined as any patient that has multiple care needs and requires increased input to facilitate discharge). • Once the patient has stabilised, all members of the multi-disciplinary team to agree the plan for discharge, ensuring it is safe and meets the patient’s needs • Each member of the MDT is clear of their role/actions in facilitating discharge. • For the patient and family members to have information and support related to the discharge plan. • To ensure a safe and timely discharge that is viewed as a continuum of care between hospital, community and other care environments. • To enhance the patients pathway, minimising delays and enhancing patient outcomes. • To prevent readmission due to poor discharge planning. • To ensure safe, efficient, use of resources • To ensure discharge/transfer processes and planning are continuous and take place seven days a week. Rules • Suggested membership of the MDT is Occupational Therapist, Physiotherapist, ward staff, Discharge Liaison Nurse, Social Worker, Complex Care Managers, Psychiatric Liaison Nurse. • The ward staff will identify the complex patients and bring their individual nursing notes to the MDT meeting. • An up to date copy of the electronic handover document will be available for each meeting. ( please ensure these are disposed of in line with the Trust’s disposal of confidential waste policy and under no circumstances should these be removed from Hospital site) • The nominated ward representative will lead the meeting. • Each patient will be discussed in geographical order within the ward layout. • Each patient’s individual needs will be identified, as well as their progress to date. • Once the patient’s condition has stabilised (this needs to be identified by the Clinician in the patient notes) the MDT meeting will set a pDD.
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• The MDT will then identify what actions, equipment referrals or issues need to be addressed in order to facilitate discharge. • The MDT will then identify the person responsible for undertaking the actions and the time this is to be delivered by. • If a case conference is required the date will be planned, any reports identified and the date required by. • All discharge plans will be shared with the patient and their family post MDT, this will be both verbally and via the patient passport document. • As each patient is discussed, the nominated ward lead will complete the MDT audit form per patient and put in the nursing documentation. • On completion of the MDT the nominated ward lead will transfer all pDD on to the whiteboard and complete all required referral forms. • All pDD will be communicated to the medical team. Responsibilities • • •
•
It is the responsibility of the nominated nurse to lead the MDT meeting, take any actions that are identified and ensure the patient, family and medical staff are informed re the discussion and discharge planning. It is the responsibility of the members to ensure they attend, assist in identifying the patients needs and take any actions identified in the timescale agreed. It is the responsibility of the medical team to ensure they identify in the patient’s case notes when the patient is stable, keep up to date with the outcomes of the MDT meeting and where they disagree with the planning ensure they communicate this to the nominated ward lead or the relevant health professional. It is the responsibility of the members of the MDT to identify a pDD once the patients condition has stabilised.
Auditing •
There will be a report developed to identify performance in relation to number of complicated patients on the ward per week, number given pDD, number of pDD not adhered to and reasons why aswell as number of days patients are delayed.
•
All patients will have a MDT audit form completed and kept within their notes.
•
Compliance will be reported to the specialty via the Clinical Service Managers.
•
Compliance will be reported to the Directorate via Directorate meetings
.
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MDT meeting Audit form Date of MDT Patient Hospital No:
Date admitted to Ward:
pDD – Referring wards or hospital + admission date and transfer date
Referrals and assessments already completed by referring ward/hospital
Nurse –
Medics -
O. T. –
Complex case representative -
Physio –
Social worker -
DLN –
Other -
( In the above boxes Please Indicate who is present, actions or referrals to be taken/ made and by when)
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Standard Operating Procedure (SOP) for Case Conference This SOP will inform staff on wards of the format, timescales and responsibilities for patient case conferences, which are conducted to agree patients discharge needs. Aim • For all members of the multi-disciplinary team to identify patients care/psychology and safety needs • For patients and their family/carers to identify their needs and requirements in order to facilitate patient discharge • For all parties to agree a plan to facilitate discharge.
Preparing for the case conference • All complex patients are discussed at the weekly MDT and the majority of patients requiring a case conference will be identified at this meeting. • It is the responsibility of the person leading the MDT to either nominate or negotiate a time and date with the patient and family/carers for the case conference to take place. • It is the responsibility of the lead of the MDT to determine who will chair the case conference, the attendees and what evidence or assessments are required. • It is also the responsibility of the lead to identify venue. • Following confirmation of the date/time, it is the lead of the MDT responsibility to confirm details with all those who will be attending. • Case conferences should be carried out within 72 hours of the need being identified. Day of MDT MDTs should aim to last no longer than 1 hour. Agenda Start - Introductions and purpose of the meeting Main Body - Identification of patient’s needs from assessment reports - Feedback from patient - Feedback from family - Deciding what discharge plans/needs/equipment or next steps are required. - Formulate a plan for discharge - Agree a predicted date of discharge, if it has not been already set. - All parties to agree.
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N.B – Where no consensus of agreement can be reached the issues must be escalated to Ward Sister, Matron and Consultant Conclusion - Thank all parties for attending. Finish Post Meeting • It is the responsibility of the Chair of the case conference to inform members of the multi-disciplinary team who could not be present, the plan of action to facilitate patients discharge (this should be done within 24hours of the case conference). • It is also the responsibility of the Chair to ensure contemporaneous record keeping is achieved. • It is the responsibility of all members of the multi-disciplinary team to ensure case conference actions are carried out promptly, in order to meet the predicted date of discharge. Audit • Every case conference should have a recorded start and finish and an identified plan of discharge for patient. If you require any further information or clarification about this SOP please contact the Clinical Improvement Unit, Lincoln County Hospital ext 2073.
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Case Conference Audit Form Date – Pt Hospital No
Date the need for case Conference identified
Date took place
length of time of case conference
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Persons present
Outcome and actions
Standard Operating Procedure (SOP) for Discharge Board Round (DBR) This SOP will inform staff regarding their role and responsibilities when completing a Discharge Board Round Aim The DBR will allow a multi-disciplinary approach to reviewing patients’ predicted date for discharge. At the DBR you will ensure that clinical management plans are on target and discharge planning is in place to prevent delays to the discharge process. This will result in the early identification of delays in the patient pathway and the agreement of actions to mitigate delays. Objectives • DBR will happen twice weekly at an agreed time led by the nurse in charge with members of the multi-disciplinary team • Every patient on DBR will be reviewed with the initial question: o “When will the patient become medically fit?” • Outcomes from this question are: o Patient suitable for discharge tomorrow, plan for earliest possible discharge (use Discharge Lounge where appropriate) o Not medically fit but following current plan for pDD. Patient to be reviewed following day o Not medically fit and pDD not achievable. A new pDD in red pen (denotes change from initial to be identified and agreed and documented on ward white board and on patient passport). Responsibilities • Matron • It is the responsibility of the nurse in charge to ensure the DBR occurs at agreed time. • All members of the nursing and MDT team have a responsibility to ensure that the ward whiteboard is updated following the DBR. • All members of the team are responsible for ensuring that any changes in pDD are communicated effectively to the patient or appropriate family member If you require any further information or clarification about this SOP please contact the Clinical Improvement Unit, Lincoln County Hospital ext 2073.
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Standard Operating Procedure (SOP) for Patient Passport This SOP informs staff of their role and responsibilities when using Patient Passport. Aim All patients* admitted onto the ward are to be provided with a Patient Passport • For ‘Simple Discharge’ patients the Passport issue must be before or within 24 hours of admission. • For ‘Complex Discharge’ patients the Passport issue must be as soon as the patient is declared medically fit or has their plan of care confirmed. Objectives Patient Passport gives patients a greater understanding and control over the planning for their discharge from hospital. This includes: • What discharge date is currently being worked to • Which health and social care professionals have been engaged both during their stay and for after discharge • Their ongoing medications being ordered in time for discharge • Timely transport arrangements being organised. Responsibilities: Nursing staff are responsible for: • Identifying who will be the Patient Passport ‘holder’ if the patient is unable to manage it themselves. • Issuing patients with their Patient Passport • Clearly explaining the information on it to the patient as soon as it is issued • Emphasising at the outset that the discharge date is predicted ie not yet confirmed • Placing the Patient Passport in a location which is easily accessible for the patient • Ensuring that all discharge pathway changes are explained to the patients immediately and the Passport updated. • Ensuring that those changes are transcribed to the Ward Board (and vice versa) • Ensuring that patients know that they need to make transport arrangements for their discharge so that their discharge is not delayed • Confirming transport arrangements with patients as the discharge date approaches.
(*Note: for the purposes of this document, the term ‘patient’ should be taken to include their families, next of kin and/or carers according to who has been nominated as the Passport holder) If you require any further information or clarification about this SOP please contact the Clinical Improvement Unit. On ext 2073
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Action Plans pDD for Complex Patients Share SOP with Ward Managers Support Ward Manager to deliver education to Ward Staff regards SOP MDT Agree members to attend the MDT and arrange a time that are convenient to hold the meeting Educate staff regards MDT SOP Nominate a ward representative to lead the meeting Monitor the first couple of meetings closely, keep focussed on the SOP and its objective Use the MDT checklist to identify actions, by whom and date to be completed and agreed PDD Agree who will collect audit data, on number of PDD set, No adhered to and reasons for change Complete newsletter on plans and circulate to the team Case Conferences Agree a date and time for weekly case conferences with members of the multidisciplinary team. Agree how and when reports will be sent for those members of the multidisciplinary team who can not attend. Board Round Arrange times that are convenient to hold the board rounds with Social Services and therapy services and communicate them Educate staff regards Board Round SOP Monitor first couple of board rounds, keep focussed on the SOP and its objective Patient Passport Confirm that the Patient Passport used on the wards is the current version and that the master copy is filed in the templates folder Confirm location for supplies of Patient Passport and notify staff of that location along with the rules for maintaining supply levels Insert SOP into the ward’s SOP folder Determine method of staff training and agree roll-out plan. Assign responsibility for roll-out. Create log to capture confirmation of staff training and awareness of Passport procedure and requirements Agree measures (KPIs) that are to be used on the ward to monitor usage of Passport and produce Audit Tool Produce audit timetable and agree ownership
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October 2009
Ward 6
Issue No 1
Delayed Transfer of Care Project. In June 2009 United Lincolnshire Hospitals NHS Trust set up a Discharge Project with 3 working groups, the first focusing on Simple discharge, the second Complex discharge and the third, Delayed Transfer of Care (DETOC). Ward 6 at Grantham is where the DTOC project will be piloted for the next three months. The aim of the Discharge projects are to remove the waste in our current processes by using lean tools and techniques. The aim for Ward Six is to reduce their Delayed Transfers of Care. The project will run until 4th January 2010. The project is led by Carolyn Fairbrother, Clinical Service Manager for Emergency Care at Grantham and is supported by Sister Jane Lyon, Ward 6 Sister. We have involved Lincolnshire PCT, Allied Health Professionals, Social Services, Continuing Care team, Clinicians, Discharge Liaison Nurses, and many other health professionals. So far we have held interviews with staff to identify our issues and problems. We have also mapped the current pathway and our future pathway for our patients . The changes commence on the 5th of October 2009 on Ward 6.
Thank you To all staff who contributed to the planning of the project, by sharing their issues, frustrations and ideas. The input from all concerned is invaluable to the success of the project!
Delayed Transfer of Care The mapping sheets for the new ways of working will be displayed in Clinical Management Team offices. The action plans from these events are also available.
Communication We will communicate by: • Ward meetings • Newsletter • On the Ward 6 Productive Ward notice board.
Improvements The main changes that have been identified and are being implemented on Ward 6 from the 5th October are: • Weekly MDT meetings will take place every Wednesday to discuss complicated patients and focus on improved discharge planning. • Case Conferences will take place on a Thursday afternoon. • Introduction of patient information to identify the discharge date and discharge plan. • Introduction of Predicted date of discharge for all patients on the ward. If you have any questions or comments do not hesitate to contact us
Further information is available from Carolyn Fairbrother (CSM ‐ Grantham), Jane Lyons, Ward 6 Sister and Dawn Slack, Service Improvement Facilitator, ULHT Page 18
Patient Discharge Checklist Patient Name: Patient address and postcode: NHS No: 1. Plans for discharge pDD and place of discharge Discussed at MDT Discharge discussed with the patient Discharge discussed with relatives / carers Continuing healthcare assessment required Social worker referral required
Date of Birth: pDD: Date: Yes / No Yes / No Yes / No
Place of discharge: By whom: Date: By whom: Date: Date completed:
Signature: Signature: Signature:
Yes / No
Date referred: Name of referrer: Name of assigned social worker: Contact number for social worker:
Psychiatric liaison
Yes / No
Date referred: Name of referrer: Name of assigned psychiatrist: Contact number for psychiatrist:
2. Therapy Services Access visit required Home visit required
Yes / No Yes / No
Date completed: Planned date: Date completed: Equipment ordered: Yes / No By whom:
Equipment required (please list):
3. Referral to other services
Referral date
Start date requested
District nursing service Community physiotherapy Community occupational therapy Home care/domicillary agency Info on meals at home Other (please state)
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Signature: Signature: Signature:
Referral letter completed – Y / N
Signature:
4. Transport and access arrangements Transport arranged: Yes / No By whom: Signature:
Transport type (please circle) Patient own
Hospital Access arrangements to home (please describe if relevant)
Key safe required Dossett box required
5. Medication Clexane required Family instructed in use Medication to take home (TTOs) ordered (and clexane if required) TTOs received and checked Compliance chart required Patient’s own medicines returned (if appropriate)
Yes / No Yes / No
Booking ref no:
Date ready: Date ordered: Date to be collected by family:
Signature:
Yes / No Yes / N/A Yes / No
Date: By whom:
Signature: Signature:
Yes / No Yes / No Yes / No
By whom: By whom: By whom:
Signature: Signature: Signature:
6. Other arrangements for day of discharge Completed Signature eDD Outpatient appointment Hospital transport Medication Property and valuables
Signature Dressings/products Single assessment documentation (SAP) DNAR form (if appropriate) Skin integrity check completed and documented Food available and heating at patient home (if appropriate)
Locker key returned (if appropriate) 7. Other key information Please include any further key information relevant to the patient’s discharge
Name of discharging nurse: Signature: Date:
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Contact details Louise Jeanes Clinical Improvement Facilitator Clinical Improvement Unit Lincoln County Hospital Greetwell Road Lincoln LN2 5QY Tel. 01522 512512 ext 2073
[email protected]