Burton Hospitals NHS Foundation Trust. On: 24 October Review Date: October Corporate / Directorate. Clinical / Non Clinical

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1 POLICY DOCUMENT Burton Hospitals NHS Foundation Trust DISCHARGE POLICY Approved by: Trust Executive Committee On: 24 October 2017 Review Date: October 2020 Corporate / Directorate Clinical / Non Clinical Department Responsible for Review: Distribution: Corporate Clinical Capacity Management Team in conjunction with Senior nursing teams and partner organisations All staff Burton Hospitals NHS Foundation Trust Essential Reading for: All wards and Departments, Discharge teams, SSOTP and relevant partners Information for: All staff involved in the process of patient discharge/transfer On Call Managers and Executives Policy Number: Version Number: Signature: Chief Executive Date: 24 October 2017 Discharge Policy / Version 12 / October 2017

2 Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Discharge Policy Original Issue Date: November 2010 Date of Last Review: May 2015 Reason for amendment: Responsibility: Internal Audit review of Discharge Policy Head of Capacity Stored: Intranet Linked Trust Policies: Major Incident Policy Adult Protection Policy Policy framework for Safeguarding Children Medicines Management Policy Frailty Policy Escalation Policy Transfer Policy E & D Impact assessed: EIA 149 Responsible Committee / Group None Consulted: Divisional Directors Matrons Divisional Nurse Directors Trust Executive Committee Head of Therapy Chief Pharmacist Head of Capacity Discharge Team Discharge Policy / Version 12 / October 2017

3 REVIEW AND AMENDMENT LOG Version Type of change Date Description of Change 6 15/09/11 To reflect changes to the Governance structure 7 Internal Audit review of Discharge Policy 18/10/12 To reflect the findings of the Internal Audit review of the policy 8 Internal Audit review 12/07/13 To reflect the changes in the monitoring structure and discharge process 9 Transfer of care 28/11/13 To reflect the changes to the updated policy added transfer of care protocol 10 Planned review of 12/12/14 Reflection in changes in structure and Discharge Policy process related to complex discharges 11 Review of policy to 15/05/15 To reflect the implementation of the reflect legislative Care Act from 1 st April 2015 changes 12 Review and update 12/10/17 Review and update Discharge Policy / Version 12 / October 2017

4 DISCHARGE POLICY CONTENTS PAGE Paragraph Number Subject Page Number 1 Statement of Intent 1 2 The Scope of The Policy 1 3 Underpinning Principles Responsibilities of Key Staff Nurse Initiated Discharge Discharge of Vulnerable Adults From Wards 14 7 Transfer To Other Care Providers 15 8 Maternity Discharge/Transfer 15 9 Neonatal Unit Discharge/Transfer Protocol Paediatric Unit Discharge/Transfer Protocol Self-Discharge Implementation of the Policy Monitoring Effectiveness 30 Appendix 1 Confirmation of assessment for transfer of care 32 Appendix 2 Discharge Flow Chart 33 Appendix 3 Checklist for Patients Discharged from Hospital with a Medical Device 34 Appendix 4 Self-discharge documentation 35 Appendix 5 Risk assessments 36 Appendix 6 Monitoring matrix 37 Appendix 7 Transfer of Care Protocol 38 Discharge Policy / Version 12 / October 2017

5 BURTON HOSPITALS NHS FOUNDATION TRUST DISCHARGE POLICY 1. STATEMENT OF INTENT To provide a framework for Trust staff to facilitate appropriate and safe discharge of patients from hospital to home or alternative care facilities to achieve the following: Objectives: Avoidance of delays in discharge or transfer of medically stable patients not requiring acute care Reduce length of stay for patients across the Trust To reduce the risk of re-admission following inappropriate discharge To reduce delays in discharge and support optimal bed management To ensure timely access for elective and emergency admissions To ensure pro-active discharge planning at the earliest opportunity resulting in safe and appropriate discharge of patients To involve the patient and family on the planning and implementation of discharge plans, taking into account the specific needs of the patient Establish and maintain effective communication with patients, relatives and partner organisations To work within the Safeguarding Children and Vulnerable Adult Policies and Guidance To ensure patients with a known diagnosis of dementia do not spend longer in hospital and ensure carers needs are addressed during the discharge planning process. Information regarding support and discharge (written in plain English or other appropriate language) should be made available to patients and their relatives on admission. To work within the Dementia Strategy guidelines. Monitor the effectiveness of the discharge process, taking action to address shortfalls as required To transfer patients into Community Hospital beds once deemed medically fit if ongoing rehabilitation care is needed To work in partnership with outside agencies i.e. Social Services/Virgin healthcare to ensure timely and effective discharge 2. THE SCOPE OF THE POLICY For all staff employed by the Trust involved in the process of discharging / transferring patients. This Policy builds on the existing collaborations and joint protocols between all partner agencies such as Social Services and local Clinical Commissioning Groups (CCGs). Discharge Policy / Version 12 / October

6 3. UNDERPINNING PRINCIPLES 3.1 Principles in this Policy are underpinned by the Discharge From Hospital Pathway Process and Practice DOH 2003, The NHS Continuing Healthcare (Responsibilities), Directions 2012, NHS-funded Nursing Care Practice Guide (revised) 2012, The National Health Service (Nursing Care in Residential Accommodation) Directions (England) 2009 and The National Dementia Audit (2009) Standard 3.1 Discharge policy. Ready to go Ten steps to discharge DOH 2010, Care Act Avoidance of delays in discharge must be a priority for all staff. As soon as the acute phase of care is completed, medically stable and functionally optimised patients, including those whose period of rehabilitation is completed, or can be provided elsewhere, should be discharged from acute hospital beds in a timely and safe manner to their interim/other or final destination. Discharges take place across a 24 period and the same principles and processes apply at all times. (see appendix 1) 3.3 If a transfer of care cannot be achieved for whatever reason the patient will be offered a placement in an interim setting which the Multi-Disciplinary Team deem appropriate to meet the needs of the patient from the time of discharge until the permanent destination is ready. Consideration however must be given to vulnerable adults including patients with dementia as an interim setting may be detrimental to their recovery and safety. 3.4 The patient, family and carers will be made aware of the Discharge Plan from admission. The Multi-Disciplinary Team will ensure that good communication and involvement is maintained throughout the process with all stakeholders and a discharge plan agreed. In the interests of patients with dementia, they should only be moved for reasons pertaining to their care and treatment. Any move should take place during the day and relatives and carers should be kept informed of any move and given adequate notice. 3.5 Involving appropriate agencies, for example interpreting and advocacy services, is an integral part of the discharge process and will be facilitated through the nurse responsible for the discharge. 3.6 Registered nurses are responsible for the assessing, planning and implementation of the uncomplicated discharge of patients not requiring the involvement of multiagency services. The nurse will also be responsible for initiating referral to other professionals All patients will be assessed for potential discharge needs prior to elective surgery either at pre-admission clinics or on admission All emergency admissions will have an assessment started within 24 hours All assessments will be reviewed daily and updated as deemed necessary. Discharge Policy / Version 12 / October

7 3.7 The Trust Discharge Liaison Nurses will co-ordinate with the Community Liaison Nurses to facilitate the timely transfer of care for patients with complex nursing care, such as those that have high level needs and warrant an Emergency care plan for the community, this is done with input gained from the MDT. The Discharge Liaison Nurses are able to support and advise all hospital staff involved in the discharge of patients on all aspects of the discharge process. 3.8 Procedures relating to Safeguarding children or the protection of vulnerable adults will be followed. If a patient has been referred for assessment within the terms of these policies, procedures for the protection of the patient will take precedence over the Policy Framework for Safeguarding Children. All staff should refer to the Adult Protection Policy and the Policy Framework for Safeguarding Children for detailed information. Further support and advice is available from the Matrons for Adult and Child Safeguarding or Social Services upon request. 3.9 Local multidisciplinary speciality guidelines for Gynaecology, Obstetrics, Day Case Surgery, Palliative Care Discharge Pathway and Emergency Department (ED) will be adhered to in conjunction with this Discharge Policy Staff caring for patients who request to self-discharge against advice, and are not required to be detained under the Mental Health Act and are deemed as having capacity, should refer to the relevant guidance and inform the appropriate Matron/Duty Sister for further support if required. A discharge letter must be sent to the patients GP. Please refer to section 11 of this policy 3.11 Major incidents may escalate the Discharge Policy to facilitate the movement of patients out of the hospital. The Discharge Liaison Nurses and Social Worker will identify patients who are known to be fit to transfer to interim care settings or discharge Patients who have been deemed fit to transfer and are waiting the start of social care will be tracked in accordance with the reimbursement protocols (Sitrep) Final discharge arrangements will be co-ordinated to enable the patient to leave the ward before am unless clinical reasons prevent this All patients that fit the criteria for the Discharge Lounge will be discharged via this facility. Discharge Policy / Version 12 / October

8 4. RESPONSIBILITIES OF KEY STAFF 4.1 Medical Staff will: Wherever possible, discuss and agree a patient management plan and an expected date of discharge (EDD) with the MDT on admission to the ward. The EDD will be recorded on the ward board and the Medworxx system Inform both the patient and ward nursing staff when the patient is medically fit or stable with adequate support, for discharge and will record this information clearly in the patient record Identify patients who are undergoing assessment for discharge and record a medically safe to transfer Liaise directly with the GP to facilitate the discharge of vulnerable patients or those with complex medical needs Record details of the inpatient episode and ongoing treatment in the discharge slip, which must be processed on the day of discharge and forwarded to the General Practitioner (GP). A full discharge letter will be completed on the day of discharge The discharge letter must also provide the GP with information relating to the patients admission covering changes to medication (and the reason for changes), Investigations and Findings plus any complications and treatment/procedure Ensure that the patient s medication is updated and ordered through the electronic prescribing system. Take home medication (TTOs) should not be prescribed until the patient is medically stable.-. All TTOs should be available 24 hours prior to discharge. Planned discharges medication should be ordered where possible 24 hours prior to discharge Ensure that TTOs include a supply of drugs for a minimum of 14 days (normally 28 days supply will be issued). Surgical Dressings and dietetic supplies will be supplied for 7 days. Patients own medication will be returned if still prescribed along with any newly started medication(s) Ensure that when prescribing Controlled Drugs, consideration should be given to the risk of accumulation of these drugs in the patient s home. A supply for 14 days is considered suitable If a patient is to be discharged to another hospital it is preferable, but not essential, that TTOs are supplied. Please check with Pharmacy if in doubt. Discharge Policy / Version 12 / October

9 If a patient is being transferred to a Community Hospital, do NOT supply Enoxaparin, laxatives and analgesics as TTOs as the Community Hospital wards keep these as stock. For other TTO items a whole or a part pack should be supplied with details of name and expiry date. The Pharmacy at each Community Hospital will review and supply the next working day If a patient has an adequate supply of their medicine (with no dose changes) at home a TTO is not required Review patients on the day of discharge unless a discharge plan has been agreed and the Consultant has delegated the responsibility of discharge to nursing / therapy staff (See section 5: Nurse Initiated Discharge) Document Infection control risks and precautions on the discharge slip by the discharging medical staff. The Infection Control and Prevention Team will be actively involved with the discharge of these patients. Further advice is available from the Infection Control and Prevention Team. 4.2 Ward Nurse Responsibilities To commence a discharge plan and activate the social discharge assessment with target date of discharge on admission, co-ordinating the referral to and assessment by the multidisciplinary team. Ensure that all risks are assessed for discharge of the patient and documented in the patient s notes and assessment documentation (Discharge flow Chart, Appendix 2) It is the responsibility of the Senior Sister or designated ward nurse to inform the Capacity Team of all definite and potential discharges in a timely manner throughout the day. During the night they should ensure the Clinical Site Practitioners are informed promptly. Where possible a time of discharge should be provided with consideration of utilising the discharge lounge Registered nurses will facilitate the ongoing involvement of the patient, carer and family in the discharge planning process. In particular, it is important to discuss with the family / carers at the point of admission the patient s home social conditions If a patient is admitted with an established care package, it is the responsibility of the ward nurse to inform Discharge liaison of the anticipated date of discharge and when the reinstatement services will be required.. It is usual for wards to refer to District Liaison Nurses (DLN) to reinstate care in for Staffordshire patients for up to 7 days post admission To ensure suitable provision is made to transport the patient to their discharge destination, taking into account the patient s assessed mobility needs. Transport arrangements will be made as soon as the discharge date is agreed ensuring relative / carers are informed. Ambulance transport will only be provided when other options are deemed Discharge Policy / Version 12 / October

10 inappropriate or unavailable. The patient requires assessing as fit for chair or stretcher Discharge of vulnerable patients including patients with dementia will be discussed and plans agreed with community nursing and/or mental health services and Social Services prior to discharge The ward nurse will ensure that relatives have provided the patient with suitable clothing for discharge and that blankets are provided to maintain comfort and dignity during the journey from hospital, if necessary. Arrangements will be made, if required, for a suitable person to meet patients at their discharge destination The ward nurse will ensure that any valuables, which have been stored in the hospital safe, are returned prior to discharge The ward nurse will, prior to discharge, assess whether the patient can self-medicate and if a medication compliance aid is required TTOs will be checked against the discharge prescription in accordance with Pharmacy policies by either the ward nurse or Discharge Lounge nurse. Information about these medications including dosage and storage instructions will be discussed with the patient and a printed TTO list explained. This will include the name of medication, dose and frequency and will accompany the patient on discharge If the ward keeps TTO packs (appropriate quantities should be issued to the patient at the point of discharge appropriate to the patient s needs (refer to Medicines Management Policy) Nurses should complete a pharmacy assessment form whenever they consider a patient to require a Medication Compliance Aid (MCA, Venalink ). The ward nurse must ensure that the Pharmacy is informed of the proposed discharge of a patient requiring an MCA as soon as the discharge date is agreed. This will be discussed with the patient and relatives if required to ensure safety of the patient. Normally Pharmacy will need 24 hours notice to prepare discharge medication in a compliance aid. For weekends and bank holidays this must be preplanned to be available ready for discharge It is the responsibility of the nurse to ensure that provision for continence and catheter care has been organised prior to discharge and this will be documented in the discharge plan and given to the patient. Consideration must be given to what the needs of the patient were prior to admission and any changes to their management on discharge The ward nurse is responsible for informing the medical staff if the patient s condition deteriorates in the interval between the discharge decision and the patient leaving the ward. Discharge Policy / Version 12 / October

11 The ward nurse will highlight and arrange to transfer suitable patients to the Discharge Lounge The ward nurse will be responsible for checking that patients and/or carers discharged with medical devices state they have the skills and information to safely use them in the care setting (Appendix 3). 4.3 Therapy Services Each service will work according to professional standards and within their own scope of professional code of conduct. A referral system operates when the nursing or medical staff request Therapy Services as appropriate. On receipt of referral, assessment should take place on the same day if possible, or at the latest within 24 hours, to ensure no delays to discharge Therapists are responsible for assessing referred patients, documenting in the patient record and liaising with other professionals, patients and carers as appropriate Therapists will communicate with other members of the multi-disciplinary team about the progress and status of the patient in relation to discharge planning Therapists will arrange for delivery and fitting of equipment to the patient s home or interim setting prior to or following discharge as appropriate to the patient s need and safety Therapists will be responsible for recommending and ordering equipment required for discharge Therapists will ensure that follow up appointments are arranged as required, liaising with patient, carers, relatives and ward staff and documented in the discharge plan When carrying out Discharge Home Visits, the Occupational Therapist will work in accordance with the Home Visit Protocol. They will liaise with ward staff to facilitate the preparation of TTOs and documentation to support discharge Therapists should complete a Pharmacy Assessment form whenever they consider a patient to require a Medication Compliance Aid (MCA) Therapists will follow the principles of home first 4.4 Pharmacy A Pharmacist will, (wherever possible during office hours), provide advice on discharge medication for individual patients and may be available to carry out pre-discharge counselling. Discharge Policy / Version 12 / October

12 4.4.2 NHS patients will be provided with 28 days treatment as required (a minimum of 14 days). Surgical dressings and dietetic supplies will be supplied for 7 days Prescriptions for Controlled Drugs should consider the risk of accumulation of these drugs in the home. A supply for 14 days is considered suitable If a patient has an adequate supply of their medicine (with no dose changes) at home, a TTO will not be required Pharmacy will monitor any patient with an MCA to facilitate appropriate dispensing at discharge. When informed of a new patient requiring an MCA, review of the assessment form will be undertaken. The named pharmacist will liaise with the ward nurse to agree requirements for the patient and liaise with the named community pharmacy to ensure continued supply of the medicines post discharge. 4.5 Social Care and Health The CCG will be responsible for arranging and funding continuing health care services where, following an assessment of the individual s needs, they have a clinical condition that is so complex or intense that the general eligibility criteria applies. Refer to National Health Service Act 2006, Local Authority Social Service Act 1970, the NHS Continuing Healthcare (Responsibilities) Directions 2009 and NHS Funded Nursing Care Practice Guide (revised 2012). The assessment for, and delivery of NHS Continuing Care and NHS-Funded Nursing Care should be organised so that individuals and carers understand the process, and receive advice and information to enable them to participate in informed decisions about their future care When a patient is deemed medically stable and further nursing care is required (either at home or in a 24 hour placement) the ward nursing staff should carry out a NHS Continuing Healthcare checklist at the earliest opportunity so that they are considered for Continuing Health Care or NHS funded nursing care. This is done with all patients now due to new referral on version 6, however based on the patients clinical need it may be beneficial to screen using the checklist due to everyone being entitled for assessment Immediately following this, where appropriate, a Notification for assessment referral to the social work department is then required indicating the outcome of the Continuing Healthcare checklist, if a checklist has not been used the nursing staff can override the score boxes on the referral by typing in 0 in all boxes If the outcome of the checklist is positive a Decision Support Tool (DST) DoH Screening Assessment for funding meeting is required. A professional, who is familiar with the needs of the patient and the CHC Discharge Policy / Version 12 / October

13 process should lead the meeting. Family should be advised of the date and time of the meeting Co-ordination of the DST is done by the DST co-ordinator. This role may also be fulfilled by a senior ward nurse the ward nurse familiar with the patient s needs A minimum of two professionals from different specialities should be present at the meeting to enable facilitation. Any persons absent from the meeting will be seen as being in agreement with the decisions made. Further advice and support can be obtained from the Discharge Coordinators or the Community Discharge Liaison Nurses The Acute Trust, Social Services and the CCG must ensure that the process, including completion of paperwork and funding decisions, does not delay treatment or appropriate care being put in place. Any actual or potential delays must be highlighted to the Matron for the area immediately. Any delays in CHC funding process are highlighted to head of discharge who escalates to head of CHC Acute Trusts have a duty under the Care Act, Transforming Social Care (2014) to notify local authorities of patients who have been deemed medically stable and are likely to need social care services on discharge from hospital. The legislation allows Social Care (SC&H) 2 days following receipt of the notification for assessment (previously a Section 2) to carry out their assessment. The notification (previously section 2) should include a planned discharge date to assist Social care in managing their response and encourage discharge planning at the earliest opportunity Trust and Social Care staff must consider alternatives to remaining in an acute bed for the purposes of assessment. These step down alternatives should be in the least dependent setting and include the patient s own home, NHS Rehabilitation, Intermediate Care or SC&H Enablement. Social care will access the beds within given facilities as required as well as considering other alternatives for patient enablement The Notification for Assessment should be accompanied by the Single Assessment Process (SAP/CCA ) document when required. The Contact Assessment and the initial Overview assessment is completed by the social worker and should always be following the consent of the patient or their representative Ward staff are required to identify the responsible local authority for the patient and direct non-staffordshire residents to the Discharge Coordinators for Derbyshire & Leicestershire Social care welcome requests for assistance and general enquiries direct from patients and their representatives as well as from Trust staff. They will provide support and advice and act as a signpost to support services outside their area of responsibility, where this will assist the discharge planning process and reduce anxieties for patients/representatives. If a Discharge Policy / Version 12 / October

14 community care assessment is indicated at this point Social care staff will advise Trust staff to issue the Notification for Assessment Social care staff will base the level of assessment required on the information included on the Notification for Assessment (previously section 2) referral and, where necessary, from discussions with health professionals caring for the patient. The Single Assessment Process defines the following levels of assessment: - Contact and Overview All initial requests for assessment should include these documents and, for some patients with very limited changes in their circumstances, will be sufficient to determine the Social care response Specialist Assessments These will be required where opinions from at least one professional other than Social care are essential to determine the discharge needs Comprehensive Assessments (formerly CCA) Patients with very complex needs will require a comprehensive assessment with Specialist Contributions from the range of interested parties including Social care and the multi-disciplinary team. It will be coordinated by an appropriately trained and skilled professional 4.6 Eligibility for services Social care staff will determine eligibility for services following assessment under the Fair Access to Services (FACs) framework. Staffordshire County Council provides services only where there is a critical or substantial risk to the service user if services were not provided. Social Care services may be subject to charges following a financial assessment under Fairer Charging procedures but this should not delay discharge for the patient Derbyshire County Council Assessment staff will also determine eligibility under the Fair Access to Care Services; however services would be provided when a moderate risk has been identified. Currently Domiciliary Care provided or commissioned by Derbyshire County Council is at nil cost to Service Users It is essential that Trust staff do not offer services to patients / representatives but should indicate that a request for an assessment for services will be made on their behalf. In addition, patients in need of services from Social care, including home care, residential or nursing home care should not be discharged without the agreement of Social care. Any such discharge could incur charges for the hospital Trust. Further information can be obtained by accessing: Discharge Policy / Version 12 / October

15 dance/dh_ Discharge Notification Following the completion of the assessment, Trust staff are required to notify Social services of the proposed discharge date using Discharge notification.( formally Sect 5 ) This should follow the guidance of the Department of Health s safe to transfer protocol and should be issued when the following three criteria are met: - A clinical decision that the patient is ready for transfer The multi-disciplinary team agree that the patient is ready for transfer The patient is safe to transfer / discharge (See Appendix 7) Social Services have 24 hours following the Discharge Notification to ensure discharge services are in place. Reimbursement liability will occur if delays are the sole responsibility of Social services Communication between all parties is essential to good discharge planning and reduces stress to patients / representatives. The Single Assessment process requires robust inter-agency communication and avoidance of the duplication of assessments. Trust staff will keep Social care informed of any changes in the patient s condition or circumstances at all stages of the assessment. Similarly Social care must keep the multi-disciplinary team informed of any factors that affect the patient and their discharge planning, informing ward staff of the outcomes of discussions with patients / relatives and recording in the ward notes and / or on HISS any discussions and proposed action Once the MDT has agreed the discharge plan and issued a Discharge notification via order entry notification, any funding issues should not delay provision of care for the patient being put in place. 4.8 Supporting Services There are a number of Voluntary and Care Services that can be utilised to support and facilitate the discharge process. Further information regarding community based support services and criteria for referral is available through the Trust s Discharge Co-ordinators or Social Workers. 4.9 Hospital Discharge Liaison Team A Discharge Liaison Nurse (DLN) will attend the daily Ward boards at least 3 times a week to identify complex discharge planning with a focus on expediting discharges identified for that week. They can also be referred to via order entry on Version 6 system for early recognition of complex cases, and manage a case load. There will be ongoing communication between the DLN and ward staff between planned meetings to update discharge plans Discharge Policy / Version 12 / October

16 4.9.2 The Lead Discharge Nurse (or representative) will attend the daily 12 pm Operational meetings on the main site, and will act as the point of referral for all complex/problem discharges for that day that require an urgent response The Discharge Co-ordinators will provide advice, support and education to Trust staff relating to the discharge process. They also provide advice regarding support services available in the community. 5. NURSE INITIATED DISCHARGE SURGERY 5.1 Introduction This protocol provides a framework for nursing staff to discharge patients from the hospital following assessment against condition based protocol or by specific criteria detailed in the patient record by the Consultant or his/her designated deputy. 5.2 Accountability The overall legal responsibility for care from admission until discharge is that of the named consultant/named GP. The consultant/named GP may delegate responsibility for discharge to a nurse with appropriate knowledge and skills The nurse taking responsibility of discharging the patient is professionally accountable for their actions and must always work in accordance with Trust policy and the Nursing and Midwifery Code of Conduct The Senior Sister is responsible for implementing the protocol within their area of responsibility. 5.3 The Benefits of Nurse Initiated Discharge Improvements to the quality and timeliness of the patient s journey for both elective and emergency admission Medical staff / MDT can determine individual criteria for discharge in collaboration with the nurse in charge / nursing team leader The nurse is empowered to facilitate early decision-making to promote the safe discharge of the patient The Trust will benefit from the timely discharge of patients to enable elective and emergency targets to be achieved Delays in starting Theatre lists will be avoided Bed Management will be able to predict bed availability more accurately Reduction in complaints relating to delays in treatment and waiting time Hot clinics To support increased weekend discharges Discharge Policy / Version 12 / October

17 5.4 Definition of Nurse Initiated Discharge The nurse s responsibility to facilitate discharge in accordance with the Discharge Policy is unaffected by this protocol. This aim of this protocol is to reduce delays in discharge by avoiding the need for a doctor to see the patient immediately prior to discharge Protocol based discharge Specialities may develop protocols for discharge for specific conditions. This process is most likely to apply to surgical or investigative procedures Criteria based discharge Senior medical staff or their designated deputy may write specific criteria for discharge, against which the nurse can assess the patient and make the final decision for discharge. It is expected that 40% of patients will be discharged by this process. 5.5 Education and Training Nurses will undertake a core discharge skills analysis with their Senior Sister, undertaking training to address shortfalls in knowledge and skills. Nurses will be deemed competent to follow discharge protocols / criteria appropriate to their usual area of work. Review of competency will take place at appraisal. 5.6 Accountability Medical Staff Continue to have overall responsibility for the clinical care from admission to discharge. The criteria for Nurse discharge must be clearly documented in the patient record and signed by the Consultant or a designated deputy such as a Registrar The doctor completing the criteria for Nurse Discharge must ensure that TTOs are prescribed and follow up arrangements are clearly Senior Sisters Responsibilities To identify which nurses can facilitate discharge To ensure staff are familiar with the process and paperwork To assist in the evaluation process and incorporate that learning into practice skills on the ward To take overall responsibility for the patient s safe discharge Discharge Policy / Version 12 / October

18 5.6.3 The Responsibilities of the Nurse Initiating Discharge The competent delegated nurse will be accountable for selecting the patient for nurse-initiated discharge and completion of the process in accordance with Trust Protocol and Policy and the NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics 2015). The responsibilities are summarised below: 6. DISCHARGE OF VULNERABLE ADULTS FROM WARDS Prior to discharge the discharge plan will be agreed with the Consultant and the multi-disciplinary team. The discharge of an adult recognised as vulnerable must be planned for a smooth, safe transfer into the community. Good communication and documentation is essential Adults recognised as vulnerable may have been subject to Adult Protection Investigations or planning meetings. Where Social Care are working with the family or care providers, staff must liaise with social worker as part of discharge planning Prior to discharge, a plan will be agreed with the relevant people Should a vulnerable adult, under adult protection investigation be removed from Burton Hospitals NHS FT without the consent of the relevant agencies then Social Services and the police will be informed, where an Emergency Protection Order may be sought. 6.2 People who are homeless or living in temporary or insecure accommodation includes: Rough sleepers Individuals or families living in temporary accommodation (under the homelessness legislation, local authorities must ensure that suitable accommodation is available for applicants who are eligible for assistance, unintentionally homeless and who fall within a priority need group (e.g. families with children) Staff should signpost the patient to the local housing office to register as homeless where they should be offered temporary accommodation; the responsible Council authority is the last place where the patient was resident The Discharge Liaison nurses must work in partnership with the local, the voluntary sector and the local authority to ensure safe and effective discharge Close liaison with the local housing authority and involvement with the homeless strategy is vital. Discharge Policy / Version 12 / October

19 6.2.4 If the patient is medically fit for discharge and requires ongoing Social care support ensure they have been referred to them and they will be transferred to interim accommodation until suitable accommodation is found and the costs met by the provider of the ongoing care. 7 TRANSFER OF CARE 7.1 The Trust s Transfer of care Protocol has been implemented to assist clinicians and managers to improve the discharge process for those patients who are expressing their right to choose regarding discharge plans, which have been agreed by the Multi-Disciplinary Team (see Appendix 7. 8 MATERNITY DISCHARGE 8.1 This section provides guidance for the women being transferred from the maternity setting in hospital to continuing care within the community or other healthcare provider. Maternity care aims to be seamless across the boundaries and good communication is essential. 8.2 Discharge / transfer of the women will fall into the following categories: Antenatal In-utero Post Natal 8.3 Antenatal Discharge Antenatal women will have an agreed discharge plan made in conjunction with the patient and the Consultant or Registrar The plan is agreed with the woman and is entered into the woman s hospital and hand held notes Appropriate appointments are made and documented on the hand held notes Investigation results to be entered in the hand held notes including copies of ultrasound scans that have been performed The midwife discharging the woman completes 2 discharge letters. One copy is filed in the woman s hand held notes and the other filed in the hospital case notes Where the plan requires a community midwife to visit at home the midwife will inform the maternity office giving details of the woman s name, address, GP, gestation and special instructions or information for the community midwife. The administrative staff in the maternity office will inform the community midwife. Discharge Policy / Version 12 / October

20 8.3.7 Where information required by the community midwife is urgent or sensitive the midwife discharging the woman will contact the community midwife directly herself and convey the information verbally making a record of the conversation in the notes TTOs will be ordered and checked by the midwife in accordance with Trust policy. 8.4 In-Utero Transfers In-utero transfers may be due to: - Specialist Neonatal care requirements Pregnancy related condition requiring specialist care Neonatal cot unavailable at Queen s Hospital There are agreed lines of communication between the obstetric and neonatal teams. When the need for in-utero transfer has been confirmed the following action will be taken: Read in conjunction with the Guideline for Transfer of the Obstetric patient The Obstetric Registrar will: Inform the mother and relatives of need to transfer and keep informed Inform the patient s Consultant / Service Consultant or on-call Consultant Obstetrician The Consultant Paediatrician will be informed by the Paediatric Registrar Identify neonatal facilities that have availability Confirm neonatal cot and document name of hospital accepting transfer Contact Obstetric department of Unit with Neonatal Cot availability and confirm that obstetric facilities are also available The notes will be completed to indicate: Reason for transfer Receiving hospital Destination ward of the mother Name of designated doctor accepting transfer A transfer letter will be written When the Neonatal Cot and Obstetric services have been confirmed by the receiving hospital the midwife in charge of the ward area will coordinate transfer Discharge Policy / Version 12 / October

21 Ambulance control will be contacted to book ambulance and level of urgency will be given. The time of call will be documented with the estimated time of arrival of the ambulance Identify a midwife to accompany the mother Arrange for all relevant notes to be photocopied to accompany the patient Inform Matron or senior midwife of transfer Confirm stability of patient prior to transfer, check any equipment to be used is functioning correctly Confirm relatives are aware of the transfer / confirm destination / give directions Ensure notes and documentation accompany patient The accompanying midwife will give verbal handover of care at the receiving unit 8.5 Post Natal The professional making the decision for discharge / transfer to community care will be determined by the history of the woman For low risk patients having had a normal delivery with no complications the midwife will agree discharge with the woman For women where medical intervention or complications had arisen a medical review is made for fitness to discharge / transfer to care of community midwife/gp A postnatal discharge letter for both mother and baby will be completed by the midwife on HISS - 4 copies of each will be printed. The mother will be given 1 copy addressed to the Community Midwife, 1 copy will be posted to the GP, I copy will be sent to the maternity office and 1 copy filed in the Patient s medical record The baby NHS number will be given to the mother for registration of the birth and for reference for relevant healthcare professionals e.g. Health Visitor The mother will be made aware of contact numbers for midwives in the community The Maternity office will inform the appropriate community midwife of the discharge from hospital For discharges / transfers outside of normal office hours ( ) it is the responsibility of the midwife discharging the woman to ensure the appropriate community midwife is informed. Outside of normal hours this Discharge Policy / Version 12 / October

22 will usually be the on-call community midwife for the patient s area of residence TTOs will be arranged as appropriate, checked in accordance with Trust policy. 8.6 Transfers to the Samuel Johnson Community Hospital See guideline for Transfer of Obstetric Patients. 8.7 Discharge of Vulnerable Children from Maternity Wards Prior to discharge the discharge plan will be agreed with the Consultant. The discharge of a child recognised as vulnerable must be planned for a smooth, safe transfer into the community. Good communication and documentation is essential. The discharge will either be into the care of parents / carer or Children s Social Care Babies recognised as vulnerable pre-birth may have been subject to strategy or planning meetings. Where Children s Social Care are working with the family under service plans staff will liaise with Children s Social Care. Where children are monitored under a CAF the midwife will liaise with the Lead for the CAF Where a baby is subject to a Child Protection Plan a pre discharge meeting will be held and discharge plans agreed between all agencies involved Prior to discharge the discharge plan will be agreed with the relevant people Follow up appointments will be in place prior to discharge where possible Where possible babies will not be discharged at weekends unless agreed by other involved agencies The baby will have a registered GP prior to discharge; this may need to be facilitated by hospital staff. For Staffordshire addresses contact Staffordshire Patient Registration , Derbyshire Primary Care Support Hospital notes will be created for the baby and relevant documentation from case conference will be filed within them Should a child deemed vulnerable be removed from Queen s Hospital without the consent of the relevant agencies then Children s Social Care and the police will be informed where an Emergency Protection Order may be sought. 9 NEONATAL UNIT DISCHARGE AND TRANSFER PROTOCOL 9.1 This section includes guidance for the discharge of the neonate back to the postnatal ward, to the community, either to the care of the parents or identified carers, or transfer to another health care provider. Discharge Policy / Version 12 / October

23 9.2 The maintenance of good communication is essential in providing a seamless transition into the care setting required. 9.3 Discharge of the Baby into the Community Parent craft forms are completed by nursing staff in co-operation with the parent as an ongoing process from the time of the infant s admission Concerns re the home situation, parenting skills or safeguarding issues identified during the time of admission should be addressed in advance of making plans for discharge Where a child is subjected to a Child Protection Plan the senior nurse and doctor checks with all agencies that the Child Protection Plan is followed If a discharge-planning meeting is required, this will be agreed by the MDT and the most relevant agency concerned will arrange all meetings with relevant agencies. If a provisional discharge date has been set, agencies should be made aware of this prior to the meeting. The senior nurse and medical staff should ensure that, following the meeting, all processes are put into place ready for discharge Parents are invited to be resident with their baby in a parent s flat for a minimum of 24 hours prior to discharge to establish breast or bottlefeeding and parent craft. Baby should be gaining weight and feeding well and maintaining their temperature, before a provisional discharge date is given Parents receive teaching on basic resuscitation on an individual basis as requested by the Consultant or as indicated by their condition For babies who require home oxygen, parents must be competent in all aspects of caring for baby and in the use of home oxygen equipment. See guideline for Chronic Lung Disease of Prematurity (May 2005). A pre-discharge planning meeting is arranged with multi-agencies involved in order to support the family in the community. Appointments will be required for administration of Synagis and the baby usually requires overnight admission to Children s Ward for routine immunisations TTOs are ordered. These are checked by the nurse in accordance with Trust policy. The nurse ensures that the parent or carer has previously demonstrated they are competent to measure and administer the medicines to the baby Follow-up appointments are made as required and recorded on the baby s discharge letter. Babies who have had retinopathy screening are reviewed in Ophthalmology at 18 months of age. Babies <31 weeks gestation or <1500 grammes require developmental assessment at 6 months corrected age. Discharge Policy / Version 12 / October

24 The ward clerk informs the health visitor of discharge and any special instructions discussed. If sensitive issues need to be relayed, this should be done by the Nurse in charge The neonatal nurse ensures that all appropriate agencies are involved and aware of the discharge plan and good communication has been maintained throughout the discharge process The SHO performs a full discharge examination and records the findings on the discharge sheet of the medical notes A hearing screen is performed by the Audiology Department. Results are recorded in the patient s notes, HISS, and also entered in to the baby s red book If the baby has received any vaccinations, these should be recorded on the discharge letter, medical notes and red book. Batch numbers should be documented The doctor completes the discharge letter and prints 5 copies. The Health visitor / community midwife, family doctor, parent/carer each receive a copy. The neonatal nurse gives the parent or carer the letter for the midwife or health visitor and sends the letter to the GP through the post. One copy is retained in the notes and the fifth letter is sent to the Maternity office The nurse completes the discharge plan and the Badger Summary is completed by the SHO, who prints 3 copies: 1 copy for notes / 1 copy for the GP / 1 copy for the Parents The nurse completes the care plan and discharges the baby on HISS. 9.4 Discharge to the Postnatal Ward Some babies may be well enough to be discharged back to the care of their mother on the postnatal ward The Paediatric SHO performs a discharge examination of the baby and completes one copy of the discharge letter The neonatal nurse informs the parent that the baby will be discharged to the ward and discusses any concerns with them The doctor or neonatal nurse informs the midwife on the postnatal ward of transfer and any special instructions The neonatal nurse completes the nursing care plan prior to transfer The baby is transferred on HISS to the postnatal ward, ensuring that the service is changed from Special Baby Care to Neo. Discharge Policy / Version 12 / October

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