DISCHARGE POLICY & PROCEDURE

Transcription

1 Wirral University Teaching Hospital NHS Foundation Trust Policy Reference: 027 DISCHARGE POLICY & PROCEDURE Version: 13.3 Name and Designation of Policy Author(s) Approved By (Committee / Group) Lesley Metcalfe Deputy Director of Nursing Janice Evans Specialist Nursing Services Manager Wirral Community Trust Care Standards Executive Date Approved 26 th April 2012 Date Ratified by HMB 25 th May 2012 Date Published 22 nd January 2015 Review Date 25 th May 2015 All Health & Social Care Agencies and their staff involved with discharge and Target Audience transfer of patients. Consistent with the WUTH business plan, operational procedures relating to bed management and the patient transfer policy. Links to Other Trust Policy Discharge Against Medical Advice (Adult) Strategies, Policies, Trust Policy Discharge Against Medical Advice (Minor) Procedures, etc Trust Policy Safeguarding Children Policy & Procedure Trust Policy Safeguarding Adults - Procedure & Guidance Dementia Care Pathway #PROUD TO CARE FOR YOU #proud

2 Content CONTENTS Page 1 Introduction Purpose Scope Discharge Planning Pre-operative Discharge Planning for Elective Admissions Discharge Planning for Emergency Admissions Process for Discharge Adults Simple Discharge Process Discharge Summary Information Requirements Discharge Documentation & information Complex discharge NHS Continuing Healthcare Needs Checklist Discharge Arrangements for Patients at the End of Life Discharge Arrangements for Patients Who Require Equipment Discharge Documentation & information Process for Discharge Paediatrics Discharge Arrangements for Paediatric Patients Equipment Assessment for Equipment Ordering Equipment Standard Stock Non-Standard Stock Equipment / Bespoke Equipment Community Equipment Provision Exceptions Process for Discharge Out-of-Hours Definitions Duties / Responsibilities Responsible Nurse / Midwife Corporate Nursing & Midwifery Audit Team Associate Directors of Nursing Ward Sisters Community Discharge & Liaison Team For Adults Integrated Discharge Team (WUTH & DASS) Definitions Duties / Responsibilities Responsible Nurse / Midwife Corporate Nursing & Midwifery Audit Team Associate Directors of Nursing Ward Sisters Community Discharge & Liaison Team For Adults Integrated Discharge Team (WUTH & DASS)... 13

3 13 References Appendix 1 Nurses Discharge Plan Appendix 2 Discharge Information Appendix 3 Continuing Care Process (October 2007) Appendix 4 Hospital Discharge and Homeless Prevention Pathways Appendix 5 Nursing Home Discharge Form Appendix 6 Discharge Action Plan for Patient... 19

4 1 Introduction This policy is designed to standardise and provide a coordinated approach to the management of patient discharge. It is written in accordance with the NHS and Community Care Act 1993/98, DoH Discharge from Hospital: Pathways, Process and practice 2003, the Community Care Act (Delayed Discharge) 2003, National framework for continuing healthcare and NHS funded Nursing care 2007, Achieving Simple Timely Discharge from Hospital 2004 and Ready to Go? (DoH 2010). Safe, efficient discharge requires input from an experienced practitioner who has an understanding of the discharge planning process, working closely with the multidisciplinary team and other agencies. The role is usually undertaken by nurses and midwives; however it may be appropriate in a transitional or rehabilitation service for a therapist or social worker to be the care co-ordinator / case manager. 2 Purpose This policy and procedure describes the framework which exists to facilitate safe discharge where any risks are accounted for and minimised. It supports person-centred discharge where adult and paediatric patients receive appropriate and timely packages of care which meet their needs regardless of health and social service boundaries. This policy aims to ensure that unplanned re-admissions do not occur as a result of poor discharge planning. 3 Scope This policy applies to all staff who are involved in the discharge of adult and paediatric patients from hospital. This may involve discharge to an intermediate or transitional care facility, a nursing or residential home or to a patient s own home. It does not cover transfer from one acute setting to another. 4 Discharge Planning The philosophy at the Trust is to treat all patients as individuals and ensure that they are cared for holistically. An assessment of the specific needs of a patient is made on admission to the Trust, for example the patient may have a healthcare associated infection (e.g. MRSA or C. difficile), their first language may not be English or the patient may have a sensory impairment. It is important to consider and communicate specific needs where appropriate to enhance the patient experience and reduce the risks of incidents, complaints or claims which may result from the sub-optimal discharge of patients. 4.1 Pre-operative Discharge Planning for Elective Admissions Discharge planning for patients admitted for elective procedures is undertaken at the Pre-Operative Assessment Clinic and the nurse will document relevant information from the patient and carer(s) in order to facilitate a safe discharge plan. This will include: Taking a history of medical conditions/previous hospital admissions/current medication regime Wirral University Teaching Hospital NHS Foundation Trust Page 1 of 20

5 Asking the patient about services currently being received, including health/social care/adaptations/equipment With the patient s consent contact may be made with services to identify the level of service input Considering the needs of the carer(s) Ensuring that the patient and carer(s) are provided with relevant information so that they understand what is likely to happen when the patient is discharged Identification of equipment that may be required 4.2 Discharge Planning for Emergency Admissions The Trust s nursing documentation used in the Medical and Surgical Divisions (including gynaecological surgery), and Children s services, prompts nursing staff to ask appropriate questions to ascertain any specific needs an individual patient may have and any specific relevant information is recorded in the documentation. This provides a record of the needs assessment, documents any specific needs identified and also acts as a communication tool for patient specific information which may need to be communicated at discharge. For obstetric patients specific needs are identified during the booking process and recorded and retained in the patient hand held notes to ensure specific requirements are communicated when patients are discharged. The Continuing HealthCare Needs Checklist is not completed for maternity patients unless there are ongoing non obstetric related care needs. In this case the relevant referral for assessment would be made by the named midwife. The Continuing Healthcare Needs Checklist is not completed for paediatric patients. 5 Process for Discharge Adults Many aspects of the discharge process apply to all patients. The general discharge process begins on admission and the Nurse / Midwife responsible for the patients care will ensure that all communication with the patient regarding discharge is recorded in the patient s medical case notes (paper / electronic), nursing notes (paper / electronic) or hand held maternity notes. With the patient s consent this will include informing relatives and carers about an estimated date of discharge which will be documented. The name of the responsible nurse or named midwife should be clear to all those involved in the patient s care and clearly documented in the nursing documentation or hand held maternity notes. All discharges follow the process for a simple discharge and additional requirements for specific discharge categories. 5.1 Simple Discharge Process The discharge process begins on admission or at a pre-admission clinic where appropriate. After assessing the needs of a patient on admission to the Trust, specific discharge arrangements may be identified. A Discharge Care Plan (Appendix 1) contained within the Nursing documentation is initiated within 24 hours of admission (excluding maternity & paediatrics) by the nurse responsible for the patient s care to identify specific needs such as: Wirral University Teaching Hospital NHS Foundation Trust Page 2 of 20

6 Referrals required to the Community Discharge & Liaison Team Equipment required Homelessness Transport arrangements Adequate supply of dressings and medication required Continuing health or social care including restart package of care Infection control issues End of life care Follow up arrangements The patient and /or carers must agree the discharge plan including an estimated discharge date which is documented by the nurse on the discharge care plan. The estimated date of discharge will not be documented in the observation or assessment wards. If an existing package of care needs to be restarted, the nurse undertaking the discharge plan will need to contact the IDT via Cerner Millennium. NB: Requests received after 4:45 pm on Fridays, weekends and bank holidays to re-start packages of care will not be responded to until 9am Monday or the next working day. If a community nurse is required, a referral should be made on Cerner Millennium by the responsible nurse / midwife and recorded in the discharge care plan of the nursing documentation (appendix 1). Requests after 16:00 hours, at weekends and on bank holidays for patients registered with a Wirral GP must be faxed to the GP Out of Hours service The referral includes detail of specific infections such as Methycillin Resistant Staphylococcus Aureus (MRSA) the patient may have to ensure that appropriate treatment is continued in the community. Medication To Take Home (TTH) is ordered as soon as possible so that it will be readily available for discharge prior to the patient leaving the ward. Once the TTH has been prescribed, notify pharmacy. The Pharmacist will undertake a clinical check of the TTH before the patient is discharged to ensure that the prescription is safe and appropriate. Supply of TTH medicines to patients must follow the processes defined in the Medicines Management Policy. The discharging nurse also advises the patient about the medication side effect information which is documented in the discharge care plan (Appendix 1). Patients must be informed that any follow up appointments required will either be arranged prior to discharge or sent in the post. Transport arrangements for discharge must be considered on admission in discussion with the patient, relative or carer. The nurse coordinating the discharge must ensure that the patient, relative or carer or healthcare professional receive specific instructions on care required after leaving hospital. This may include specific instruction relating to a known infection and would be recorded on the discharge care plan (appendix 1). Specific infections the patient may have are also recorded on the discharge summary generated from Cerner Millennium. Wirral University Teaching Hospital NHS Foundation Trust Page 3 of 20

7 A copy of the discharge summary is given to the patient, sent to the GP and Consultant, and a copy is filed in the case notes. The nurse discharging the patient should ensure that if required they are given a 5 day supply of dressings, appliances or continence pads. The nurse must also ensure that the patient is fully clothed before discharge and must not discharge the patient in their nightwear unless this complies with the patient s wishes. Homeless patients should be identified on admission and their situation made known to the Local Authority Health and Housing Link Officer on or When a patients housing problem only becomes known while in hospital, the responsible nurse should contact the Local Authority Health and Housing Link Officer as soon as possible (see Appendix 4 for flowchart). Homeless patients in Urgent Care including A & E Department: When the Health and Housing Link Officer is informed about a homeless patient in Urgent Care including A & E Department every effort will be made to find that patient suitable accommodation to be discharged to, taking into account the discharge timescale of these acute wards. The accommodation may only be temporary. Homeless patients on other wards: The Health Housing Link Officer will arrange a suitable housing option that will not delay their discharge. The only exception to this is when the patient expressly wishes that a referral is not made and the patient does not lack mental capacity. Discharge Lounge is available between 8am and 8pm Monday Friday (excluding Bank Holidays) patients who have been identified as safe for discharge can be transferred to the discharge lounge with the exception of patients who are violent and aggressive, require palliative care or special supervision. Patients can only be transferred to the Discharge lounge if their take home medications have been prescribed on Cerner Millennium and clinically checked by a pharmacist. Take home medication can be delivered to the discharge lounge, checked and signed for as correct by two qualified staff members. Private, Hospital or Ambulance transport can be arranged to collect the patient from the discharge lounge. 5.2 Discharge Summary Information Requirements The following criteria are the minimum dataset agreed at a national level required to go in every discharge letter. A record that a copy of the discharge summary has been sent to the GP is held on Cerner Millennium and the Electronic Health Record and a hard copy filed in the patient s medical record. NB Discharge letter (in this instance) is defined as the document that leaves with the patient, generated from Cerner Millennium and is received with the GP Practice via Electronic Health Record within 24 hours. Subsequent information may be sent but this is the information needed for the GP to manage the patient following discharge. There is evidence that getting this information into the discharge document supports the avoidance of readmissions. Wirral University Teaching Hospital NHS Foundation Trust Page 4 of 20

8 1 Admission date 2 Discharge date 3 The name of the responsible Consultant at the time of the patient s discharge 4 Summary of key diagnosis 5 Findings of clinical examination (including any internal/pelvic examination) 6 Details of any services provided to the patient including any operations and diagnostic procedures and their outcomes 7 Details of any medication prescribed at the time of the patient s discharge and what has started or stopped during the inpatient stay and reason why 8 Any adverse reactions or allergies to medications or treatment 9 Contact details of discharge co-ordinator / social worker/ot etc 10 Any immediate post discharge requirements from the primary health care team e.g. home visits 11 Any planned follow up arrangements e.g. clinic appointments or fall service referrals 12 Whether the patient has any relevant infection to be confirmed with I CT team 13 Who should be contacted in the event of a query (ward area and publicise WUTH medicine helpline) Four copies of the discharge summary are generated from the Cerner Millennium. The content must be explained and given to the patient on discharge with instructions about the benefits of sharing it with Healthcare professionals providing care on discharge. A copy of the discharge summary is also filed in the patient s medical notes, sent to General Practitioner and the Consultant in charge. 5.3 Discharge Documentation & information The discharge documentation and information given to patients, parents, relatives or carers and / or receiving healthcare professional at discharge is recorded in the nursing documentation (appendix 2 & 6) or hand held notes for maternity patients by the discharging Nurse or Midwife The following documentation and information must be given to the patient, parent, relative or carer on discharge: A copy of the discharge summary generated from Cerner Millennium Patient Medication Administration Chart (PMAC) if required for drug administration by Community Nursing staff Hand held notes for maternity patients, all post natal women discharged are given their hand held notes to take home with them and any follow up appointments required are made for ante natal and post natal women by the discharging midwife. The discharge letter for post natal women is given to the community midwife and a copy is sent to the relevant General Practitioner and Health Visitor. Clinic appointment if available at the time of discharge Completed discharge information sheet from the nursing documentation (Appendix 2 & 6) Wirral University Teaching Hospital NHS Foundation Trust Page 5 of 20

9 Other relevant information sheets e.g. post operative advice sheets, Warfarin booklets or infection control advice The nurse responsible for the discharge ticks a box on the Nurses Discharge Care Plan to record that they have given the patient a copy of the discharge summary The following documentation and information must be given to the patient on discharge for the receiving healthcare professional: A copy of the discharge summary generated from Cerner Millennium is sent to the GP electronically Copy of Nursing Home discharge form if appropriate (appendix 5) Copy of the completed discharge information sheet (appendix 2 & 6) Patient Medication Administration Chart (PMAC) if required for drug administration by Community Nursing staff Hand held notes for maternity patients, all post natal women discharged are given their hand held notes to take home with them and any follow up appointments required are made for ante natal and post natal women by the discharging midwife. The discharge letter for post natal women is given to the community midwife and a copy is sent to the relevant General Practitioner and Health Visitor. Clinic appointment if available at the time of discharge Other relevant information sheets e.g. post operative advice sheets, Warfarin booklet or infection control advice 5.4 Complex discharge The process for a simple discharge must be followed. However, if the healthcare professional coordinating the discharge assesses the discharge to be complex the following additional steps should be implemented as necessary according to the individual patient s needs: 5.5 NHS Continuing Healthcare Needs Checklist The NHS Continuing Healthcare Needs Checklist (CHC) must be completed for all patients who have either an evidenced primary healthcare need or a potential primary healthcare need following Multi Disciplinary Team (MDT) assessments (Appendix 3 describes the process). The NHS Continuing Healthcare Needs Checklist is available on every ward. Following completion of the checklist a record of nursing needs form or a decision support tool may be required to be completed. The Integrated Discharge Team (IDT) will offer support and guidance regarding this. If a primary healthcare need is evidenced an application will be made by the IDT on behalf of the MDT to NHS Wirral for funding. 5.6 Discharge Arrangements for Patients at the End of Life Patients identified as being near the end of life and wishing to be discharged to their preferred place of care which may be: Home - must be identified at the discharge planning board round and referred to the Community discharge & liaison team via Cerner Millennium Care home setting - must be identified at the discharge planning board round, to enable the IDT to facilitate the completion of the NHS Continuing healthcare fast track documentation, to forward to NHS Wirral for funding approval. This will take place once a care home has been identified as able to meet the needs of the patient. Wirral University Teaching Hospital NHS Foundation Trust Page 6 of 20

10 5.7 Discharge Arrangements for Patients Who Require Equipment In order to facilitate the safe and timely discharge of patients into the community, consideration must be given to any need there may be for the provision of equipment from the Community Equipment Service (CES) to support the personal independence, health, safety, wellbeing and safe handling of patients as well as contribute to the wellbeing of potential carers. For further information regarding the provision of equipment refer to Section Discharge Documentation & information Follow the steps detailed in Sections 5.2 and Process for Discharge Paediatrics 6.1 Discharge Arrangements for Paediatric Patients The patient, parent or carer for the child is informed of the discharge. The Nurse in Charge of the patient s care will arrange take home medication, any follow-up appointment required and a copy of the discharge summary generated from Cerner Millennium will be given. A copy will be filed in the medical records and sent to the General Practitioner and Consultant in charge. The Ward Clerk sends a copy of the discharge summary to the relevant Health Visitor and the GP for all children admitted to this hospital aged under 5 years (excluding day cases). For children about whom there is a specific concern the nurse responsible for the child s care will contact Health Visitor by telephone and make a record in the nursing documentation. Any children for whom there is or have been safeguarding issues, the nurse in charge of their care will complete the documentation mandated in Safeguarding procedures and will liaise with the relevant health and social care professionals. Children assessed as suitable for hospital at home care are discharged by the Hospital at Home Nurse according to specific care pathways. Children over 5 years of age with complex social, medical or continuing care needs are referred on discharge to the appropriate agency by the Nurse in Charge of the child s care and includes: Continuing Care Team Social Worker School Nurse Child and Adolescent Mental Health Team On discharge all paediatric patients and parents/carers are advised that advice is available from Children s Ward (52) and the Assessment Ward or Hospital at Home for 48 hours. A photocopy of the discharge plan (appendix 6) is taken and together with the Cerner Millennium generated discharge summary is given to the patient, parent, relative or carer. Wirral University Teaching Hospital NHS Foundation Trust Page 7 of 20

11 7 Equipment The range of equipment supplied is detailed fully in the Community Equipment Catalogue available from the Community Discharge & Liaison Team or the ward based occupational therapists. Broadly, the equipment available from the Community Equipment Service falls into the following major categories: Mobility equipment Moving and handling equipment Bedroom and nursing equipment Bathing and toileting equipment Living room equipment Kitchen / dining equipment Miscellaneous equipment 7.1 Assessment for Equipment Patients who may require equipment must be assessed by a member of the Multidisciplinary Team to identify their particular equipment needs in order to facilitate safe discharge planning. A referral to order equipment identified by a member of the Multidisciplinary team to meet the patient s needs will only be made to the CES by the Ordering Officers listed below: Community Discharge & Liaison Team (for ongoing community nursing needs) Occupational Therapy and Physiotherapy staff from WUTH Wirral Community NHS Trust Occupational Therapy staff from Wirral Social Services and Cheshire & Wirral Partnership NHS Foundation Trust Specialist Tissue Viability Nurse for Nursing Homes 7.2 Ordering Equipment Standard Stock The CES Standard Stock Requisition Form must be completed by the ordering officer. Failure to complete this documentation accurately will introduce delay to supply of the required equipment and may affect discharge date. The completed requisition form must then be faxed to the CES for action on ext (safe haven fax). Requisitions will be processed and equipment will be made available for supply in no more than 7 working days. Delivery will be dependent upon ready access to the proposed delivery address and the premises being prepared for the installation / delivery / fitting of the equipment, e.g. room cleared appropriately for delivery of bed Non-Standard Stock Equipment / Bespoke Equipment Equipment that is not listed in the Equipment Catalogue as a standard stock (standard supply) item is considered bespoke / specialist. The delivery time for these items will be outside the 7 working day delivery arrangements and will be Wirral University Teaching Hospital NHS Foundation Trust Page 8 of 20

12 subject to the response and availability from the supplier / manufacturer of the equipment. In the event that the need for such equipment is identified, it is imperative that the correct documentation (non stock order form and questionnaire) is completed as soon as possible to expedite the supply of the required items and support timely discharge. In circumstances where a Purchase Order for the equipment will need to be raised with an external provider (supplier / manufacturer), a counter-signature from the Ordering Officer s Manager will be needed on the Non-Stock Item Order Form before the CES can process the requisition. For specialist seating and slings a visit to CES must be made as suitable equipment may be in the store. CES can be contacted at any stage of the equipment ordering / supply process for advice and guidance to support discharge. 7.3 Community Equipment Provision Exceptions Equipment will not be issued from the CES for communal use within Residential Homes and Nursing Homes. If the discharge destination is a Nursing Home, the CES will supply the patient with walking aids if required. Pressure Relieving Equipment will be supplied following assessment from the Specialist Tissue Viability Nurse with dedicated responsibility for Nursing Homes. Where the discharge destination is a Residential Care Home in Wirral, community equipment can be provided for the use of the individual patient in the Home. An ordering officer must carry out an assessment of need in the usual way and identify and order equipment required by the patient on discharge. Moving and handling equipment will only be supplied to patients being discharged into Residential Care Homes to support the delivery of ongoing care from the Community Nursing Service. This equipment must be withdrawn when the nursing input ceases. It is the responsibility of the Residential Home to ensure that there are adequate arrangements in place to protect the safety of residents and their staff when equipment is in situ. If the discharge destination is an intermediate care bed for on-going rehabilitation prior to discharge home, ordering officers from that facility can requisition community equipment for supply to the patient s home when needs are assessed, identified and discharge from the facility is agreed. The CES will not supply equipment for use outside the boundaries of the Metropolitan Borough of Wirral. 8 Process for Discharge Out-of-Hours Patients should not be discharged after 20:00 hours or before 07:30 hours, with the exception of patients from A&E, AAU, AMAU, SAU, HAC, OTU, Isolation, Labour and Wirral University Teaching Hospital NHS Foundation Trust Page 9 of 20

13 Paediatric Wards when discharge may occur at any time as patients are identified as safe for discharge. The safety and welfare of patients being discharged out of hours may be compromised and consideration must be given to admit the patient over night. Document the reason clearly in the patient s medical record and complete an incident form. An incident form will be completed by the nurse / midwife when a discharge has taken place after the 20:00 hours or before the 07:30 shift change and the reason for the discharge documented in the patient s medical record. If the patient is medically fit and safe for discharge and wishes to go home out of hours, completion of an incident form is not required but a record of the discharge is made in the medical notes. 9 Definitions Discharge out of Hours from Wirral University Teaching Hospital (WUTH) is defined as a discharge that has taken place after the 20:00 hours and before the 07:30 shift change with the exception of patients from Emergency Department (ED), Acute Assessment Unit (AAU), Acute Medical Assessment Unit (AMAU), Surgical Assessment Unit (SAU), Heart Assessment Unit (HAC), Orthopaedic Trauma Unit (OUT), Isolation, Labour and Paediatric ward when discharge may occur at any time as patients are identified as safe for discharge. Patient Groups Include : Under this policy and procedure Paediatric patients admitted to the Trust are 0-16 years of age with the exception of young people who have complex needs up to the age of 19 years Adults who require any of the following: Community Nursing Services; Equipment; Packages of Care; have a Known Infection; and End of Life Care Homeless patients with no fixed abode Simple Discharge process A simple discharge is one that: Will involve minimal disturbance to the patient s activities of daily living. Facilitates a patient s return to their usual place of residence. Will not require a significant change in support offered to the patient or their carer in the community. Have simple ongoing care needs that do not require complex planning and delivery. Complex Discharge process Complex discharges occur when there are significant changes in the care needs of a patient since admission resulting in the patient being unable to return to their usual place of residence or requiring increased input from health or social care providers on discharge. 10 Duties / Responsibilities 10.1 Responsible Nurse / Midwife Within Wirral University Teaching Hospital Foundation NHS Trust, the discharge process is led by the responsible nurse or named midwife who is accountable for the coordination of the patient s care. Wirral University Teaching Hospital NHS Foundation Trust Page 10 of 20

14 The responsible nurse or named midwife has the lead responsibility for coordinating all aspects of the patient s care including discharge planning. This role requires a proactive seven-day approach to ensure that: the discharge plan is progressing smoothly the specific needs of each patient are met the patient is discharged in a safe and timely manner 10.2 Corporate Nursing & Midwifery Audit Team The Corporate Nursing & Midwifery Audit Team are responsible for conducting the annual discharge audit and ensuring that the results are presented to Trustwide Clinical Governance Team Associate Directors of Nursing The Associate Directors of Nursing are responsible for ensuring that a divisional action plan is produced as a result of any deficiency identified from the annual discharge audit presented at Trustwide Clinical Governance Team. They will also ensure that the action plan is monitored for completion at the Divisional Management Teams Ward Sisters Ward sisters are responsible for ensuring that new staff are made aware of the discharge policy and procedure at local induction Community Discharge & Liaison Team For Adults The Community Discharge & Liaison Team are nurses employed by Wirral Community NHS Trust who are responsible for: being the initial point of contact for community services about individual patient discharge plans Facilitating referrals to intermediate care via single point of access for patients in the community they will act in the role of ordering officer for community equipment services, for patients requiring community nursing services, ensuring that equipment needs are identified and equipment ordered in time for the discharge to take place safely 10.6 Integrated Discharge Team (WUTH & DASS) The Integrated Discharge Team (IDT) consists of Patient Flow Practitioners, Social Workers, and Assessment Support Officers. Members of the IDT attend the daily discharge planning board rounds to support and facilitate the discharge process, which includes relevant assessments, and completion of the documentation ensuring safe and timely discharge to a variety of settings. In most cases this will be on a short term basis pending review of care needs. The Team will liaise with Locality Social Workers, community based services and voluntary agencies supporting the responsible nurse and minimising any avoidable delays to the patient journey. Wirral University Teaching Hospital NHS Foundation Trust Page 11 of 20

15 The IDT and Community Discharge Liaison team will review and monitor complex discharges. The IDT is also responsible for ensuring all patients that are deemed to be a Delayed Transfer of Care (DTOC) are recorded in the appropriate way. 11 Definitions Discharge out of Hours from Wirral University Teaching Hospital (WUTH) is defined as a discharge that has taken place after the 20:00 hours and before the 07:30 shift change with the exception of patients from Emergency Department (ED), Acute Assessment Unit (AAU), Acute Medical Assessment Unit (AMAU), Surgical Assessment Unit (SAU), Heart Assessment Unit (HAC), Orthopaedic Trauma Unit (OUT), Isolation, Labour and Paediatric ward when discharge may occur at any time as patients are identified as safe for discharge. Patient Groups Include : Under this policy and procedure Paediatric patients admitted to the Trust are 0-16 years of age with the exception of young people who have complex needs up to the age of 19 years Adults who require any of the following: Community Nursing Services; Equipment; Packages of Care; have a Known Infection; and End of Life Care Homeless patients with no fixed abode Simple Discharge process A simple discharge is one that: Will involve minimal disturbance to the patient s activities of daily living. Facilitates a patient s return to their usual place of residence. Will not require a significant change in support offered to the patient or their carer in the community. Have simple ongoing care needs that do not require complex planning and delivery. Complex Discharge process Complex discharges occur when there are significant changes in the care needs of a patient since admission resulting in the patient being unable to return to their usual place of residence or requiring increased input from health or social care providers on discharge. 12 Duties / Responsibilities 12.1 Responsible Nurse / Midwife Within Wirral University Teaching Hospital Foundation NHS Trust, the discharge process is led by the responsible nurse or named midwife who is accountable for the coordination of the patient s care. The responsible nurse or named midwife has the lead responsibility for coordinating all aspects of the patient s care including discharge planning. This role requires a proactive seven-day approach to ensure that: the discharge plan is progressing smoothly the specific needs of each patient are met the patient is discharged in a safe and timely manner Wirral University Teaching Hospital NHS Foundation Trust Page 12 of 20

16 12.2 Corporate Nursing & Midwifery Audit Team The Corporate Nursing & Midwifery Audit Team are responsible for conducting the annual discharge audit and ensuring that the results are presented to Trustwide Clinical Governance Team Associate Directors of Nursing The Associate Directors of Nursing are responsible for ensuring that a divisional action plan is produced as a result of any deficiency identified from the annual discharge audit presented at Trustwide Clinical Governance Team. They will also ensure that the action plan is monitored for completion at the Divisional Management Teams Ward Sisters Ward sisters are responsible for ensuring that new staff are made aware of the discharge policy and procedure at local induction Community Discharge & Liaison Team For Adults The Community Discharge & Liaison Team are nurses employed by Wirral Community NHS Trust who are responsible for: being the initial point of contact for community services about individual patient discharge plans Facilitating referrals to intermediate care via single point of access for patients in the community they will act in the role of ordering officer for community equipment services, for patients requiring community nursing services, ensuring that equipment needs are identified and equipment ordered in time for the discharge to take place safely 12.6 Integrated Discharge Team (WUTH & DASS) The Integrated Discharge Team (IDT) consists of Patient Flow Practitioners, Social Workers, and Assessment Support Officers. Members of the IDT attend the daily discharge planning board rounds to support and facilitate the discharge process, which includes relevant assessments, and completion of the documentation ensuring safe and timely discharge to a variety of settings. In most cases this will be on a short term basis pending review of care needs. The Team will liaise with Locality Social Workers, community based services and voluntary agencies supporting the responsible nurse and minimising any avoidable delays to the patient journey. The IDT and Community Discharge Liaison team will review and monitor complex discharges. The IDT is also responsible for ensuring all patients that are deemed to be a Delayed Transfer of Care (DTOC) are recorded in the appropriate way. 13 References DOH: (2010) Ready to Go? DOH: (2007) National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care Wirral University Teaching Hospital NHS Foundation Trust Page 13 of 20

17 DOH: (2003) Discharge from hospital: pathway, process and practice: Health & Social Care Joint Unit & Change Agent Team Wirral University Teaching Hospital NHS Foundation Trust Page 14 of 20

18 Appendix 1 Nurses Discharge Plan NURSES DISCHARGE CARE PLAN This care plan should be commenced when a patient is admitted to hospital. TASK DETAILS/COMMENTS DATE / SIGN Expected Date of Discharge Discharge date agreed and with patient s informed consent, care and discharge arrangements discussed with family and carer(s). Self directed assessment required for health and social care Following assessments if it is deemed that the patient is not safe for discharge back to their own home, the Patient/relative/carer will be informed that once the patient is safe for transfer out of hospital they may be moved into an alternative short term care setting prior to permanent arrangements being put in place. New / restart package of care in place and date confirmed. Agreement obtained for discharge to residential / nursing home Care Placement. NH Discharge form completed. Has the Patient got end of life care needs? If Yes inform the Community discharge & liaison team via Cerner Millennium or telephone Agreement obtained for discharge to intermediate care Delivery date of equipment to discharge destination confirmed and shared with the patient, carer(s) and teams providing care Transport required? Relatives/taxi/PTS Arranged? Dressings / appliances / medication instructions discussed with patient and/or carer(s). Medication to take home (TTHs) clinically checked by pharmacist & Side effects explained? Voluntary Service referral required? Relevant community teams informed (e.g. Community Matron/Community Nurse/Therapist). Outpatient appointment required? Discharge Summary letter given to patient. Yes Yes/No Yes/No Yes/No Delivery Date / / Yes/No Yes Yes Yes Yes/ No/ NA Yes / No / Post / N/A Yes Cash & Valuables / property returned to patient. Yes N/A Cannulae removed. Yes N/A Specific Instructions given:- Driving Yes N/A Returning to work Yes N/A Infection Control Advice Yes N/A Advice Sheets/Instruction for Yes N/A further concerns following discharge contact details given to patient. Other relevant information/comments Complete Discharge information sheet for Patients Wirral University Teaching Hospital NHS Foundation Trust Page 15 of 20

19 Appendix 2 Discharge Information Patient Details Name C/S No Discharge Information for the Patient To be given on Discharge from Hospital Information Record Yes / No / NA Date & Signature Date of Discharge Transport Equipment in place Medication/dressings to take home & side effects explained Wound Care Discharge form given (copy sent to GP) Outpatient appointment Specific Discharge instructions given: Warfarin Booklet Driving Return to Work Advice sheets Infection Control Advice Other:- Health Passport/This Is Me documentation PLEASE return to patient/relative/carer Care will commence on (state date) Community Nurse / Matron will visit on (state date) Volunteer will visit (state date) Any additional information required? Contact details for help and advice recorded Signature of discharging Healthcare Professional Remove this page from the Nursing Documentation and give to the Patient/Relative/Carer or Healthcare professional on discharge with the Discharge Summary generated from Cerner Millennium. Wirral University Teaching Hospital NHS Foundation Trust Page 16 of 20

20 Appendix 3 Continuing Care Process (October 2007) Continuing Care Process (October 2007) Fast Track Other NHS-funded Services Start Assessment Process Look at individual s overall care needs Has the individual reached their full rehabilitation potential? Consider eligibility for NHS Continuing Healthcare by applying the checklist Possible eligibility for NHS Continuing Healthcare No eligibility for NHS Continuing Healthcare Full consideration for NHS Continuing Healthcare by using the DST Care Planning Including determination of requirement for nursing care in a care home providing nursing care Establish primary health need: qualify for NHS Continuing Healthcare NHS Funded Nursing Care NHS contribution to services of a registered nurse Other Care Package NHS and Local Authority contributions Written rationale for decision Communicated to individuals, families and carers Care Package provided and funded Review Three months from initial assessment at least annually thereafter Wirral University Teaching Hospital NHS Foundation Trust Page 17 of 20

21 Appendix 4 Hospital Discharge and Homeless Prevention Pathways Hospital Discharge and Homeless Prevention Pathways for both the main wards and A & E Department Rough Sleepers: As soon as possible, the Responsible Nurse should For Hostel Dwellers: The Responsible Nurse should Patient has accommodation but cannot return to it. The Responsible Nurse should Telephone the Local Authority Health and Housing Link Officer or Telephone the hostel and they will keep the room available, otherwise they may let the room to somebody else The Ark Rose Brae YMCA Wirral Woman s Refuge Forum Housing Our House Telephone the local authorities Health and Housing Link Officer on or With as much information as possible If the patient is 17 or under, contact Social Services and ask for an assessment under the Children s Act Telephone CADT If it is out of hours of the weekend or Bank Holiday, telephone Social Services Emergency Duty Team on and ask for the Homeless Duty Officer Wirral University Teaching Hospital NHS Foundation Trust Page 18 of 20

22 Appendix 5 Nursing Home Discharge Form Nursing Home Discharge Form Title: First Name: Surname: Known as: Date of Birth: Age: Religion: 1 st Language English Yes/No Specify Transfer from Ward/Dept Discharge Address: GP Name/Practice Next of Kin Details Name: Address: Relationship: Tel: Allergies (please specify) Tel Home: Mobile: NOK informed of transfer Yes/No Special Dietary Requirements/Feeding Problems Risk Assessments Falls: No Risk Yes/No Moderate Risk Yes/No High Risk Yes/No Waterlow Score = Skin Intact/Broken Present Wound Management: Site Dressings Frequency Pressure Relieving Equipment in use: Infection Control Status: MRSA C Diff Other (please state) PROPERTY With Patient With Relative Other Clothing Valuables Spectacles Hearing Aid Mobility Aids Prosthetics DISCHARGE SUMMARY, ACTION PLAN AND MEDICATION LIST MUST BE ATTACHED Additional Information.. Nurses Name Print).. Signature:. Designation:. Date:.. Wirral University Teaching Hospital NHS Foundation Trust Page 18 of 20

23 Appendix 6 Discharge Action Plan for Patient Wirral University Teaching Hospital NHS Foundation Trust Page 19 of 20

24 Wirral University Teaching Hospital NHS Foundation Trust Page 20 of 20

25 Consultation, Communication and Implementation Consultation Required Authorised By Date Authorised Comments Equality Analysis Lesley Metcalfe 14 th November 2011 Policy Group Other Stakeholders / Groups Consulted as Part of Development Trust Staff Consultation via Intranet Joe Roberts 18 th November 2011 Full impact assessment completed. Checked for workforce / development, medicines, finance, NHSLA standards or wider corporate implications. WUTH, Wirral Department of Adult Social Services, Wirral Community NHS Trust, Cheshire & Wirral Partnership Trust Health & Wellbeing Partnership Board and individual organisations 21 st November th December 2011 Date notice posted in the Team Information Exchange (TIE) May 2012 Date notice posted on the intranet May 2012 Describe the Implementation Plan for the Policy / Procedure (Considerations include; launch event, awareness sessions, communication / training via DMBs and other management structures, etc) New clinical staff will be made aware of this policy at local induction which will be documented on their personal file. Existing staff will be made aware of this policy through TIE brief. The policy is available to access on the Trust intranet. By Whom will this be Delivered? Ward / Department Managers Version History Date Ver Author Name and Designation Summary of Main Changes May Sue Elliott, Deputy Director of Operations Mar Sue Elliott, Deputy Director of Operations Mar Sue Elliott, Deputy Director of Operations Mar Sue Elliott, Deputy Director of Operations Jan Sue Elliott, Deputy Director of Operations Dec Jun Nov April Sept Feb Heather Rimmer, Joint Commissioner Pat Elliott DDGM (Medicine) Heather Rimmer, Joint Commissioner Pat Elliott DDGM (Medicine) Heather Rimmer, Joint Commissioner Pat Elliott DDGM (Medicine) Lesley Metcalfe Deputy Director of Nursing Lesley Metcalfe Deputy Director of Nursing Janice Evans Specialist Nursing Services Manager Lesley Metcalfe Deputy Director of Nursing New legislation and guidance in relation to CHC and change required to working practices within partnership arrangements. Discharge action plan updated. Updated for new KPI template - no change in practice Discharge Group now monitor action plans arising from KPIs. Discharge checklist replaced with new version. Job / Team Title changes & amendments made to specific discharge arrangements section & removal of CC1 form from appendix Policy altered to reflect PCT changes and the establishment of the new Community Trust and changes to documentation and discharge process Updated to comply with the new NHSLA standards June Lesley Metcalfe Deputy Director of Nursing Updated section 7.2 for further clarity

26 June 2012 August Dec Dr Melanie Maxwell, Associate Medical Director 13.1 Joe Roberts, Head of Assurance Lesley Metcalfe, Deputy Director of Nursing Jan Karyn Dean, Assurance Support Officer Updated section 7.1 for further clarity Changed references to committees to reflect new corporate governance structure; included references to electronic records for those areas that are implementing Wirral Millennium; changed job titles; additional KPI (does not represent change in practice but reflects audit that is already done); redundant KPI removed Change made to time limit patients may be discharged as out of hours from 21;30 to 20;00. Explanation made about consideration given to patients safety and welfare when discharging out of hours Replacement of references to PCIS with Cerner Millennium. Re-formatted to new Trust template.

27 Monitoring Compliance with the Policy Describe Key Performance Indicators (KPIs) Target How will the KPI be Monitored? Which Committee will Monitor this KPI? Patients will have discharge requirements met. 100% Nursing & Midwifery Audit Trust-wide Clinical Governance Team Patients will have the correct information on discharge. 100% Nursing & Midwifery Audit Trust-wide Clinical Governance Team Receiving Healthcare Professionals will be given 100% Nursing & Midwifery Audit Trust-wide Clinical information regarding the patient on discharge Governance Team The discharge documentation and information given to 100% Audit Trust-wide Clinical patients, parents, relatives or carers and / or receiving Governance Team healthcare professional at discharge is recorded in the nursing documentation or hand held notes for maternity patients by the discharging Nurse or Midwife Frequency of Review Annually Annually Annually Annually Lead Nursing & Midwifery Audit Team Nursing & Midwifery Audit Team Nursing & Midwifery Audit Team Nursing & Midwifery Audit Team Performance Management of the Policy Who is Responsible for Producing Action Plans if KPIs are Not Met? Which Committee Will Monitor These Action Plans? Frequency of Review (To be agreed by Committee) Lead Nurses TWCGT Quarterly