SECTION 2 RESPONSIBILITIES OF GROUPS/AGENCIES INVOLVED WITH THE DISCHARGE PROCESS... 21

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1 Trust Policy and Procedure Discharge Planning Operational Policy Document Ref: PP(15)062 For use in: For use by: For use for: Document owner: Status: Trust Wide All staff All staff Discharge Steering Group Approved INTRODUCTION... 3 ACKNOWLEDGEMENTS... 3 DISCHARGE PLANNING PATHWAY... 4 SIMPLE... 5 COMPLEX... 6 THE DISCHARGE TEAM (ADULT SERVICES)... 7 SECTION 1 ADULT AND CHILD DISCHARGE POLICY... 8 Principles... 8 The Multidisciplinary Team (MDT)... 9 Case Conference... 9 Section Routine Discharges (Simple) Section Points for a Complex Discharge Discharging Patients with MRSA (Methycillin Resistant Staphylococcus Aureus).. 12 Departmental Issues Specific discharge responsibilities of individual members of the MDT Child and Family Section Irregular Discharges Section Discharges out of hours Section 1.5 Alternative Discharge Destinations Nursing & Residential Care Homes Sheltered/Warden Controlled Accommodation Hostels Hospices Section 1.6 Discharge Planning in End of Life Care and Last Days of Life 17 Principles Rationale multidisciplinary team SECTION 2 RESPONSIBILITIES OF GROUPS/AGENCIES INVOLVED WITH THE DISCHARGE PROCESS Section Registered Nurses Discharge Responsibilities Section Consultant Teams Discharge Responsibilities In-patients on Discharge Source: Sally Lawrence/Sue Jones Status: Approved Page 1 of 63

2 Attendance at A&E GP Discharge Notification Section Discharge Planning Team Discharge Planning Team (DPT) Discharge Responsibilities Section Care Co-ordinators Section Adult Care Services Referral Criteria Discharge Responsibilities Section Physiotherapists Referral procedure Discharge Responsibilities Section Occupational Therapist (OT) CRITERIA FOR OCCUPATIONAL THERAPY Section Speech and Language Therapy Discharge Responsibilities Enhanced Early Intervention Team.. 37 Section Pharmaceutical Services Section Nutrition & Dietetic Services Discharge Planning for Inpatients Section Community Nursing Services Section General Practitioners Discharge Responsibilities SECTION 3 DEPARTMENTAL ISSUES Section Accident and Emergency (A&E) Section Day Surgery Section Maternity Section Mental Health Section Patients with Learning Dis and/or with Discharge Planning.. 50 Discharge Unit... SECTION ADDITIONAL INFORMATION Section Transport Facilities Section How to book Section Other issues relating to discharges via Ambulance Transport Section Patient Escorts Section Equipment Section Patients Property Section Suffolk Family Carers Section Welcome Home Service REFERENCES Bibliography APPENDIX 1 VULNERABLE PATIENTS APPENDIX 2 MEDICAL CERTIFICATES AND REPORTS Source: Sally Lawrence/Sue Jones Status: Approved Page 2 of 63

3 INTRODUCTION West Suffolk NHS Foundation Trust provides either acute care to a population of approximately 280,000 people. This policy identifies the roles of those involved in the discharge of patients and guides the reader through the processes of discharge. It has long been recognised that collaborative working and good communication between agencies are key in ensuring that people needing care have the supporting services they need at home or elsewhere. The aim of this policy is to ensure that all agencies involved in the provision of social, nursing or medical care work together to deliver an effective, smoothly co-ordinated service that meets the needs of it users, patients, carers and families. The document will be reviewed as new developments and processes are implemented. ACKNOWLEDGEMENTS The following departments and agencies have contributed to this Discharge Planning Policy. They have reviewed and commented on this document. Adult Care Services Suffolk County Council Service Managers Patient Forum Groups Consultant Teams Patient Flow Team Occupational Therapists Paediatrics NHS Suffolk Pharmaceutical Services Physiotherapist Speech & Language Therapists Nutritional & Dietetic Services East Anglian Ambulance Trust All those practitioners who are detailed in this policy Source: Sally Lawrence/Sue Jones Status: Approved Page 3 of 63

4 DISCHARGE PLANNING PATHWAY Discharge Planning Pathway Within 24 hours of admission Within 24 hours of admission Patient Admitted Medical/Surgical Team Within Team to to identify estimated potential discharge date. Discharge 48 hours discharge date (EDD). Letter information booklets of admission A and Discharge information booklets given given to patient to patient GO TO Nursing Nursing and Social history taken Within and Social history taken SIMPLE by admitting/named nurse and 24 by hours admitting nurse and documented documented in Discharge Health of admission in nursing and AHP assessment booklet Assessment Within 24 hours of admission Identification Within of any potential Identification of any potential 24 hours difficulties difficulties No of admission Yes Yes Inform Inform Specialist Liaison Discharge Discharge Planning Planning Team (LDPT) Team Extension Bleep: 605/ GO TO COMPLEX Does patient have an identified key worker? Named/Team Nurse to share information with SDPN of patient admission and/or any discharge planning difficulties Yes No GO TO COMPLEX Source: Sally Lawrence/Sue Jones Status: Approved Page 4 of 63

5 SIMPLE Key key worker can be hospital or community based e.g. Social Worker, Registered Nurse, Nurse Specialist, Health Visitor, Occupational Therapist, Physiotherapist, Speech & language therapist, District Nurse Liaison SIMPLE Review medically [Type a quote from the document or the summary of an interesting point. You can fit status: position the text box anywhere in the document. Use the Drawing Tools tab to Indicate as change the formatting of the pull quote text box.] appropriate on white board. Yes Mentally & physically independent or living with carers. Support package sufficient to meet needs No Nursing staff to inform patient, relatives/carers of estimated discharge date. Refer to Therapy and Social Services if necessary. Provide if required: Outpatients appointment Dressings if required Equipment if required Information leaflets/advice sheets To Take Out (TTO s) medications Request transport if required Ensure a copy of the completed EPRO is sent electronically SPOA to be sent for any medication to be administered by the District Nurse. Identify where action of Discharge Planning team is required GO TO COMPLEX DISCHARGE PATIENT HOME Source: Sally Lawrence/Sue Jones Status: Approved Page 5 of 63

6 COMPLEX COMPLEX If medically fit, set as fit on Whiteboard Social & Nursing needs, discharge Options/outcomes clear Yes No Plan discharge date Key worker/specialist Discharge Planning Nurse /Multi-disciplinary team to institute meeting or case conference if required to explore options and identification of patients needs Document plans Document Actions Make arrangements as described in simple discharge planning pathway Options identified & appropriate actions taken (e.g. Home Visit) Proceed to actual discharge date Source: Sally Lawrence/Sue Jones Status: Approved Page 6 of 63

7 THE DISCHARGE TEAM (ADULT SERVICES) Multi-disciplinary Team Members and agencies who can be involved in the Discharge Process Care co-ordinators Registered Nurses & Nursing Assistants Transport Physiotherapists Consultant Teams Occupational Therapists Pharmacist/Technicians Social Workers/ Community Care Practitioners Specialist Discharge Planning Nurses/ Discharge Planning Practitioners The patient Specialist Nurses Sheltered Accommodation Nursing & Residential Care Homes Voluntary Groups and Charities Warden Controlled Accommodation Clinical Commissioning Group Relative/Carer CNS care of the Elderly Medically fit team NHS Suffolk Intermediate Care Resources District Nurses General Practitioners MacMillan Nurses Source: Sally Lawrence/Sue Jones Status: Approved Page 7 of 63

8 SECTION 1 ADULT AND CHILD DISCHARGE POLICY Principles There are a number of principles, which underpin practice across all aspects of discharge planning; these are listed below. Each patient's discharge will be planned by the multi-disciplinary team in conjunction with the patient, relatives, and/or carer, and will begin on or before the patient's admission to hospital. It will be an on going process that will involve the patient, relatives and carer, and will provide a seamless transfer from hospital to the most appropriate environment. The estimated discharge date will be identified by the consultant and persons responsible for actions to ensure the discharge process progresses must be identified. Each patient will be treated with dignity. The right to accept or decline care will be respected at all times. Respect will be shown for the specific needs of people with disabilities and these needs will be addressed. The multi-disciplinary team will identify those patients who may be vulnerable and have special needs, which will need additional consideration. Guidance on patients who may be considered to be vulnerable is given in Appendix 1. Such patients must be identified as soon as possible and their needs addressed in order to facilitate their discharge. All elements of discharge planning along with dates and contact details will be clearly documented in the patient's documentation, using the multi-disciplinary communication sheet and any checklists available should be used. The standard requirement is that hospital care providers should by the multidisciplinary documentation, be instantly informed about the patients plan for discharge. Respect and consideration will be shown for the needs of relatives and carers. Where necessary, and in conjunction with social services, needs assessments for relatives and carers can be instigated. A carer is defined as any person, voluntary or professional, who is involved in providing care related services (Carers Charter and Carers Recognition and Services Act (2) All patients will be provided with the relevant health education and support relating to the discharge process, whilst encouraging self-care wherever possible. All information given to patients, families and carers will be consistent with that given by community agencies. The individuals will have access to information regarding their discharge arrangements, which will be relevant, consistent and timely. In addition will have access to information in accordance with the Data Protection Policy PP(06) 110. Written information should support and reinforce any verbal instructions given regarding discharge arrangements. This can include for example: Leaflets Booklets Source: Sally Lawrence/Sue Jones Status: Approved Page 8 of 63

9 Advice sheets following operations (operation specific) Relevant contact numbers should the patient or carer experience a problem following discharge. The Multidisciplinary Team (MDT) This title refers to all staff involved in the patient s care and management. Most commonly these include nurses, doctors, physiotherapists, occupational therapists and social worker. Pharmacists are included in the MDT in the 7 day working documents. Many other hospital staff are involved where required, as are community services. Individual members of the multi-disciplinary team involved in the care of the patient should identify when referrals need to be made to other disciplines not currently involved in the patient's care. Referral criteria for physiotherapy, occupational therapy and speech and language therapy are given in Sections 2.6, 2.7 and 2.8 respectively. The MDT should decide the appropriate date and method of the patient s discharge. Some Consultants schedule formal MDT meetings where they can co-ordinate their patient s plan of care with all team members present. Alternatively, individual members of the team can liaise at ward rounds, white board meetings or on an individual basis. Which ever method is employed the crucial factor is that effective communication occurs amongst the group. The named or appropriate nurse should document and co-ordinate this information. Case Conference It may be deemed appropriate to hold a case conference for a particular patient. The MDT will meet (as described above), with the addition of the patient, relative, and /or carer. It may be necessary for a sub meeting to be held prior to the case conference with professionals, to establish the agenda of the conference. In some instances the patient or relative may request a particular aspect of care or service not to be discussed at the conference; this must be acknowledged and taken into account with the best interest of the patients the prime consideration. Source: Sally Lawrence/Sue Jones Status: Approved Page 9 of 63

10 Section Routine Discharges (Simple) A routine discharge is one that: Will involve minimal disturbance to the patient s activities of daily living. Does not prevent or hamper their return to their usual place of residence. Points for Routine Discharge The multi-disciplinary team gathering information will start the discharge plan. An estimated discharge date should be identified within 48 hours of admission where possible. When informing the patient of this date, remind them that it is estimated and subject to change. The named or appropriate nurse must inform any established community care services of the patient s admission within 24 hours. If the patient is admitted over the weekend the community care services must be informed as soon as possible on the next working day. Admission documentation should identify as much information about the patient as possible and include details of community and family support being delivered. Any discharge needs that are identified should be documented and the named or appropriate nurse should be informed. If the patient was in receipt of a community services prior to admission, for example District Nursing Services (DNS), the DNS must be informed of the impending discharge date so that, if appropriate, their care can be re-established. If a patient was in receipt of social services input prior to admission or expected to require their input on discharge the Section 2/5 process should be instigated at the appropriate time. Ensure the patient has all their discharge requirements eg: aids, appointments etc. Ensure TTO medication is checked against the EPRO TTO prescription and explained to the patient or carer prior to discharge. e.g. TTO medications, aids, appointments etc. TTO medication must be checked against the EPRO TTO prescription and explained to the patient or carer prior to discharge. For the patient, relative and carer even the most simple discharge can be concerning. They may require additional information and advice about potential lifestyle changes following their discharge. Providing advice sheets or booklets are useful for the patient to take home. Always ensure that the patient and if appropriate, carer is given the opportunity to ask questions prior to leaving the ward. General Practitioners (GP) must receive notification of the patients discharge from hospital within 24 hours for all patients and on the day of discharge when the patient will be receiving a package of health and/or social care support in the community. The electronic discharge summary should be ed to the GP and a copy should be kept in the patient s notes and a copy given to the patient. If the patient is discharged at the weekend or a bank holiday, notification must be given to the GP on the next available working day. It is the responsibility of the Registered Nurse discharging the patient to follow the discharge plan and ensure Discharge Planning is complete. He/she must be satisfied that the patient will leave with the best and most appropriate support. Source: Sally Lawrence/Sue Jones Status: Approved Page 10 of 63

11 Section Points for a Complex Discharge All the points relating to simple discharges also apply to complex discharges; however there are some additional points to consider. The patient s needs may have changed. This could result in the patient not being able to return to their usual place of residence. The psychological effect of this can be considerable and needs to be recognised. A complex discharge may involve several primary and secondary services. Effective and timely communication between the hospital and the community is essential. The Specialist Discharge Planning Team plays a vital role in the complex discharge and they must be informed as soon as possible in the light of a patient becoming complex. The multi-disciplinary team meeting should highlight those patients who have complex discharge issues. The outcome of such meeting should be documented appropriately in the patients nursing records, notes or by using the MDT combined information documentation. Referrals to particular services should occur as soon as the need is identified. Where a dosset box has been issued, liaison with care provider may be appropriate. Drug restrictions apply when discharging a prisoner. If any changes are made to the discharge plan by a member of the MDT then the patient and the nurse co-ordinating the patient s discharge should be informed as soon as possible. It is the responsibility of the medical staff to specify when a patient is medically fit for discharge, and this date should be documented in the patient's medical notes. This should be indicated on the whiteboard. However, the actual date of discharge will also depend on other factors as determined by the multi-disciplinary team. When confirmed, the proposed day of discharge must be clearly documented in the patient's notes and on the whiteboard. Patients discharged with equipment such as PEG feeds or an indwelling catheter will need to be educated in its use and management. Information must be provided prior to discharge with contact numbers and names given to the patient, relative or carer in case of difficulties. The relatives and informal carers must be involved in the discharge arrangements. Relatives and informal carers may benefit from a pre-arranged meeting with the doctor responsible for the care of their relative. When the patient is a child, all the discharge planning will be undertaken in partnership with the child and parent or carer. Discharge will generally only occur after a full assessment of individual needs. Everything reasonably practicable will be done to secure any necessary care in the community. Wherever possible, patients will be reviewed at multidisciplinary ward meetings and discussed with relevant community health staff before discharge. If the individuals are assessed against any of the continuing health care eligibility criteria they will be kept informed and given written evidence of the outcome by the relevant Clinical Commissioning Group (CCG). Patients who are homeless. Includes people who have no fixed address or are unable to return to their own homes due to violence, financial difficulties or people who have refugee status. The team will not normally plan discharges on weekends, bank holidays and after hours for vulnerable/end of life patients unless planned in advance and agreed by all parties involved and not until any services required are available and ready. (See section 5.6 for discharges outside of hours) Source: Sally Lawrence/Sue Jones Status: Approved Page 11 of 63

12 Discharging Patients with MRSA (Methycillin Resistant Staphylococcus Aureus) MRSA is not a contra-indication for discharge if the patient is clinically well. If the patient is to be discharged to their own home, the details of the MRSA positive site(s) should be recorded in the discharge letter together with any current treatment. If the patient is to be discharged to a nursing, residential or other care facility it is the responsibility of the nurse discharging the patient to ensure that the patient s current MRSA status and treatment is communicated to the receiving facility via the transfer or discharge letter. For further information and advice regarding the discharge of MRSA positive patients can be discussed with the Infection Prevention Team on extension Departmental Issues Specialist departments have additional procedures, which need to be followed to ensure safe discharge. Specific discharge requirements for A&E, Maternity, Mental Health and Day Surgery are given in section 3. Specific discharge responsibilities of individual members of the MDT In addition to the shared responsibilities of the MDT, each of the professional groups within the team has their own responsibilities in the discharge planning process. These are detailed in the principles of good practice detailed in Section 2:3 of this document. Child and Family Over recent years paediatric nursing has changed and there is now a strong emphasis in nursing children at home. Paediatric nurses have an essential role to ensure a safe transition from hospital to community care. The role they play is to ensure parents and caregivers have appropriate teaching and support to care for their child at home. Therefore discharge planning should be started from the time of admission. The named nurse has an ideal opportunity to discuss problem issues the child and family may have at home and support systems should be initiated at this point. Source: Sally Lawrence/Sue Jones Status: Approved Page 12 of 63

13 Section Irregular Discharges Patients who wish to discharge themselves against advice do so for a number of reasons: Those patients suffering from a condition that has changed their perception of the environment or those who have an altered mental state. Some patients may feel uncomfortable being in a hospital or even threatened. This could be due to a simple fear of hospitals or more complicated mental health conditions and paranoia Those under the influence of alcohol or drugs Those who are unhappy with the care they are receiving and wish to raise a concern or make a complaint. If by discharging themselves the patient could potentially be at risk then all staff should endeavour to persuade the patient to stay. They should not, however risk their own personal safety. Any treatment or medication should be given wherever possible to remedy any inappropriate behaviour due to a medical complaint and TTO s supplied. If after all appropriate personnel have been informed and have spoken to the patient, the rational patient still wishes to leave, they should sign a Discharge Against Medical Advice form. The patient should be advised to contact their G.P practice, as they may need services or treatment in the community. The Doctor will, as with regular discharges send a discharge letter to the GP and should contact the GP by telephone if they have any immediate concerns. Nursing staff should inform any appropriate community staff or relatives/carers and their senior nurse on duty. If the patient is under sixteen and wishes to leave against advice or leaves without permission the nurse should inform: the parent or carer, the senior nurse on duty, their Medical/Surgical team, the police (only by the authority of the Chief Executives office via the manager-on-call), security and the child psychiatrist (if involved in the child s care). All appropriate paperwork should also be completed. If a parent attempts to discharge a child who is under a child protection order, the police and social services must be informed immediately. If a patient wishes to discharge him or herself because they have concern or complaint, all efforts need to be made to resolve the problem in order to allow their care to continue. Further information on dealing with complaints can be sought by contacting the PALS Manager on ext 2555 who will give appropriate advice. Please also refer to the formal complaints leaflets in ward and clinical areas and the Trusts Complaints Policy pp(12) 002 Source: Sally Lawrence/Sue Jones Status: Approved Page 13 of 63

14 Section Discharges out of hours Discharges made outside hours of and during holiday periods for vulnerable patients (as defined in Appendix 1) requiring community support are only appropriate if planned well in advance and agreed by all parties involved. Unplanned discharges at such times can fail and can consequently result in re-admission. To ensure patients are discharged appropriately: The patient, relative and any carer must agree on the date and time of discharge and know when the services are due to commence. If the patient lives alone and require services commencing then these should be confirmed with the patient s social worker before discharge. The patient must be told if these services will commence immediately and if not when. Patients, relatives and carers should be given contact details of a named person and a contact telephone number in the event of services not starting as planned after discharge. If transport is required out of hours then this can be arranged via the Patient Flow Team bleep; 358 /888. If the patient requires TTO medication it must be available on the ward for the patient. In urgent circumstances the on-call Pharmacist can be called to dispense the medication and contact via the Site Clinical Practitioner. The duty Social Worker can be contacted if there is an important issue relating to a patient being discharged out of hours. Duty Social Worker contact details (out of hours only) Suffolk County Council Telephone Source: Sally Lawrence/Sue Jones Status: Approved Page 14 of 63

15 Section 1.5 Alternative Discharge Destinations Illnesses that require hospitalisation can sometimes mean that patients are unable to return to their original place of residence and require an alternative discharge destination. It is important to ensure that communication regarding the patient s discharge destination is explained clearly to the patient, relatives and carers. Nursing & Residential Care Homes Do the patient and relatives know where the home is, how to get there and the contact number? It is the named nurses /team nurses responsibility to contact the home and confirm the time of transfer Written transfer information should be provided and a copy kept in the patients notes. If the patient needs to attend any follow up outpatient appointments or clinics the care coordinator will inform appointments to send the appointment letter to the patient. It is the responsibility of the nurse discharging the patient to ensure he or she is suitably dressed when being transferred from hospital. If a patient is to be transferred to a residential home and has a nursing need, a referral needs to be made to the District Nursing Service via SPA. Sheltered/Warden Controlled Accommodation Sheltered Housing Schemes - Provide self-contained accommodation for older people. There are communication links for use in emergencies. They are managed by Scheme Managers who provide support only to patients. The nurse should confirm with the warden when the patient will be arriving and who has the door keys. The needs of the patient post discharge should be considered in advance. If they require help with shopping for example this should have been arranged in advance via Social Services or by referring to the Welcome Home Service. Council staff need permission to enter an individual s home the nurse discharging the patient must be aware of this. Hostels Patients being discharged to a hostel would be the responsibility of the social care department, if there is an existing care package in place. The nurse should communicate with the social care department to discuss the discharge and transport arrangements. Hospices Hospice referrals can be for a number of services Day care Home visiting services Source: Sally Lawrence/Sue Jones Status: Approved Page 15 of 63

16 In-patients care for respite specific symptom control and terminal care. If the patient is known to the hospital Macmillan Support Team staff should liaise with the clinical nurse specialist to access hospice care services. Source: Sally Lawrence/Sue Jones Status: Approved Page 16 of 63

17 Section Discharge Planning in End of Life Care and Last Days of Life (Please read in conjunction with End of Life Policy number PP(14)310 and Last Days Clinical Guideline number CG ) Principles The NICE (2004) Guidance for Improving Support and Palliative Care for Adults with Cancer, in the future will apply to the care of all patients with a life threatening disease, states that: Patients wish to be enabled to die in the place of their choice, often in their own home Therefore people s preferences on the location of care are followed whenever possible All patients should have a dignified death with family and other carers adequately supported during this process Discharge Planning in End of Life Care and Last Days of Life Patients reaching the end of their lives will often require special attention to their discharge planning and clear communication is essential for good co-ordination of care. Patients (and carers) will need to be involved in discharge planning which should consider medications (required now and Just in Case ), ongoing care will also help to avoid crisis by anticipating future care needs. For some patients who have a short prognosis, or are rapidly deteriorating there may not be time to go through the normal continuing care health needs assessment. These patients may be suitable for Fast Track Continuing Care funding and this can be facilitated through the Palliative Care Team and Discharge Planning Team. The table below is a guide Prognosis Routine discharge Complex discharge Months Ward Discharge Planning Team Weeks Days Discharge Planning Team/Palliative Care Team Discharge Planning Team and Palliative Care Team Discharge Planning team and Palliative Care Team Discharge Planning Team and Palliative Care Team Yellow Folders It is important that patient information is always available to the patient, staff and carers on transfer/discharge from hospital. Therefore, establishing patient held records as a solution is an initiative that is used in Suffolk. The Yellow Folder is a patient held record which may contain current information on discussions that the patient has had about their condition and what is important to them in terms of care; this could include a community Do not attempt resuscitation document On admission, if the patient brings in their Yellow Folder, information contained in the folder should be acknowledged and discussed with the patient and family as appropriate. The Yellow Folder and contents should remain with the patient and any new information from the admission added on discharge. Source: Sally Lawrence/Sue Jones Status: Approved Page 17 of 63

18 On discharge, if a new advanced care planning discussion has taken place during admission, it may be appropriate to issue a Yellow Folder. Please contact the hospital Palliative Care Team for advice, or ask the GP to consider issuing a Yellow Folder after discharge. For all end of life care discharges, always refer to district nurses using single point of access to request a palliative care assessment and complete a comprehensive hospital discharge letter (including patients diagnosis, prognosis, understanding of condition and care arranged) suggest that the GP enters the patient on their GP GSF/palliative care register and inform their Out of Hours provider as appropriate. Discharge Home in Last Days of Life When asked, most people would prefer to die at home. Occasionally when patients and families become aware that death is imminent they express the wish for discharge home to die. The principles for care and assessment still apply but in addition consideration must be given to who will provide care once the patient is discharged, whether equipment is required, transport and communication with community health care professionals. The family will require information on the process of dying, understand the task they are taking on and who is available to call on should help be required. Families need to be informed there is a risk the patient may die on the journey in the ambulance and that if this should occur the body is likely to be returned to the hospital Emergency Department for verification rather than be taken to the patient s home. The discharge planning team and palliative care team should be informed ASAP as discharge is likely to be required the same day. The Fast Track discharge checklist, GP medication guidance and further information can be found on the Pink Book End of Life Care Discharge section. Source: Sally Lawrence/Sue Jones Status: Approved Page 18 of 63

19 Addressograph CHECKLIST FOR FASTRACK DISCHARGE This is a checklist. All decisions, care plans and arrangements should be documented in the patient s notes. Due to the complex nature of rapidly deteriorating patients, the Palliative Care Team, specialist discharge planning nurse and ward nurse should be involved and kept informed. Information for ward use Patient is identified by multidisciplinary team as appropriate for fast track discharge (FTD) If not suitable for FTD please refer to Specialist Discharge Planning team Conversation on future care planning with patient and/or family agreed Refer to Palliative Care and send EPRO referral, stating fast track discharge. Palliative care to refer to Discharge Planning Team on bleep 540 to: issue paperwork order equipment identify discharge destination Medical team complete: FTD paperwork, discharge letter and TTOs CCG - Identify discharge destination and date of discharge. Ward: Order Transport for AM discharge The ward doctors must ring the GP the day before a fast track discharge: To inform the GP that the patient is a fast track discharge, the likely rate of deterioration and any preferences or priorities the patient may have. To ensure the GP visits the patient. To ensure that Just in case medications are prescribed in a way that the district nurses can give them ie GP has completed instructions to give. Special patient notes have been completed by GP to inform the Out of. Information to confirm with patient transport when booking Name and discharge address Patient is being discharged for end of life care Type of ambulance needed ie stretcher/chair Is the patient on O2 Does patient have community DNACPR Are there any access issues (check with patient /family) Source: Sally Lawrence/Sue Jones Status: Approved Page 19 of 63

20 Discharge checklist - details should be recorded in the patient s notes Yes N/A Initials COMMUNICATION WITH PATIENT/FAMILY Are the patient/family aware and in agreement with the discharge plan/destination. Is the family aware the patient is being discharged for end of life care? Has a yellow folder been issued by the palliative care team? Has a community DNA CPR been discussed with patient/family and completed? Has the family been provided with information leaflet End of life alert and `End of Life, The Facts booklet? Do the patient/family need to have discussion regarding risks associated with travelling? If yes please document conversation in notes. If appropriate, have any outstanding out patient appointments been cancelled? Has the family been provided with emergency contact numbers? FUNDING Has the Fast Track document been scanned to the relevant CCG and discussed and care package/placement agreed? MEDICATIONS Has the hospital doctor prescribed medications for one week, including end of life medications Just In Case? Is the patient receiving medications via syringe pump? If yes please see syringe pump policy. In addition: Have extra giving sets and supplies been provided? Has the medical equipment library been informed and are documents completed for syringe pump to accompany patient into community? Has the syringe pump been reloaded and new battery inserted? Has the District Nurse been notified of the syringe pump? HOME OXYGEN (if applicable) Is the level (L/min) of home oxygen decided and documented? If receiving oxygen at home already is this sufficient for their needs - set to correct flow rate? Has the oxygen been ordered? (Specialist Discharge Planning Team) EQUIPMENT Has the patient s equipment needs been assessed? Has all equipment been delivered? Are supplies from ward being sent with patient (pads, pants, needles, syringes, gloves, aprons, catheter bags etc)? TRANSPORT Is there any problem with accessing the property? Has transport been booked and the time documented? Advise transport End of Life Care patient. DISCHARGE COMMUNICATION - Home Has a Single Point of Access Referral been sent to the appropriate District Nursing Team for palliative assessment? Has the discharge summary been completed and sent to the General Practitioner (GP) Has the hospital doctor phoned and spoken to the patient s GP to advise of discharge, discuss medication and to request a home visit? If appropriate, has a referral been made to the Community Palliative Care Team? DISCHARGE COMMUNICATION Nursing Home Nursing home staff in agreement with date/time of discharge? Discharge Health Assessment completed and sent with patient? Has the hospital doctor phoned and spoken to the patients GP to advise of discharge and to request a visit to prescribe just in case medications? IMMEDIATELY PRIOR TO DISCHARGE check Syringe pump reloaded? Are stat doses of medication required for the journey? Medications all complete? All property with patient? Is patient fit to travel? Yellow folder and EPRO sent with patient Have Palliative Care Team notified: Out of Hours GP of the discharge? Source: Sally Lawrence/Sue Jones Status: Approved Page 20 of 63

21 SECTION 2 RESPONSIBILITIES OF GROUPS/AGENCIES INVOLVED WITH THE DISCHARGE PROCESS Section Registered Nurses The role of the nurse is central to safe and effective discharge. The patient s most common source of information when planning discharge is the nurse on the ward. It is therefore essential that the nurse prepare the patient using all the appropriate resources available. Discharge Responsibilities Information about your discharge booklet should be given to the patient on admission or preadmission, along with the information booklet Planning a safe and timely return home. The registered nurse is accountable for the patient s discharge and works closely with the MDT to co-ordinate discharge. They must ensure that all relevant information is gathered, recorded and communicated in order to plan effective discharges. The nurse who admits the patient should collect as much information about the patient as soon as possible. Names and contact details of any district nurses or family support must be documented clearly. It is helpful to explain to the patient, relative or carer that this information is essential to assist in their care and to facilitate a safe discharge. The patient s name, consultant, date of admission and estimated discharge date must be written clearly in the patient documentation. If the estimated date of discharge cannot be documented at this point, then it should be identified within 48 hours of admission. The estimated discharge date can be discussed and established via ward rounds, multi-disciplinary team meetings, white board meetings and established pathways of care. It is the responsibility of the multi-disciplinary team to communicate regarding the discharge details date and the electronic patient record whiteboard should be updated accordingly. Once established the doctor should document the date in the medical notes and inform the named or accountable nurse. The registered nurse should discuss with the patient any relevant information regarding their care and discharge. A discharge plan should commence on admission (if no pre-admission planning has taken place) and the nurses can then co-ordinate the discharge. It is the nurse s responsibility to liaise with existing community support services to inform them of the admission as soon as possible. This should be within the first 24 hours and will predominately apply to emergency admissions. If a patient is admitted over the weekend the community care services must be informed as soon as possible on the next working day. When an admission is planned the patient s community support should have been informed in advance but this should be checked. The nurse caring for the patient on any shift should know the stage the patient has reached in their discharge preparation and should ensure that discharge planning is continued. The nurse who has been assigned to patient care by the nurse in charge is responsible for the patient s care. If they admit a patient they must familiarise themselves with any documentation required. As registered nurses, they are accountable for their practice and the basic principles of discharge planning. They should be informed as to what stage the patient has reached in their discharge preparation. Source: Sally Lawrence/Sue Jones Status: Approved Page 21 of 63

22 If a patient wishes to self-discharge it is the nurse s responsibility to inform the appropriate personnel and ensure that all appropriate documentation is complete. Refer to section 1.3 for more information on irregular discharges. Outpatient appointments will be arranged on discharge. Details of the date and time of the appointment will be sent to the patient s address. If there is an identified nursing need following discharge and the patient is house bound and unable to attend his/her General Practice, referral to the District Nursing Service may be required. For further details see Section 2 Community Nursing Services. The Specialist Discharge Planning Team can assist in the management of patients with complex discharge planning needs: see Section 2.3. On discharge the patient may have various requirements, these could include: To take out medication (TTO) is checked against the EPRO letter and pharmacy communications. Pharmacy communication highlight if there are patient own drugs on the ward or if the patient had sufficient supplies at home. It is also important to ensure that refrigerated and controlled drug items are removed from ward storage, documentation completed and then returned to the patient. Any dressings (minimum 3 days supply) or supplies required. Refer to community services ie.community Nurses, via SPOA Any aids the patient may need i.e. a frame. Discharge information. Any outpatient appointment if required. When the TTO medications are given to the patient, relative or carer these should be discussed in detail. It is essential that adequate time is taken to ensure that the patient and carer understand how and when to take the medication. It may be appropriate to ensure that patients demonstrate how they will administer their medications with the nurse present. The pharmacist will supply a compliance sheet for the patient to take home if required. For further details on ordering of TTOs and Pharmacy Services see Section 2. The nurse discharging the patient should ascertain how the patient would gain access to the property and ensure any keys are sent with the patient. If the patient is employed they may require a sickness certificate. The nurse who is discharging the patient must ensure that the patient receives a certificate if required. The nurse who undertakes the patient s discharge is responsible for following the discharge plan. Before the patient leaves his/her care she must be satisfied that the patient will leave with the best and most appropriate support. The nurse should not allow a patient to be discharged if there is any evidence or concerns that they could potentially be at risk once they leave the hospital. Refer to Appendix 1 for more information on identifying vulnerable patients. If the discharge date is cancelled the nurse caring for the patient on that shift must ensure that the patient, relatives, carers and appropriate services are informed as soon as possible. Source: Sally Lawrence/Sue Jones Status: Approved Page 22 of 63

23 Section Consultant Teams It is the responsibility of the doctor to specify when a patient is medically fit for discharge and this should be documented in the medical notes and on the electronic whiteboard. Length of Stay Patient Tracking system (LOSPT). However, the actual date of discharge will depend on this and other factors as determined by the multi-disciplinary team. Discharge Responsibilities Only a consultant can accept responsibility for the patient while in hospital. Patients cannot be discharged from hospital without the authority of a consultant or a deputy acting on his/her behalf. Where possible a estimated date of discharge (EDD) should be discussed and documented within 24 hours of admission. This is fundamental to ensure effective discharge planning between all internal and external health care agencies. The potential discharge date must be clearly communicated to the appropriate nursing staff and documented in the medical notes and whiteboard. Medical staff should initiate appropriate multi-disciplinary assessments and if a written referral to other disciplines is required, medical staff must complete this as soon as possible. Any such referrals should be clearly recorded in the patient s notes and communicated to the appropriate nurse. Consultants and their teams should discuss with patients, relatives and carers the likely outcomes of treatment, the estimated length of stay in hospital and any arrangements for transfer to specialist/other hospitals where appropriate. They should ensure that these discussions and any input from the patient, relatives or carers are documented. Wherever possible, patients and their relatives should be asked to expect and help expedite a morning discharge. As soon as a patient is considered medically fit for discharge this should be communicated to the nurse in charge of the ward at that time and indicate on whiteboard to inform MDT members. Any changes made to the discharge plan by the consultant team must be communicated immediately to the appropriate nurse. A doctor who is familiar with the patient s case history should prescribe any TTO medication that is required, ideally at least 48 hours before discharge. Hospital Doctors are to provide sickness certificates for as long as they feel the condition is likely to warrant it to minimise the need for the patients to go back to their GP. Source: Sally Lawrence/Sue Jones Status: Approved Page 23 of 63

24 The following procedure should be adhered to: In-patients on Discharge Hospital In-patient certificate should be completed advising the patient to refrain from work for whatever it is felt to be an appropriate time. Attendance at A&E If patients come to A&E and are discharged with a condition, which is likely to mean that they would be unable to work, they should be given an appropriate sick certificate for a period consistent with the anticipated incapacity. GP Discharge Notification The GP letter must provide the following information: Dates of admission and discharge Consultant and ward Diagnosis Significant investigations and results Treatment given and any procedures/operation carried out Rationale for any changes in drug treatment: o Pharmacy endorsements of E (equivalent dose), N (new), I (increased) or D (decreased) can facilitate identification. Any complications of treatment and required monitoring Medication on discharge Follow up appointment requirements. Referrals made to other agencies e.g. District Nurses, Occupational Therapy, Social Services Information and advice given to patient. Medical staff will write a Discharge Letter/Summary. The GP should receive this within 24 hours. Some departments, where appropriate, will follow this up with a formal typed summary within a short time and ed. Source: Sally Lawrence/Sue Jones Status: Approved Page 24 of 63

25 Section Discharge Planning Team Specialist Discharge Planning Team (SDPT) The Discharge Planning Team provides support and management of all patients with complex discharge planning needs and provides additional information and support around discharge planning. The Team also co-ordinates and manages the NHS Continuing Healthcare process for adult patients under the care of the West Suffolk Hospital NHS Foundation Trust. The Discharge Planning Team works with all members of the multidisciplinary team members and external agencies to provide an integrated approach to discharge planning. The team consists of Specialist Discharge Planning Nurses and Discharge Planning Practitioners who are allocated to adult wards and attend daily whiteboard multidisciplinary meetings. The team also collect information regarding those patients whose discharges are incomplete or may be delayed. Any member of hospital staff can make a referral to the SDPT or contact them for advice regarding both simple and complex discharges and nursing equipment needs. Discharge Responsibilities Covering a group of wards on a rotational basis in order to: Liaise with patients and their families, helping them to identify needs, keeping them informed of complex discharge arrangements. Work closely with the hospital based member of the multi-disciplinary team in the planning of a patient s discharge. They will attend MDT meetings as appropriate. Inform and liaise with community liaison teams, GPs, area social workers, MDT professionals and voluntary services as appropriate. Co-ordinate the assessment process for Continuing Healthcare and liaise with Suffolk CCG. Co-ordinate the DTOC process and produce bi-weekly reports. Provide education and training to students and staff as required. Participate in discharge planning meetings, and case conferences. Contact Details Discharge Planning Team: Telephone: / hours to 19:00 hours Monday to Friday 08:00 16:00 Weekends and Bank Holidays Telephone: ( Bleep 982) Source: Sally Lawrence/Sue Jones Status: Approved Page 25 of 63