Adult Discharge Policy

Adult Discharge Policy This document is uncontrolled once printed. Please check on the Trust s Intranet site for the most up to date version. Version: 2 Ratified by: Trust Patient Safety and Quality Committee Date ratified: Name of author: Margaret Magee Lead for Discharge and Monica Bowles Business Manager for STARRS Name of ratifying committee: Trust Patient Safety and Quality Committee Date issued: Review date: February 2013 Target audience: All NWLH staff working in clinical areas notably ward staff and A&E staff;,ward Managers, Directorate Managers, Clinical Managers, Senior Managers and Executive Directors Equality Impact Assessment outcome Associated Documents Low Medicine Reconciliation Policy Nurse Led Discharge Policy Dispensing for Discharge Scheme Policy Children s Safeguarding Policies Transfer Policy Transport Policy Complaints Policy VTE Policy Review and Amendment Log Version No Type of Change Date Description of Change V.1.2 Annual Review Feb 2010 V.2 Annual Review Feb 2012 Reformatting and addition of associate documents 1

Page Glossary 5 1.0 Introduction 7 2.0 Key Principles 3.0 Leadership and Duties 3.1 Chief Executive 3.2 Patient Safety and Quality Committee 3.3 Medical Director 3.4 Consultants and Medical Team 3.5 Director of Nursing 3.6 Matrons and Heads of Nursing 3.7 Emergency Department Manager (A&E) 3.8 Nurses and Allied Health Professionals in A&E 3.9 Ward Manager 3.10 Nurses in Inpatient Areas (Wards) 3.11 Allied Health Professionals in Inpatient areas (Wards) 3.12 Discharge Coordinators 3.13 The Rapid Response & Early Supportive Discharge (STARRS) 3.14 Pharmacist 3.15 The Palliative Care Team 8 9 9 9 9 10 10 11 11 11 11 12 12 13 13 14 4.0 Training 14 5.0 General Discharge Processes 5.1 General Discharge of patients from A&E Departments 5.1.1. Pathway and Documentation for Risk Groups 5.1.2 Medication on Discharge from A&E 5.1.3 Transport from A&E 14 15 16 17 17 5.2 General Discharge of patients from Inpatient Departments 5.2.1. Pathway and Documentation for Risk Groups 5.2.2. Estimated date of Discharge (EDD) 5.2.3. Discharge of patients with Social Care Needs (Sec 2 & 5 18 19 20 21 2

Notifications) 5.2.4. Eligibility for Continuing Care Health Needs Assessment (HNA) 5.2.5 Confirmed Date of Discharge 5.2.6 Medication on Discharge from Inpatients Areas 5.2.7 Transport from Inpatient Areas 5.3 General Discharge from Outpatient Clinics 5.3.1. Pathway and Documentation for Risk Groups 5.3.2 Medication on leaving the Clinic 5.3.3 Transport from Outpatient Clinic 5.4 General Discharge from Medical/Surgical Day Care 5.4.1. Pathway and Documentation for Risk Groups 5.4.2 Medication on Discharge from Day Care 5.4.3 Transport from Day Care 21 22 22 23 25 26 26 27 27 28 29 30 6.0 Discharge Lounge 31 7.0 The Day of Discharge 32 8.0 Specific Types of Discharge 32 8.1 Discharge Following a Planned Inpatient Admission 32 8.2 Discharge of Patients Outside of Normal Working Hours 32 8.3 Discharge Against Medical Advice 33 8.4 Discharges to an NHS Rehabilitation Unit 34 8.5 Discharge During a Major Incident and at Short Notice 35 8.6 Fast Track Discharge for Palliative Care Patients 36 8.7 Discharge of a Homeless Person 36 8.8 Discharge of an Overseas Visitor 37 8.9 Discharge of an Asylum Seeker 37 8.10 Discharge of a Patient with Dementia 38 8.11 Discharge of Patients with Infectious Diseases 39 8.12 Discharge of a Patient with Long Term Condition 39 8.13 Patients Refusing to be Discharged 39 9.0 Monitoring of the Discharge Process and Standards 40 10.0 References 42 3

11.0 Appendices: 1. General Discharge Process/Pathway Flow Chart 43 2 Setting an Estimated Date of Discharge (EDD) - Flowchart 44 3 Actions Relating to the Estimated Date of Discharge(EDD) 44 4A A&E Checklist At Point of Discharge 45 4B Inpatient Checklist At Point of Discharge 46 5A Risk Assessment Guidelines for Checklist 47 5B Risk Assessment Risk Group 2 Moderate Risk 48 6 My Discharge Preparation - Checklist for Patients 49 7 Information for Patients on Discharge 50 8 Discharge Checklist on Day of Discharge 52 9 Disclaimer for Transfer to Short Stay Units 53 10 Complex Discharge Agreed Pathway (Locate on the NWLH Intranet Discharge Planning ) 11 Major Incident & Discharge at Short Notice - Checklist 54 12 Referral to Early Supported Discharge Teams - STARRS 55 13 Discharge Against Medical Advice - Checklist 56 14 Discharge Against Medical Advice - Self Discharge Form 57 15 Transfer of Patients to a Rehabilitation Unit 58 16 Unwilling Discharge Guidelines and Checklist 59 17A Unwilling Discharge - Eviction Letter TEMPLATE 60 17B Discharge Conflict Social Services TEMPLATE 61 17C Discharge Conflict For Self-Funders Letter TEMPLATE 62 17D Discharge Conflict Family Refusal of Discharge Letter TEMPLATE 63 4

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Glossary Assessment Avoidable Admission Care Management - Care Package Care Pathway Care Planning Carer Commissioning Confirmed Date Of Discharge - Continuing Care Health Needs Assessment - Delayed Discharge Discharge Coordinators DOLS A process whereby the needs of an individual are identified and their impact on daily living and quality of life evaluated When a patient is admitted to an Acute hospital, which would be unnecessary if alternative services were available. A process whereby an individual s needs are assessed and evaluated, eligibility for services is determined, care plans drafted and implemented, and needs are monitored and reassessed. A combination of services designed to meet a person s assessed needs at home An agreed and explicit route an individual takes through health and social services A process based on an assessment of an individual s needs that involves determining the level and type of support to meet those needs, and the objectives and potential outcomes that can be achieved. A person, usually a relative or friend, who provides care in the patient s home The process of specifying, securing and monitoring services to meet identified needs. An agreed date when it is deemed the patient is medically fit and safe to be discharged from hospital. The process of identifying the complexity of needs of a patient which will determine if the responsibility to provide the appropriate long term specialist support to maximise a patient s health and quality of life lies with NHS Primary Health or to the Local Authority Patient is considered as an official delay in discharge when the required community health/social care support is not available at the confirmed date of discharge. Manage and support effective discharge planning of patients with complex discharge issues. Co-ordinate and facilitate joint working partnerships between Primary and Secondary Care Deprivation of Liberty Service An independent body supporting patients making long term decisions where they could be conflict Estimated Date Of Discharge - A predicted, realistic discharge date agreed by the multidisciplinary team in order to plan the patient s discharge from 6

hospital. This is usually within 24 hours of admission IMCA Independent Sector Independent Mental Capacity Advocate. Includes both private and voluntary organisations Intermediate Care Multidisciplinary Patient Groups Patient Discharge Leaflet Patient Information Leaflet Protocols Rehabilitation Section 2 Notification Section 5 Notification SITREPS Standards To Take Away Medicines Transfer A range of integrated services that are provided to promote independence to individuals delivered in partnership between Primary, Secondary and Social Services following an inpatient episode When professionals from different disciplines, such as social work, nursing and therapy, work together as a team. The Trust has three distinct patient groups, adults, paediatrics and obstetric/ maternity groups Comprehensive information to include check lists for patients regarding their discharge and on-going treatment Comprehensive information regarding hospital facilities, local structures e.g. visiting times which is accessible to and understandable by patients A plan detailing the steps that will be taken in the care and treatment of an individual A programme of therapy and reablement designed to restore independence and reduce disability Is issued for patients who are considered likely to require social services involvement in order to expedite their discharge; it is a notification of need of care to the relevant social services authority Is issued when a confirmed date of discharge is agreed and enables Social services to implement a care plan on discharge Situation Reports - Data collected by NHS Trusts which reflect the number and type of Delayed Discharges at a given time A tool by which the level of quality and excellence can be measured Drugs and medication dispensed for discharge i.e. for a patient To Take Away Is used in this policy when a patient moves from a ward/department to another within the Trust and the Trust remains responsible for the patient s care 7

1.0 Introduction Discharge from hospital is a process and not an isolated event. It is an essential part of care management. It should involve the development and implementation of a plan to facilitate the transfer of an individual from hospital to an appropriate setting. The individuals concerned and their carer(s) should be involved at all stages and kept fully informed by regular reviews and updates of all care plans. The North West London Hospitals NHS Trust provides an array of services which can be broadly categorised into Adult and Children patient groups and accordingly has an adult and children s policy which is informed and guided by the NHSLA standards. The Trust also provides maternity services; the transfer and discharge of clients guidelines are informed by CNST Maternity standards. For details please refer to the Postnatal guidelines and Transfer of women and babies within and out of the Maternity Unit on the Intranet. This Policy is solely concerned with The Discharge of Adults from The North West London Hospitals NHS Trust. Planning for hospital discharge is part of an on-going process that should start prior to admission for planned admissions and on admission to the ward for all other admissions. Effective, safe and timely discharge requires the availability of alternative and appropriate care options to ensure that any rehabilitation, recuperation and continuing health and social care needs are identified and met. Many people admitted to hospital fear the experience of hospitalisation and of losing their autonomy; they want to return to living their previous lives as soon as possible and every effort should be made to help them do so. Acute hospitals should only be used for the delivery of the services that cannot be provided as effectively elsewhere in the health service, social care or housing system. North West London Hospital (NWLH) NHS Trust is committed to ensuring a safe, robust system is in place so that individuals achieve their optimal outcome enabling the safe return back to the community and acute hospital capacity is used appropriately. This policy is designed to standardise and provide a coordinated approach to the management of the discharge of patients. It is written in accordance with the Department of Health (DH) policy (Discharges from Hospital, Pathway and Processes 2003) It is essential to the whole care process of discharge planning that all health professionals consider patients who may be at risk on discharge. A Risk Assessment will be carried out in accordance with guidelines within this policy. The three distinct Groups defined in this policy are: Group 1 - Low Risk or Simple Discharge No community support is required. Group 2 - Moderate Risk Discharge some community support is required (Social Services/Health) Group 3 - High Risk/Complex Discharge High level of community support for fluctuating needs which may be unpredictable Guidelines for identifying such patients are in the Risk Assessment Tools within this policy. 8

2.0 Key Principles The key principles for effective discharge and transfer of care are: 2.1 Discharge should start prior to admission for planned admissions and at the earliest opportunity (within hours) for all other admissions, ensuring that patients and their carer(s) understand and are able to contribute to NWLH discharge planning decisions as appropriate. 2.2 The active participation of patients and their carer(s) as equal partners is central to the delivery of care and in the planning of a successful discharge. 2.3 A whole systems approach to assessment, commissioning and delivering services is essential to effective hospital discharge arrangements. This whole system approach requires putting the patient at the centre of all plans and decisions and responding to their needs. An ethos of multidisciplinary and multi-agency working, to include housing, support and other needs which relate directly to the individual s health and well-being is crucial to timely, effective discharge. 2.4 Effective use of transitional and intermediate care services is essential to ensuring that the existing acute hospital capacity is used appropriately and patients achieve their optimal outcome. 2.5 The process of discharge planning for each patient should be co-ordinated by a named person who is responsible to ensure that the patient is informed and involved.. 2.6 Hospital discharge planning is a continuous process that takes place seven days a week. 2.7 All patients should be provided with an Estimated Date of Discharge (EDD) within 24-48 hours of admission which is reviewed daily and amended as necessary. Predicting the length of stay is fundamental to timely discharge. The provision of a documented discharge date allows families and carers the opportunity to plan for discharge and can reduce the demand for hospital transport, including reducing demand for ambulance transport (see section 6.0) 2.8 The assessment for, and the delivery of, continuing health and social care is organised so that individuals understand the continuum of health and social services, their rights and receive advice and information to enable them to make informed decisions about their inpatient care and future care. 2.9 Although patient choice is considered extremely important, patients who have been assessed as not requiring NHS continuing in-patient care, do not have the right to occupy, indefinitely, an NHS bed (with the exception of a very small number of cases where a patient is being placed under Part 11 of the Mental Health Act 1983). They do, however, have the right to refuse to be discharged from NHS care into a care home. In such cases the hospital, social services and community staff should work with the patient and his or her family to find a suitable alternative 9

3.0 Leadership and Duties To ensure each patient has a safe, timely and appropriate discharge from hospital strong managerial and clinical leadership is required at all levels across the whole range of services, at individual organisational level, at multidisciplinary team level and in the individual departments. 3.1 Chief Executive The Chief Executive is ultimately responsible for ensuring that the Trust has safe and effective discharge processes and for ensuring the Adult Discharge Policy is implemented across the Trust. The Chief Executive will normally delegate executive responsibility to the Medical and Nursing Directors. However, the Chief Executive is directly involved if a patient is unwilling to leave the hospital when he/she is medically fit to do so. The Chief Executive will normally request the patient s consultant to investigate that all aspects of safety for the patient have been scrutinised to ensure that the patient is medically fit to be discharged and safety measures are fully in place. This will include all on-going services if applicable. [See Section 12.0 Unwilling Discharge ; Appendix 16 and Appendix 17A] 3.2 Patient Safety and Quality Committee The Patient Safety and Quality Committee will monitor the Annual Report, (Standardised NWLH Trust Template]) regarding compliance of the Discharge Policy Standards and Processes. Recommendations of the Annual Report will be made by the Patient Safety and Quality Committee which will be supported by an action plan. 3.3 Medical Director The Medical Director is responsible for ensuring the Adult Discharge policy is implemented across the Trust by the medical staff. Two of the roles of the Medical Director or a delegated deputy is to: Monitor the Annual Report regarding compliance of setting a timely Estimated Date of Discharge (EDD), outlined within this policy. Signing-off the Electronic Discharge Note (EDN). 3.4 Consultant and Medical Team Consultants and the Medical Teams are key in ensuring that patients have an appropriate length of stay (LOS). Consultants and their teams will contribute to the discharge process by providing an estimated date of discharge (EDD) within 24-48 hours of admission which is realistic and updated on a daily basis. This should be done in partnership with the multidisciplinary team where appropriate and should include participation in any multi-disciplinary planning for discharge 10

The medical team must ensure: That within 24-48 hours of admission a realistic medical EDD is reached from the medical assessment taking into consideration investigations and treatments. The Medical Team will then inform the Ward Manager of their medical/clinical EDD. (Refer to Setting an EDD in Appendix 2 for more details). That an Electronic Discharge Note (EDN) is written and signed off before the patient is discharged. It is the responsibility of the consultants and the medical teams to monitor the compliance of the above.. A report is generated by the Information Technology (IT) systems. All investigations are completed in a timely manner or requests are made for investigations to be carried out in an outpatient department prior to discharge. That prescription medication should be written up normally 24 hours prior to discharge. Intentional changes to admission medication must be documented by the doctor discharging the patient or a member of the pharmacy staff on the discharge letter. A summary of the investigations, treatment and on-going clinical plan of each patient will be sent to the General Practitioner (GP) within 24 hours of discharge. That clinical notes relating to discharge and fitness for discharge are completed on the day of discharge as well as completing the short discharge summary accurately for coding. That when a medical report is requested to support some complex health assessments e.g. Health Needs Assessment; Referrals to Tertiary unit; Rehabilitation units; Complex Social issues.; the report should include details on the current inpatient care and relevant past medical history. The report must be completed within hours of the request. If a patient wishes to self-discharge it is the responsibility of the medical team to ensure that the clinical consequences are explained to the patient. The duty doctor will document in the patients notes what information has been given. [Appendix 13 and 14] 3.5 The Director of Nursing : The Director of Nursing has the responsibility to ensure: All aspects of the Discharge Policy (excluding medical staff processes) are implemented across NWLH Trust Delegation and nomination of other key senior staff, notably the Matrons, to implement and monitor processes and standards. All processes regarding discharge are monitored in a systematic way by the matrons and ward managers. An annual audit is undertaken (copy to be found on shared drive on NWLH Intranet DISCHARGE PLANNING which will indicate if the Standards and Processes for Discharge, set out in the policy, are adhered to. Recommendations of the Annual Report supported by an action plan will be approved by the Director of Nursing and given to all matrons and ward managers to implement 3.6 Matrons and Heads of Nursing Matrons and Heads of Nursing have the responsibility to ensure: 11

that the Discharge Policy is understood and fully implemented by all nursing staff. Training regarding the policy is incorporated into the local departmental Induction programme. Discharge planning and processes will be part of each department s in-house training programme and will be competency led. That all nursing teams participate in the annual audit of the Discharge Process. 3.7 Emergency Department Matron (A&E) The A&E Matron has a pivotal role in the supervision and the coordination of the discharge of patients from the A&E Department; ensuring the discharge is safe, timely and with the appropriate involvement of patients and carer(s). The A&E Matron will ensure that all patients will be assessed within 4 hours of arriving within the A&E Department and have a discharge plan where appropriate. 3.8 Nurses and Allied Health Professionals (AHP) in A&E Nurses and AHPs within A&E will ensure that discharge planning starts immediately on arrival within A&E. This is to enable safe and timely discharges. Duties include the following: Complete appropriate documentation as defined in Section 5 Liaise with and include the patient in any discussion and decision-making regarding their discharge destination and the on-going care and support the patient may require. 3.9 Ward Manager The Ward Manager has a pivotal role in the supervision and the coordination of the discharge of patients from the point of admission ensuring the discharge process is safe, timely, with the involvement of patients and carer(s). He/she is key, working in partnership with the medical teams and allied health professionals in ensuring the appropriate Length of Stay (LOS) of patients. The Ward Manager and the nursing team should involve the patient in the EDD as soon as one is made, normally within 24-48 hours of admission. Ward Managers will ensure, generally through the delegation of a named person: All patients have a Risk Assessment [Appendix 5B] on admission to the ward and placed in appropriate discharge Risk Group within 24 hours (see section 5 General Discharge Process) All Trust Protocols/Care Bundles are followed. This includes ensuring that appropriate referrals are made to community services in a timely and efficient manner. They will liaise closely with all disciplines and community agencies. All pertinent Discharge Checklists are completed correctly at each stage of the discharge. These Checklists are pivotal in monitoring and auditing all aspects of the Discharge Process ( Refer to Section 5 for details ) Liaise with consultants regarding appropriate nurse led discharges in accordance with the NWLH NHS Trust Nurse Led Discharge Policy A realistic Estimated Date of Discharge (EDD) for each patient is agreed by all disciplines of the multi-disciplinary team within 24-48 hours of admission, recorded on the ward board and in the Trust Electronic Reporting Programme. These need to be updated daily. 12

Be responsible with the matrons for carrying audits of the service every six months and reporting the results to the Director of Nursing. 3.10 Nurses in Inpatient Areas (Wards) For both unplanned and planned admissions the nurses must continue the Discharge Process for each Risk Group defined in Section 5 The nurses will liaise with and include the patient in any discussion and decision making regarding the discharge destination and the on-going care and support the patient may need. The nurses must inform the Pharmacist each morning of the names of patients who are to be discharged that day in order to prioritise these groups of patients 3.11 Allied Health Professionals (AHPs) in Inpatient Areas (Wards) All AHPs have an important and key role in preparing patients for discharge by assisting the patients appropriately during the hospital admission, promoting independence and supporting them, which can greatly contribute to a shorter and reduce the hospital Length of Stay (LOS). Therapists can do this by: Ensuring that AHPs follow the pathway defined for each Risk Group and complete all relevant documents as defined in Section 5. Responding promptly as soon as a patient is referred to them (same day response). Assist in establishing an EDD within 24 hours of assessment from a therapy aspect and inform the Ward Manager and document in the patient s medical record. (see Setting an Estimated Date of Discharge in [Appendix 2] Referring patients swiftly to community colleagues, and/or liaising regularly with outside agencies to ensure a timely and safe continuity of care on discharge. Ensuring that reports are completed when required in a timely manner (same day as requested) and forwarded to the appropriate agencies to prevent delays in the discharge process. Promptly ordering equipment required for a safe discharge. Completing home visits timely and efficiently for those patients with some complex needs. 3.12 Discharge Coordinators The role and responsibility of the Discharge Coordinators is to take the lead in the discharge of patients with complex social needs ensuring that these patients are discharged to an appropriate destination in a timely fashion with all the support means necessary in place to promote independence. The Discharge Coordinators have the responsibility to: Involve and inform patients of their rights regarding discharge destination and the home care plans. 13

Liaise closely with patients, family and carer(s) involving them in the process and decision making regarding discharge to ensure appropriate discharges and preventing discharge delays Support all ward staff in achieving the EDD. They will ensure referrals are made as early as possible in the discharge process. Assist ward staff in the identification of patients with on-going care needs, facilitate assessments and case manage complex discharges Support ward staff with the on-going assessment of patient discharge needs and assist ward staff in making alternative discharge plans as appropriate Advise ward staff about suitability for and availability of Community Hospital beds Advise ward staff about the official Delayed Discharge Procedures and its implications. (SitReps) Advise ward staff about eligibility for Continuing Care Health Needs Assessments (HNA) in conjunction with the lead nurse within the PCT for Continuing Care Participate in multidisciplinary ward meetings/ward rounds with physicians and medical staff as appropriate Provide together with their PCT colleagues an on-going programme of education for ward/department staff regarding discharge process and continuing care process. Be responsible for the weekly official reporting of all delays of discharge (SitReps) to NHS London. 3.13 The Rapid Response and Early Supported Discharge Teams (STARRS) In order to promote safe and timely discharge STARRS provide Hospital at Home care for those patients medically stable enough to have an early discharge from the inpatient ward and continue their care within their home. The responsibility of STARRS is to liaise several times each day with all wards and A&E helping reduce the LOS as well preventing some inappropriate admissions. They can do this by: Attending daily ward report/rounds, being pro-active in suggesting and offering to continue the care and support within the patient s home if the patient is medically stable. Providing expert advice to medical teams, nurses and AHPs regarding some community processes, referrals and links with community agencies Responding within one - two hours to referrals from wards and within half an hour to referrals from A&E in order to prevent any delays in discharges. Providing care at home and/or in the community seven days a week and accepting referrals and hospital discharges at weekends. Bridging some social care for social services if they are unable to provide care at short notice. 3.14 Pharmacist 14

It is the responsibility of the inpatient pharmacist to ensure that medication to take home (TTA) is dispensed and checked at an appropriate time for the patient before discharge and will not cause a delay in the discharge process. Pharmacists should be informed by the ward staff each morning of the names of patients who are to be discharged that day (morning or afternoon) in order to prioritise these groups of patients. Pharmacists must also ensure that procedures and protocols are in place in each ward regarding the safe management of medicines and they are adhered to. The pharmacist will provide or ensure there are processes in place on wards to provide education, explanations to patients and/or family to ensure adequate knowledge and understanding of their medication and on-going medication needs following discharge. Ref to: NWLH NHS Trust Dispensing for Discharge Scheme Policy 3.15 The Palliative Care Team If the palliative care team have been involved with a patient during their hospital admission they will take the responsibility of liaising with palliative care teams in the community as well as with GPs ensuring that optimal symptom control and support networks are in place before the date of discharge. The teams provide education and support to patients before discharge ensuring adequate knowledge and understanding of their disease process, symptoms and medicines enabling the patient to maximise their potential as well maintain their personal choice and dignity. The palliative care nurse ensures that all community referrals and support mechanisms regarding palliative care are in place before discharge. The palliative care nurse will ensure the patient has all relevant contact names and telephone numbers. 4.0 Training All staff involved directly or indirectly with patient discharge will: Read, understand and abide by this Discharge Policy Receive explanations and have the opportunity to become familiar with the Discharge Policy within the department. Compliance and understanding will be monitored within the department. Will have an experienced mentor who will assess them at each of the stages of the discharge process. Training and advice will be given by the Trust Discharge Coordinators to nursing and AHP staff to assist them in the discharge of patients within the Complex/High risk Group. 5.0 General Discharge Process There are many common processes and protocols for all hospital discharges, however there are also some specific processes which are unique to the different areas of the hospital. To assist staff working within these areas this policy divides discharge processes into distinct groups: 5.1. General Discharge of patients from the A&E Departments 15

5.2. General Discharge of patients from Inpatient Departments 5.3 General Discharge from Outpatient Clinics 5.4 General Discharge from Medical/Surgical Day Care Clinic Managers and Service Managers are responsibility for ensuring all staff understand and implement the Discharge Policy of all patients, from all clinical departments and that staff adhere to the appropriate operational protocols and procedures. Managers need to have in place systems for monitoring staff compliance. [see Section 9 Monitoring and Standards 5.1 General Discharge process from the Accident & Emergency Department (A&E) The A&E Department includes patients admitted to ACDU (CMH) and the A&E Observation ward (NPH) under the care of an A&E consultant. The planning for discharge of patients who attend A&E commences as soon as the patient arrives within the department. Demographic information such as the following must be checked and amended accordingly by the A&E receptionist: Current Address, patient telephone contact details Contact details of relative or next of kin (NOK) or carer(s) GP Name and contact details It is essential to the whole care process of discharge planning that all health professionals consider patients who may be at risk on discharge. A risk assessment will contribute to safer discharges as well as to reducing some inappropriate re-attendances into A&E. Questions staff can ask patients and/or family/carer within A&E will help towards defining into which Risk Group the patient will be placed. Guidelines to identify who may need a Risk Assessment can be found in Appendix 5A. Defining the Risk Groups Group 1 - Low Risk or Simple Discharge A patient is considered Low Risk if, following the assessment in A&E NO on-going community support is required This does not exclude the patient having a follow up clinic appointment. Group 2 - Moderate Risk Discharge A patient is considered moderate risk if he/she requires some assistance from Social Services and/or Health community services on discharge. It is therefore important that during the Risk Assessment staff discuss with patients any assistance they were receiving prior to attendance at A&E and any new on-going care and support they may require on discharge. It is essential that patients discharged directly from the A&E Department have had their investigations completed, a medication review and medication prescribed (if applicable). A discharge summary must be entered onto the electronic ICS system to be sent to their GP and written details of the plan scanned into the electronic patient record scanning system. 16

A short summary of any new referrals to community services or new care packages that have been organised in the community will be given to the patient and scanned into the A&E scanner system into the patient s record.. [Appendix 7] Group 3 High Risk/Complex Discharge A small group of patients may be considered as having Complex Needs or be High Risk. This can be determined by the severity and the complexity of those needs. Such needs can also be unpredictable with the degree of needs fluctuating and thereby create challenges in managing them. It is unlikely that this group of high risk patients will be discharged from A&E. 17

5.1.1 Pathway and Documentation for Risk Groups Group 1 Low Risk or Simple Discharge A patient is considered low risk if NO on-going community support is required. If however a Risk Assessment is deemed appropriate then it must be scanned into the A&E scanner system with the patient s records. A risk assessment in A&E is not mandatory. A copy of all completed documents must be scanned into the A&E Scanning system with patient s medical records GROUP 1 LOW RISK A&E Documentation to be completed By Whom Timescale Copy to Patient? Complete A& E Discharge checklist for all Nurse within 1 hour prior No patients discharged from ACDU or the Obs. Ward A&E to discharge [Appendix 4A] from Obs/ACDU Group 2 Moderate Risk The Table below explains the Pathway for Discharge and Documentation to be completed for Patients considered Moderate Risk A copy of all completed documents must be scanned into the A&E Scanning system with patient s medical records GROUP 2 MODERATE RISK A&E Documentation to be completed By Whom Timescale Copy to Patient? Risk assessment [Appendix 5b] Complete A&E Checklist Point of Discharge [Appendix 4A] My Discharge Checklist only if no family/carer is present in A&E [Appendix 6] Information for Patients on Discharge (only to be completed if there is follow-up required in the community.) [Appendix 7] Nurse or Therapist Nurse or Therapist Nurse or Therapist Nurse or Therapist Within 4 Hrs. Within 4 Hours of presenting to A&E 4 hours of presenting to A&E 4 hours of presenting to A&E No Yes Yes Yes Group 3 - High Risk/ Complex Normally patients who placed in Group 3 (Complex/High Risk) will be admitted into the acute hospital. However, some patients with complex needs may be transferred from A&E to other specialist units. In such cases, refer to the NWLH Transfer Policy. The Table below explains the Pathway for Discharge and Documentation to be completed for Patients considered to be High Risk A copy of all completed documents must be scanned into the A&E Scanning system with patient s medical records. GROUP 3 Documentation to be completed By Whom Timescale Copy to 18

HIGH RISK Patient? A&E Risk assessment [Appendix 5b] Complete A&E Checklist Point of Discharge [Appendix 4A] Information for Patients on Discharge (only to be completed if there is follow-up required in the community.) [Appendix 7] Follow Guidelines regarding Contract with Ambulance Service (LAS) re: transfer to other specialist units. Nurse or Therapist Nurse or Therapist Nurse or Therapist A&E Nurse Within 4 Hrs. Within 4 Hours of presenting to A&E 4 hours of presenting to A&E Prior to Transfer No Yes Yes No It is important that some specific information be gathered within A&E even when it is agreed the patient is to be admitted to an inpatient area. Guidance for staff can be found in the General Discharge Process/Pathway [Appendix 1] 5.1.2 Medication on Discharge from A&E Once a clinical decision is made to discharge the patient from either ACDU or the A&E Observation Units an electronic Discharge Note (EDN) must be written and, if TTAs are to be dispensed, either sent electronically to pharmacy during pharmacy hours, or medication dispensed from the A&E Units outside of these times. The Discharge summary should be sent to the patient s GP, either electronically or by post. If a decision is made to discharge a patient from the A&E Department itself during pharmacy opening hours an outpatient prescription should be written and sent to pharmacy. Outside of pharmacy opening hours the prescriptions should be dispensed from A&E. The GP should be notified of any changes in medication by documenting them on the ics system from whence a letter will be sent electronically to the GP. Good Communication is crucial where any changes have been made to the patient s prescription. These must be explained carefully to the patient, checked he/she has understood and documented in the patient medical records. If the patient has not fully understood the next person responsible for the medicines management care of that patient must be informed. 5.1.3 Transport from A&E Patients will normally make their own arrangements for their transport home. However, it may be agreed that hospital transport is essential for taking the patient home. All patients awaiting transport should be transferred to the Discharge Lounge within the working hours of the Discharge Lounge where light refreshments are available. The A&E Discharge Checklist [Appendix 4A] must be completed, if applicable before the patient leaves the A&E Dept. 19

5.2 General Discharge process from Inpatient Areas Ward Managers are responsibility for ensuring all staff understand and implement the Discharge Policy and adhere to the operational protocols and procedures. Managers need to have in place systems for monitoring staff compliance.. [see Section 9 Monitoring and Standards] It is essential to the whole care process of discharge planning that all health professionals consider patients who may be at risk on discharge. A risk assessment will contribute to safer discharges as well as to reducing some inappropriate re-admissions. Some questions staff ask patients and/or family/carer will help towards defining into which Risk Group the patient will be placed. Guidelines to identify who may need a Risk Assessment can be found in Appendix 5A Defining the Risk Groups Group 1 - Low Risk or Simple Discharge A patient is considered low risk if the outcome of the assessment indicates that NO on going community support is required on discharge. This does not exclude the patient having a follow up clinic appointment. Group 2 - Moderate Risk Discharge A patient is considered moderate risk if he/she requires some assistance from Social Services and/or Health community services on discharge. It is therefore important that during the Risk Assessment staff discuss with patients any assistance they were receiving prior to admission and any new on-going care and support they may require on discharge. Group 3 High Risk/Complex Discharge A small group of patients may be considered as having Complex Needs or be High Risk. This can be determined by the severity and the complexity of those needs. Such needs can also be unpredictable with the degree of needs fluctuating and thereby create challenges in managing them. It is normally the responsibility of the registered nurse looking after the patient to coordinate the discharge plan. An Allied Health Professional (AHP) or a Discharge Coordinator who has been closely involved in the discharge planning can also be the Lead for this. It is imperative that NO unplanned re-admissions occur as a result of poor discharge planning. 20

5.2.1 Pathway and Documentation for Risk Groups Group 1 Low Risk or Simple Discharge The Table below explains the Pathway for Discharge and Documentation to be completed for Patients considered Low Risk A copy of all completed documents must be inserted into the patient s medical records GROUP 1 LOW RISK Inpatients Documentation to be completed By Whom Timescale Copy to Patient? Complete Risk Assessment [Appendix 5B] My Discharge Preparation Checklist [Appendix 6] Information for Patients on Discharge if applicable [Appendix 7] Inpatient Checklist at Point of Discharge [Appendix 4B] Named Nurse Within 24-48 hours of admission Named Nurse 24 hours prior to D/C Nurse/Therapist 24 hours prior to D/C Ward Clerk, Nurse/Therapist Day of D/C No Yes Yes Yes Group 2 Moderate Risk The Table below explains the Pathway for Discharge and Documentation to be completed for Patients considered Moderate Risk A copy of all completed documents must be inserted into the patient s medical record. GROUP 2 Moderate Risk Documentation to be completed By Whom Timescale Copy to Patient? Inpatients Complete Risk Assessment [Appendix 5B] My Discharge Preparation checklist [Appendix 6] Information for Patients on Discharge [Appendix 7] Inpatient Checklist at Point of discharge [Appendix 4B] Named Nurse Within 24-48 hours of admission Named Nurse 24 hours prior to D/C Nurse/Therapist 24 hours Ward Clerk, Nurse/Therapist prior to D/C Day of D/C No Yes Yes Yes If required: Complete identification of Health Needs Assessment Group 3 [on shared drive] Nurse/Therapist or Discharge. Coordinator Within 72 hrs of admission. No 21

Group 3 - High Risk/ Complex The Table below explains the Pathway for Discharge and Documentation to be completed for Patients considered to be High Risk Copies of all completed documents must be inserted into the patient s medical records. GROUP 3 High Risk or Complex Documentation to be completed By Whom Timescale Copy to Patient? Inpatients Complete Risk Assessment [Appendix 5B] Follow Complex Discharge Pathway if appropriate [locate on shared drive] Named Nurse Within 24-48 hours of admission Discharge Coordinator. Within 72 hrs of admission No No Complete Health Needs Assessment Checklist [locate on shared drive] If required: Complete identification of Health Needs Assessment Group 3 [on shared drive] My Discharge Preparation checklist [Appendix 6] Information for Patients on Discharge [Appendix 7] Inpatient Checklist at Point of discharge [Appendix 4B] Discharge Coordinator - Nurse/therapist Discharge Coordinator - Nurse/therapist Named Nurse Nurse/Therapist Ward Clerk, Nurse/Therapist Within 72 hrs of admission Within 72 hrs of admission. 24 hours prior to D/C 24 hours prior to D/C Day of D/C No No Yes Yes Yes 5.2.2 Estimated Date of Discharge (EDD) Setting a realistic Estimated Date of Discharge (EDD) is an essential part of the inpatient care pathway for all patients. This will enable all members of the Multi Disciplinary Team (MDT) to address the key questions of what should be done, when, where and by whom. It will also give patients time to prepare for leaving hospital. Involving patients in the EDD will contribute in helping them plan and prepare their safe return home. All members of the MDT have a responsibility and must contribute towards setting a realistic and appropriate EDD taking into consideration all aspects of a patient s recovery including investigations and on-going support on discharge. It must be set within 24-48 hours of admission. EDDs are reviewed daily, recorded on the ward board and in the Trust Electronic Reporting System. The process for setting a realistic EDD for all wards is set out in the Flowchart. [Appendix 2] 22

5.2.3 Discharge of Patients with Social Care Needs (Section 2 & 5 Notifications) It is essential to the whole care process and discharge planning that all health professionals consider patients who may be at risk on discharge. Guidelines for identifying such patients are in the Risk Assessment Tools [Appendices 5A & 5B Please refer to Section 5.2 - Risk Group 2 (Moderate Risk) and Section 5.3 Risk Group 3 (Complex/High Risk) The outcome of the Risk Assessment will identify the need for the following referrals to Social Services: Section 2 Notification [Located on the shared drive] The nurse or health professional who has undertaken the initial assessment of the patient, the outcome of which identifies that the patient will require on-going care and assistance on discharge must ensure the prompt referral to Social Services by sending a completed Section 2 Notification to Social Services indicating recommendations of the type of care required. This should be possible within 24 hours of admission (Section 2 Notification - Community Care Act 2003), (All Social Services notifications can be found on the shared drive.) A completed Health Needs Assessment Checklist (HNA) [located on the shared drive] must follow a Section 2 Notification for all new requests for Nursing Home placement. Section 5 Notification [Located on the shared drive] As soon as a Confirmed Date of Discharge is agreed, a Section 5 Notification is completed and sent to Social Services. This must happen at least 24 hours prior to the confirmed discharge date. This allows Social Services the time to organise the care required. It is the responsibility of the Ward Manager or senior nurse to ensure there is no delay in sending this Notification. Withdrawal of Section 5 Notification [Located on the shared drive] If after sending the Section 5 Notification the patient becomes unwell, or the patient requires further assessment prior to discharge It is the responsibility of the Ward Manager/senior nurse together with the discharge coordinator to ensure there is no delay in sending this Notification to Social Services. When a revised confirmed date of discharge is confirmed a new Section 5 is sent with the new Date of Discharge. Re-Start of the Care Package [Located on the shared drive] If an existing care package needs to be re-started without any changes on discharge, Social Services must be informed at least 24 hours prior to discharge to facilitate the organisation of the required care package. Staff will need to complete and fax the Re-Start Care Package form to the relevant Social Services department 5.2.4 Eligibility for Continuing Care Health Needs Assessment All patients are entitled to screening for Continuing Care Health Needs Assessment (HNA). (DH Continuing Care Policy October 2009). It is the MDT s responsibility to highlight the possible need for a HNA. (Guidelines in making this decision is in the Complex Care Checklist) [located on the shared drive] 23

The MDT and the Discharge Co-ordinator together will ensure that the HNA Checklist is completed correctly and in a timely manner together with the patient/family. The ward manager/senior nurse or Discharge Co-ordinator will liaise with the patient and family updating them of the outcome of the Health Needs Assessment (HNA) Checklist. Some patients may not meet the criteria for a full HNA. If the criteria are met for the full HNA, an assessment is completed within 24 hours. This is forwarded to the Continuing Care Team and to Social Services together with relevant health reports. The patient and with their consent, family should be involved in this process. The continuing care team and social services should then carry out a joint assessment with the patient. The outcome of this assessment should be reported immediately and documented in the patient s medical records. A confirmed discharge date is set and if applicable a Section 5 Notification sent to Social Services Immediately. NB: NWLH Trust together with their Brent and Harrow PCT and Social Services colleagues have formally agreed and signed up to a workable Discharge Pathway and timescale for patients who may need a HNA or ongoing complex assistance. [Appendix 10]. The Discharge Coordinators will advice and support staff in this process. For all other PCTs and Social Services, ward staff will need to liaise with Discharge Co-ordinators on a case by case basis regarding the process for HNA and ongoing assistance 5.2.5 Confirmed Date of Discharge The MDT should agree the confirmed date of discharge. The patient, and with their consent, their family will be informed of the confirmed discharge date. Opportunity should be given for the patient/family to discuss this date with the relevant clinicians. The agreed confirmed discharge date is to be documented in the patient s medical record. It is essential that all assessments and management care plans be completed as soon as the confirmed discharge date is confirmed and forwarded to the appropriate agencies. Failure to do this will cause a delay in discharge. Evidence of faxes etc. must be filed in the patient s medical record. 5.2.6 Medication on Discharge from Inpatient Areas Once a clinical decision is made to discharge the patient an electronic Discharge Note (EDN) must be written and sent electronically to pharmacy if TTA to be dispensed. It is a legal requirement for a TTA to be checked by a Pharmacist before it is issued to a patient. Therefore, nurses or doctors MUST NOT issue medicines supplied from pharmacy if the TTA has not been checked by a Pharmacist. See NWLH Policy for the Dispensing for Discharge Scheme A copy of this Discharge Summary is: Sent to the patient s GP (electronically or by post) within 24 hours of discharge Given to the Patient Placed in the Patient s Medical Record Changing the medication needs, including some compliance aids Medication Management is an important part of the general A&E assessment. It is normally the ward Pharmacist who will take the lead regarding Risk Assessments of a patient s requirements for support with taking/administration of all medication. Nurses may be asked to participate in this Risk Assessment. See NWLH Medicines Reconciliation for Adults Policy 24