Discharge Protocol for Hospital Patients in Shetland Approved by: Sandra Laurenson, Chief Executive, Shetland NHS Board Hazel Sutherland, Executive Director Education & Social Care, Shetland Islands Council Reviewed On: August 2009 Review Date: August 2010 Responsible Officer: Director of Clinical Services
Contents Page 1. Introduction Page 3 2. Aim of protocol Page 3 3. Definition of Delayed Discharge Page 3 4. Policy Context Page 4 5. Principles and Values Page 5 6. Joint Working Page 5 6.1 Information Sharing Page 7 7. Discharge Planning Page 7 7.1 Who is Involved? Page 8 7.2 Process of Discharge Page 9 8. Patient Involvement Page 12 9. Carers Page 13 10. Vulnerable or At Risk Individuals Page 13 11. Dealing with Disputes Page 13 12. Free Care on Leaving Hospital Page 13 13. Monitoring and Reviewing Page 14 Training and Staff Development Page 14 Variation Page 14 Appendix 1: Discharge Pathway Tool Page 17 2
1.0 Introduction Shetland NHS Board (NHS Shetland) and Shetland Islands Council (SIC) recognise the importance of a jointly agreed protocol for discharge from both acute and longerterm NHS facilities. The protocol is to be followed when a patient s needs indicate that they are medically fit for discharge. The aim is to provide a consistent coordinated approach with multi disciplinary, multi agency input while maintaining the individual s interests as central to the discharge planning process. We recognise that by working together as a partnership we will get better outcomes for us, as service providers, and for our clients. This is a live document and as services and practices develop, it will be reviewed to improve or add to ways of working and to accommodate new service developments. The forum for which will be the admissions and discharge group. 2.0 Aim of this Protocol The aim of the protocol is to: ensure a positive experience for the service user, ensure the needs of the service user are met fully, and reduce the delays associated with the unavailability of resources linked to assessed need at the point where service users are assessed as medically fit to leave hospital. It will also address reasons where a service user may be ready-for-discharge, but the discharge is delayed due to: Social care reasons; Housing reasons; and/or Patient/carer/family-related reasons. 3.0 Definition of Delayed Discharge The following categories have been developed to define delayed discharges. Zero delay is defined as a patient who has a delay of 3 full working days or less from their ready-for-discharge date. Delayed discharge. Patients delayed for more than 6 weeks. For non-short stay facilities there is a period of 6 weeks beyond the clinically ready for discharge date during which all assessment and follow-on arrangements are expected to be put in place. o During this period: o the completion of the Single Shared Assessment may take place; o the Service User may be discharged from hospital; 3
o the Service User may be transferred to another health specialty if their assessed need determines this, and o the Service User may be transferred to another health specialty to await discharge from hospital. More detailed information on current definitions can be found in the Delayed Discharges Definitions and Data Recording Manual 1 Scottish Ministers launched the Delayed Discharge Action Plan 2 in March 2002. The Plan contained a number of short-term and long-term measures to reduce the number of patients inappropriately delayed in hospital. Our 2009-10 target relating to delays in discharge, taken from Shetland Community Partnership Single Outcome Agreement, No person will wait more than 6 weeks to be discharged from hospital into a more appropriate care setting. This is to maintain at Zero, unless exercising 71X* 2 With regard to care in the above target, this does not necessarily mean residential setting. This relates to the best possible outcome for the service user, whether that is sheltered tenancies, supported accommodation, their own home with personalised care or residential care. 4.0 National Policy Context National Guidance The main national guidance documents regarding discharge protocols are listed below. These and other national guidance are referenced in the text. In January 2004, the then Scottish Executive issued a circular, CCD 9/2003 3, which provided a model framework for the production of joint hospital discharge protocols. This followed on from its Delayed Discharge Action Plan 4 (March 2002), which included a commitment to develop, implement and audit joint discharge policies and protocols. The basis for this was first provided in Scottish Executive Circular SWSG 10/98 5 Community Care Needs of Frail Older People Integrating Professional Assessments and Care Arrangements, paragraph 29: 1 http://www.isdscotland.org/isd/files/revised_data_definitions_recording_manual_oct07.pdf 2 limited cases where an interim move under the choice of accommodation guidance is deemed to be unreasonable for the patient. This may be where reasons of extreme distances or transport infrastructures make visiting residents impossible. This code should only be applied where remaining in a hospital setting is the only viable alternative. In all other choice cases (code 71) the underlying principle remains that remaining in hospital is not an option ; and cases where a patient is exercising statutory right of choice where an interim placement is not possible or reasonable. 3 http://www.sehd.scot.nhs.uk/publications/cc2003_09.pdf 4 http://www.show.scot.nhs.uk/sehd/publications/dc20020305delaydisch.pdf 5 http://www.scotland.gov.uk/library/swsg/index-f/c216.htm 4
All [NHS] Boards, NHS Trusts, social work and housing authorities should agree local protocols that enable discharge from hospital when the person s in-patient treatment is concluded. Choice of Accommodation Discharge from Hospital 6 (CCD8/2003) outlines how Local Authorities and NHS Boards should actively manage choice of care homes for people moving from hospital, in a way which is consistent and fair and minimises delays. NHS Continuing Healthcare CEL 6 (2008) issued by the Scottish Government on 7 February 2008 provides revised guidance on NHS continuing health care and replaces previous guidance contained in MEL (1996) 22. The objectives of the guidance include to: Promote a consistent basis for the assessment of, and provision of, NHS continuing healthcare. and Agree a basis for the development of effective local agreements on inter agency and multi disciplinary working in relation to NHS continuing healthcare. The Scotland Act (1998) gives the Scottish Government power to encourage equal opportunities, particularly the observing of the equal opportunities requirements. It also has power to impose duties on Scottish public authorities and cross border public bodies operating in Scotland. The Scotland Act defines equal opportunities as: The prevention, elimination or regulation of discrimination between persons on the grounds of sex or marital status, on racial grounds or on grounds of disability, age, sexual orientation, language or social origin or of other personal attributes, including beliefs or opinions, such as religious beliefs or political beliefs 4.1 Local Policy Context Shetland s Community Planning Single Outcome Agreement is the overarching corporate document that all partners feed into and it contains all relevant targets that staff will be working toward. Single Outcome Agreement 2009/10 Shetland s Community Health and Care Partnership Agreement provides the local policy context. http://www.shetland.gov.uk/socialwork-health/jointfutures.asp Shetland s Single Shared Assessment and Care Management guidance (SSA) are key components of the discharge process 7. The Single Shared Assessment is 6 http://www.sehd.scot.nhs.uk/publications/cc2003_08.pdf 7 http://www.shetland.gov.uk/socialwork-health/documents/ssa.pdf The SSA was fully revised in 2007/08 and approved by NHS Shetland and SIC in March 2008 5
available from Community Care or the Health Service. There are staff in both areas who can explain the assessment procedure for you. Further information regarding the assessment of care and support needs, the care planning process and how to access care services in the community, can be found on the following Council and NHS websites -. http://www.shetland.gov.uk/socialwork-health/services.asp http://www.shb.scot.nhs.uk/documents/index.asp 5.0 Our Guiding Principles Shetlands Community Planning Partners are committed to the following principles and values, which are drawn in part from work published in the NHS in Scotland Planned Care Improvement Programme 8 : Putting the needs and wishes of the individual and their carers at the centre of the discharge planning process, Full involvement of the patient in all aspects of the discharge process wherever it is medically possible, Excellent communication and information sharing to ensure a smooth, effective, safe and prompt transition for the patient, from hospital to home setting or further care facility, Not closing down options by inappropriate early messages (e.g. you need a care home ), A collaborative multi-disciplinary multi agency approach, Mutual respect across all agencies and disciplines, A no blame culture and constructive relationships on the ground, A shared analysis of the reasons for delays locally, Support for staff involved in the discharge process through regular training e.g. in the Single Shared Assessment process, and A willingness to learn from the discharge experience of patients and carers. 6.0 Joint Working Joint working is essential for the effective management of discharge from hospital. In some cases, decisions on the best care for an individual following discharge from hospital are based on a professional assessment of his/her health, social care and housing needs. It is important therefore, that the input from these professionals is coordinated effectively and promptly. Admission to hospital (secondary care) will normally either be electively at the request of the patient s General Practitioner, for planned investigations or surgery, by transfer from another NHS facility or as an emergency. The discharge planning process will begin as soon as practicable after admission and in the case of planned admissions may begin prior to admission to hospital. The information required for effective discharge will be collated using the Single Shared Assessment process. Requests for background information and access to existing assessments, Care Managers or Care Coordinators can be made through 8 http://www.vhscotland.org.uk/library/executive/planned_care_improvement_plan.pdf 6
the Social Care Service duty administrator, duty social worker or the Health Service Liaison Social Worker, at present 9. If the patient or family have identified an existing Care Manager or Social Worker, they should be contacted directly. This allows for effective information sharing and early identification of potential discharge problems. It also ensures that any existing services can be informed. It is important that any existing powers of attorney or guardianship are identified, documented, and made party to all discussions/decisions. Communication between members of the multi-disciplinary team must be robust if the protocol is to be effective. The Responsible Nurse, Health Service Liaison Social Worker and care manager will work closely to ensure that the appropriate staff/agencies are involved as part of the multi disciplinary team depending on the circumstances of each service user. The Multi Disciplinary Team may include: Primary Care Team, Care Manager, Care Co-ordinator or Social Worker, Mental Health Officers OT and other allied health professionals, Pharmacists (hospital and community) SIC housing, Ambulance service and Voluntary services e.g. independent advocacy. If an appropriate referral is not made to the right team/person within an appropriate time frame this can become a barrier to appropriate care management which can: cause great anxiety to the client, and result in conflict between the client and health and care team, which can have a negative impact on establishing a partnership approach to care. Further details on the co-ordination of the assessment and care planning process are provided in the Single Shared Assessment 10 documentation. 6.1 Information Sharing It is an accepted form of practice, experience and research that the sharing of information between professionals helps to ensure that adults and children receive the care, services, protection and support they need. Sharing personal information between partner agencies is vital for a coordinated and seamless service for people. Personal information is shared in accordance with the joint Personal Information Sharing Policy 11 developed by NHS Shetland, Shetland Islands Council, Northern Constabulary, Shetland Area Command and Shetland Council of Social Services. 9 This process will be due to change in line with the Single Shared Assessment Lean Review. Due for completion April 2010 10 This process will be due to change in line with the Single Shared Assessment Lean Review. Due for completion April 2010 11 http://www.shb.scot.nhs.uk/board/meetings/documents/2007_83.pdf 7
It provides a framework for the secure and confidential sharing of information between partner organisations enabling them to meet the needs of individuals and groups for their care, protection, support and delivery of services in accordance with government expectations and legislative requirements. Information is shared on a case-by-case basis subject to the agreement of the service user. 7.0 Discharge Planning Work published by the NHS in Scotland Planned Care Improvement Programme 12 (the Programme) considers that planning for discharge from hospital should start as early as possible and that failure to plan properly can lead to protracted stays in hospital or people ending up in the wrong place without proper care or treatment. The programme identified the following categories of patients as having particular care needs and might require careful discharge planning: Patients who live alone; are frail and/or elderly; have care needs which place a high demand on carers and carers who find difficulty coping; have a limited prognosis; have a serious illness and will be returning to hospital for further treatment; have continuing disability; have learning difficulties; have mental illness or dementia; have dependants; have limited financial resources; live in a particular remote part of Scotland; are homeless or live in poor housing; do not have English as their first language; have been in hospital for an extended stay ; and require aids/equipment at home. The needs of patients in these categories will be determined through the Single Shared Assessment process prior to discharge. 7.1 Who is involved? Primary Care Team The Primary Care Team is responsible for the promotion of health and independence in the community working with colleagues across Shetlands Community Health and Care Partnership. They will strive to support people at home as far as possible and prevent inappropriate hospital admissions. The Primary Care Team will also be involved in the planning and support of complex discharges. The GP will identify when admission to secondary or tertiary care is necessary and communicate with the appropriate specialist team involved and with the individual s care manager and family where appropriate. For planned admissions, many of the discharge arrangements can be planned and discussed in advance. 12 http://www.scottishexecutive.gov.uk/resource/doc/197953/0052905.pdf 8
Secondary Care Team The Consultant in charge has responsibility for the decision to discharge a patient from hospital. The decision is made as part of a multi-disciplinary process, which focuses on the needs of the individual patient. The lead (named) Consultant will determine when discharge from hospital care is appropriate, setting an expected discharge date as early as is practicable, and communicate this with the individual and their families, carers and other agencies or disciplines, involving them as appropriate to liaise with Primary Care and Social Care in the planning of complex discharges. Social Care The care planning process is used to identify the necessary resources, including the most appropriate environment to meet the assessed needs of the patient and their carer(s). The care planning process engages with both primary and secondary care teams, the voluntary sector as appropriate and ensures that the views of the patient and their family/carer(s) are at the centre at all times. 7.2 Process of Discharge The Consultant The named Consultant is ultimately responsible for the discharge process, which will be carried out by members of the multi disciplinary team. The Responsible Nurse and named Social Worker or care manager will ensure effective communication and co-ordination throughout the process. The consultant will inform the multi disciplinary team of the expected discharge date as soon as possible to facilitate timely discharge planning. Wherever possible, the patient (and with their consent) their carer(s) will be involved and any decisions should be discussed at a multi-disciplinary level. The Consultant is responsible for identifying the need for a case conference / discharge planning meeting for complex discharges, especially where the health / social care needs have changed significantly. The named Consultant chairs any case conference and will liaise with the relevant health and care professionals as necessary to arrange these, and agree appropriate people to attend. The format of the meeting should be focused around service user need. The Consultant in discussion with the multi-disciplinary team, family and care manager ensures that the patient has capacity to understand the decisions that are being made and the information he/she is being given. If this is in doubt, the principles of the Adults with Incapacity (Scotland) Act 2000 should be followed with advice from a Mental Health Officer. 9
Any concerns regarding abuse or exploitation of a vulnerable person, or a person considered to be at risk, should be shared and the Adult Support and Protection Procedures followed. The Consultant is responsible for ensuring: that immediate discharge documentation is completed to allow for prompt ordering of medication; that an appropriate discharge letter is sent to the patient s GP clearly indicating any actions required of the GP, that Health Centres and pharmacies are given copy of the discharge documentation clearly indicating any change to medication. that an appropriate discharge letter is sent to social care staff, i.e care at home staff or unit managers, to allow for prompt start up of services that community pharmacists are contacted directly when discharges are planned for out of hours, indicating any change to medication, and that a medical decision is made as to whether or not ambulance is required (where possible, the Ambulance Service should be given 24 hours notice for the mainland and 48 hours notice for outlying islands). Whilst being medically fit may be considered the minimum criteria for discharge, other factors such as availability of accommodation and social circumstances need to be considered. Discharge should not therefore be carried out until all planned and agreed arrangements are completed and in place. This allows for same day, rapid discharge of patients who require little support services, as well as for more complex discharges, that require a larger degree of support and co-ordination. A dischargeplanning (or case conference) meeting would be considered an integral part of more complex discharges. Nursing Staff Many of the tasks on discharge will be undertaken by nursing staff in the hospital and the service users named nurse should be closely involved in the discharge planning process. As part of the discharge process, a nurse (if possible the named nurse) will ensure that the service user receives their medication, follow up instructions, discusses the discharge with patient and family/carer and reports any concerns to the named consultant and multi-disciplinary team prior to discharge. In situations where the level of need has not altered, the nursing staff should contact the existing Care Manager, or Care Coordinator, or liaise with the hospital social worker to restart any existing services e.g. home care, day hospital, crossroads, lunch club, care at home and community nursing. A minimum of 24 hours and up to 3 days may be required to restart services. It is therefore essential to inform service providers of the expected discharge date indicated by the consultant as soon as this is known so that arrangements can be made for services to be resumed immediately the patient is fit for discharge. 10
Unless prior discussion has taken place, patients who need community health and care services on discharge should not be discharged at weekends or late in the day to ensure that there are no gaps in provision that would put the patient at risk. Responsible Nurse and Health Service Liaison Social Worker The Responsible Nurse and Health Service Liaison Social Worker will work together to ensure effective communication and co-ordination throughout the process. This includes coordination information sharing within the multi-disciplinary team, the primary care team and discussing all issues fully with the patient, their family/carer/guardian, any significant others and any relevant outside agencies prior to discharge. Allied Health Professions Allied Health Professions may be required to carry out assessment intervention as part of the multi-disciplinary team. Advice and information will be given to the patient and where appropriate their family / carers / representative. Any requirement for ongoing physiotherapy will be communicated to the Community Physiotherapist. Requests for aids and adaptations should be made as early in the process as possible to streamline the discharge process. The Occupational Therapist will arrange visits to the person's home as appropriate to assess the environment and advise/arrange any equipment appliances or adaptations that may be necessary for appropriate safe activities of daily life or manual handling requirements. Pharmacist The Pharmacy Department provides discharge medications and advice, where applicable, for the patient. Where appropriate advice should also be given to the carer or representative. The pharmacy should receive discharge prescription or electronic notification of discharge at least 3 hours in advance of discharge from acute wards and 24 hours before discharge from long stay settings. The Pharmacy Department does not provide discharge medication on weekends. Liaison with Care Managers / Care Coordinators is useful where there are specific requirements for administration arrangements at home e.g. as part of a care at home package. Requests for laminated notices, patient counselling, dosette boxes or existing arrangements in the community should be discussed with the ward pharmacist or community pharmacist during the discharge planning process. If discharge should be cancelled, it is critical to inform the relevant pharmacist (hospital or community). Care Manager, Care Co-ordinator, Social Worker Where either the patient s circumstances indicate that care services will be needed on discharge or where the patient is currently receiving services, the Community Care Service should be notified by hospital staff of the patient's admission to hospital so that the patient s care manager, care coordinator or social worker can be informed or if this is a new case, a lead assessor allocated. 11
Where an assessment or re-assessment of needs is required, this will be done using the Single Shared Assessment process. Targets for completion of assessments are indicated in the SSA documentation, which is available separately. The Lead Assessor / Care Manager will liaise with the Consultant and agree on the need and timing for a case conference, agree on contact with family and familiarise all concerned with the current demands and pressures on the service, however the needs-led focus on assessment and care planning will always be uppermost. Unmet need will be documented and interim measures, including the Interim Placement Unit and Delayed Discharge will be discussed at the case conference. The Care Manager should be confirmed at the case conference, and the care plan agreed. It is then the Care Manager s responsibility to request, monitor and review provision of the agreed services. Discharge to Residential Care Where a service user is returning to residential care, staff at the care centre will ensure that this is achieved in the shortest possible timescale and staff will ensure that all necessary support is in place prior to discharge. If the outcome of the Single Shared Assessment is a need for residential care, or if it is apparent early in the assessment process that residential care may be the preferred option to meet ongoing needs, then information on this process and the available choices should be given to the patient or where appropriate, the patient s family, representative, or carer at the earliest practicable stage in the process. Premature discussion of long-term care can cause considerable distress and should be avoided. A case Conference may be appropriate if there is a significant change in circumstance/need. The existing care manager will need to be informed. The process for admission to residential care is documented separately. See Consideration of Residential Care procedure 13.The allocation of residential care works on a needs based system. The outcome of a Single Shared Assessment highlights priority need and therefore the service user with the highest priority will be allocated first. 9.0 Patient Involvement Patients and Carers will be involved in decisions at each stage of the assessment and discharge from hospital process. The patient and, where appropriate, their carers will be invited to multi-disciplinary meetings, discharge planning and case conferences. Information will be provided in an accessible format on patients rights, post-hospital care services and choices of accommodation. 13 http://www.shetland.gov.uk/socialwork-health/documents/considerationofresidentialcare.pdf 12
10.0 Carers A carer is, generally defined as, a person of any age who provides unpaid help or support to a relative friend or neighbour who cannot manage to live at home or in their current setting without the carer s help. With the patient s consent, carers will be included at all stages of the admission, assessment and discharge process. Carers who provide care on a regular and substantial basis 14, as defined by the Scottish Government, have a right to an assessment to establish their ability to provide or continue to provide care for another person. Carers issues must be taken into account when planning the discharge of a cared-for person. Carers assessments are an integral part of the SSA process and especially important during discharge planning. It is the responsibility of the Lead Assessor/care manager to identify and inform carers of their right to an assessment and involvement in the process. Specific supports for carers should be discussed and requested as appropriate e.g. Crossroads, carer support groups, benefit advice. Carers should be made aware of the existence of the Carers Information Strategy and Carers Strategy. Training is available for carers as an outcome of assessment e.g. manual handling, dealing with stress, administering medication. 11.0 Vulnerable or At Risk Individuals The specific arrangements for vulnerable or at risk individuals are detailed in the jointly agreed Adult support and Protection Procedures http://www.shetland.gov.uk/socialwork-health/documents/aspprocedures-jun09.pdf 12.0 Dealing with Disputes Patient or Carer complaints should be investigated using the Joint Framework for Investigating Complaints 15. Where the patient, or their carer or advocate is appealing against the clinician s decision that the patient is ready for discharge, the case will be referred to the Director of Public Health in accordance with Circular CCD 8/2003 16. 13.0 Free Care on Leaving Hospital Any client assessed as needing a domiciliary service on discharge from hospital into the community will receive it free for 4 weeks. This includes laundry, shopping, meals on wheels, care at home and domestic tasks. 14 Community Care and Health (Scotland) Act 2003 15 ELPA and Community Care Plans 2007-2010 16 Circular CCD 8/2003, Scottish Executive 13 January 2004 http://www.sehd.scot.nhs.uk/publications/cc2003_08.pdf 13
It is essential that the lines of communication are open between the lead assessors and social care so that staff are aware of who should be eligible for 4 weeks free domiciliary service. 14.0 Monitoring and Review Mechanisms The effectiveness of the discharge from hospital will be monitored using existing guidance for emergency readmission or failed discharge. Deficiencies in discharge identified by the patient, their carer(s) or others e.g. a care provider; voluntary organisation or Primary Care Team will be communicated to the named consultant in the first instance. The individual patient and/or carer s views should be sought in this process. NHS Shetland and the Council will identify individuals for whom the care provided has been inappropriate either in the level available or the timing or nature of the discharge and review procedures to remedy this, where possible. The Admissions and Discharge Group will be the forum where such cases are considered. The Admission and Discharge Group will review this policy on an annual basis unless new legislation, guidance or operational difficulties dictate otherwise. The review will use the checklist of minimum requirements set out in the Framework for the Production of Joint Hospital Discharge Protocols 17. Delayed discharges will be reported to the Scottish Government Health Directorates as detailed in the Delayed Discharges Definitions and Data Recording Manual 8. NHS Shetland and the Council commit to an annual audit that will inform the review of this document. This protocol has been reviewed and benchmarked against current national standards and JIT 18 s Admission, Transfer and Discharge Protocol for hospital patients in Scotland Best practice report, as well as a Self Assessment pathway tool also produced by the Joint Improvement Team (JIT), 2009. 14.1 Staff Development and Training It is essential that health and social care staff have the opportunity for continual training and development with regard to person centred care, delayed discharge, supporting patients in hospital and interim placements. A programme of relevant training should be brought up at each employee review and development session. Any changes to admissions and discharge protocols could be feedback at these sessions also. 14.2 Variation and its impact on hospital discharge Look around and you will see variation everywhere: different cars, trees, people etc. In a class of children, for example, you will find a range of weights and heights. These natural differences may seem insignificant, but they can affect the way a child 17 http://www.sehd.scot.nhs.uk/publications/cc2003_09.pdf 18 Joint Improvement Team for Scotland 14
is seen in a clinic and how much time they need: an overweight or underweight child may need more advice, and so take up more time. There are many sources of variation along elective care pathways and these can affect the flow of patients through healthcare systems. Much of the variation is caused by the way we organise and provide services this is called artificial variation. The source of variation is important as this determines what we should do next. Natural variation Is an inevitable feature of healthcare systems. Sources of natural variation include: Differences in symptoms and diseases that patients present with The times of day that emergency patients arrive The socio-economic or demographic differences between patients Staff skills, motivation etc Artificial variation 19 Is created by the way the system is set up and managed. Sources of artificial variation include: The way we schedule services The working hours of staff and how staff leave is planned The order in which we see and treat patients How much work we group and deal with in batches How we manage clinics to deal with priority or urgent cases Reducing and managing variation are essential approaches to reducing delays in services. There are two reasons: Waiting lists build up because sometimes demand for work exceeds our capacity to do deal with our work. The mismatch is due to variation in both demand for work and variation in our capacity to deal with work. There is a lot of evidence that suggests that our capacity to deal with work varies more than our demand Variation in the way we work and do work, such as the way we deal with paperwork, the timing of decision making along a clinical pathway, the decisions we make, how we organise and manage work, all impact the pace that patients progress and the number and length of unnecessary delays patients experience There will always be natural variation when working in a health and care setting. However it is essential when trying to reduce delays that we ascertain what is natural and what is artificial variation so as to make the process as streamlined for the patient/service use. 19 H:\delayed discharge\variation - An Overview - NHS Institute for Innovation and Improvement.mht 15
There are a couple of tools that may help: Clinical Engagement and Staff Perceptions. For more information or for improvement techniques go to, Delayed Discharge - Institute for Improvement 16
Appendix 1 Delayed Discharge Pathway Tool 1. Patient Information: Patient CHI Number Date of Birth (age) Admission In hours / Out of hours GP referral / self referral M / F Admitted from Home / Care Home / Other (specify) Address Post code Living on own / with carer Reason for Admission: Did the patient have dementia / episode of delirium? 2. Service History: What services was person in receipt of prior to admission? (List all) Home care Community nursing CPN OT Day care Community Alarm Other telecare / assistive technology Was the case open to Social work? Was a care manager in place? Was there an advance / anticipatory care plan in place? Was carer support provided (if appropriate?) Previous history of emergency admissions in the last three years? If so what was the SPARRA score? 17
3. Inpatient Pathway (a) Date of admission Through A&E / direct to ward? (b) Initial Ward: medical assessment / surgical / orthopaedic / psychiatry / other (c) Subsequent Ward moves (dates and reasons) (d) Date of initial AHP contact OT? Physio? (e) Date of referral to social work and date of initial social work contact (f) Assessed by medicine for elderly team? (g) Assessed by CPN / psychiatry team? Managed by medicine for elderly team? Managed by CPN / psychiatry team? (h) Was estimated date of discharge proposed? (If so provide date): (i) Was a case conference held? (If yes date): (j) Date agreed by MDT as ready for discharge: (k) Current ward setting: Acute site - short stay specialty Acute site - non short stay specialty Post acute site / community hospital bed Intermediate care facility (l) Current Reason for delay (code): (m) Current duration of delay (days): 4. Overview What services may have prevented this admission? What interventions could have changed the outcome? What improvements could have reduced the delay? 18