NURSE-LED DISCHARGE POLICY

THE NORTH WEST LONDON HOSPITALS TRUST Name: NURSE-LED DISCHARGE POLICY Communication 1. All staff must be aware of this policy. 2. All first line managers must have read and have a working knowledge of this policy. 3. Heads of Service must have read and have a sound working knowledge of this policy. 4. Nurses carrying out Nurse-led Discharge must have a sound working knowledge of this policy. 5. This policy should be available to all NHS Trust employees. 6. This policy should be available in all departments and on the intranet. 7. All external stakeholders involved in approval of policies should be sent a copy. 8. Awareness of this policy should be included in departmental specific induction programmes and departmental meetings. Author: Janet Webber, Elective Practice Development Facilitator Approved by: The Patient Safety Committee Date: October 2006 Ratified by/date;... Replaces: New policy. Review Date: October 2007

CONTENTS 1.0 Introduction p.3 2.0 Scope of Policy p.3 3.0 Identifying Patients who are Suitable for Nurse-led Discharge p.3 4.0 Categories of Staff who are Suitable to Perform Nurse-led Discharge p.4 5.0 Legal and Professional Responsibilities p.5 6.0 Monitoring and Review p.6 7.0 References p.7 8.0 Appendices Appendix 1. Nurse-led Discharge Competency Assessment Framework p.8 Appendix 2. Guidelines and Check List for Nurse-led Discharge p.23 Appendix 3.Nurse-led Discharge Flow Chart p.25 2

1.0 Introduction The North West London Hospitals NHS Trust aims to ensure the effective, safe and timely discharge of patients following the completion of their episode of care. The Trust, in line with the Department of Health [DH 2002], is also committed to the development of nursing roles within legal and professional parameters. Nurse-led Discharge involves experienced nurses making the decision to discharge patients who have met the clinical and discharge criteria stipulated by their Consultant or set out in their condition specific protocol, without any further reference to the admitting Consultant or his team. The Department of Health [2004] states that there are no legal or professional reasons why nurses with the appropriate skills, knowledge and competencies cannot take on responsibility for initiating discharge. They also state that the discharge process is improved by nurses actively managing and initiating it, increasing the number of out of hours discharges, and facilitating discharges earlier in the day. 2.0 Scope of Policy This policy should be read in conjunction with the following documents: - The Trust Discharge Policy The Code of Good Practice. - The NMC Code of Professional Conduct for Nurses, Midwives and Health Visitors [NMC 2002] and related professional policies and guidelines. The aim of this policy is to ensure that practice is safe and does not put patients at risk, by providing a framework for Nurse-led Discharge. This framework will allow for identification of patients and patient groups who are suitable for Nurseled Discharge. It will also identify the skills, knowledge and competencies that a nurse must demonstrate before they can take on this extended role. 3.0 Identifying Patients who are Suitable for Nurse-led Discharge Patients may be discharged by a nurse without further reference to the admitting Consultant or their team in the following circumstances: - Where medical staff have indicated in writing [either in the patient s medical notes or their perioperative care plan] that a patient is suitable for Nurse-led Discharge. - Where medical staff have documented in the notes that a patient is clinically fit, and that Nurse-led Discharge can proceed. - Where all clinical and discharge criteria within a condition specific Protocol have been fully met by the patient. Consultant agreement that Nurse-led Discharge can take place under the Protocol for this condition/procedure must be obtained in advance, and their agreement recorded. 3

- Where a condition specific Protocol allows for Nurse-led Discharge to occur, and where any additional criteria specified in the patients notes by the medical team or members of the Multi-Disciplinary Team [e.g. therapists, specialist practitioners, nurses or other healthcare professionals] caring for the patient have also been fully met. The medical team responsible for the patient must document in the patient s medical notes that they agree to the patient being discharged under Nurse-led Discharge once all of the general and specific criteria have been met. - Where specific individual clinical and discharge criteria for a particular patient, as agreed and documented by the Multi-Disciplinary Team, have been fully met. The medical team responsible for the patient must document in the patient s notes that they agree to the patient being discharged under Nurse-led Discharge once all of these criteria have been met. Nurse-led Discharge must not proceed if, following a decision to allow Nurse-led Discharge, there is a change in the condition of a patient. In these circumstances the medical team must be informed and the patient reviewed by them before discharge can take place. Patients who fall in to the following categories are not excluded from the Nurseled Discharge framework, providing they are medically stable, however, the Department of Health [2004] advises that they need particular attention: - Those who live alone - The elderly - People who are frail - Those with a terminal illness - People with chronic conditions, who may require admissions and treatment in the future - Those who live in sheltered accommodation. Nurses who extend their role to include Nurse-led Discharge should be aware that, even though they have been delegated responsibility for initiating and managing a patient s discharge, overall legal responsibility for the patient remains with their Consultant [DH 2004]. 4.0 Categories of Staff Suitable to Perform Nurse-led Discharge Before extending their role to include Nurse-led Discharge, nurses wishing to undertake this role must be able to demonstrate that they have the required skills, knowledge and competencies to do so. The Department of Health [2004] suggests that they should be able to demonstrate knowledge of the following: - The principles of informed consent - The Human Rights Act - The Data Protection Act - The Community Care Act 4

- Professional codes of conduct. They also suggest that individuals who are to take accountability for initiating discharge should be assessed and achieve a high level of competence in the following six areas, which they place within a suggested competency framework: - Multidisciplinary team working - Estimating expected date of discharge - Development, implementation and review of clinical management plans - Making referrals - Interpreting test results and investigations - How to respond to patients deciding to self-discharge against health care professional advice. In addition to the areas recommended by the Department of Health, the nurse who is to extend their role to include Nurse-led Discharge should also demonstrate a high level of competence in the following areas: - Ability to recognise that a patient falls within the agreed parameters, and is suitable for Nurse-led Discharge - Ability to involve patients and carers in the discharge process - Ability to document fully, accurately and precisely throughout the discharge process. Newly registered nurses are not equipped with the necessary skills and knowledge to carry out Nurse-led discharge. It is therefore suggested that competency assessment does not take place until a nurse has met the following criteria: - Registered for a minimum of one year - Identified by their Ward Sister/Charge Nurse as suitable to take on the role of Nurse-led Discharge - Undertaken a period of supervised discharges [minimum 5 supervised discharges is recommended]. The training needs of staff identified as suitable to take on the role of Nurse-led Discharge should be identified and appropriate training, coaching and education should take place prior to competency assessment using the Trust Nurse-led Discharge Competency Assessment Framework [Appendix 1]. A record of staff training and successful completion of competency assessment should be kept within the clinical area. Guidelines for Nurse-led Discharge [Appendix 2] and the Nurse-led Discharge Flow chart [Appendix 3] should also be kept within the clinical area so that staff can refer to them for information and guidance. 5.0 Legal and Professional Responsibilities Nurses who extend the scope of their practice are accountable for their practice, and are bound by the Nursing and Midwifery Councils Code of Professional 5

Conduct for Nurses, Midwives and Health Visitors [NMC 2002]. This places a specific requirement on the nurse to acknowledge the limits of their professional competence and to only undertake practice and accept responsibility for activities that they are competent in. It therefore follows, that an employer cannot require a nurse to take on a new role, such as Nurse-led Discharge, if that nurse does not consider themselves to be competent to do so [DH 2002]. The Department of Health [2002] also states that Nurse-led Discharge falls within the minimum quality standard, or rule of negligence, which requires a nurse who takes on a task or role previously performed by a Doctor to perform that role or task to the same standard as a Doctor. 6.0 Monitoring and Review All managers in areas where Nurse-led Discharge is in operation are responsible for ensuring that this policy is adhered to. Any incidents involving Nurse-led Discharge should be reported in line with the Trust s Incident reporting Policy. 6

7.0 References 1. Department of Health [2002] Developing Key Roles For Nurses and Midwives. Department of Health, London. 2. Department of Health [2004] Achieving Timely Simple Discharge from Hospital. Department of Health, London. 3. NMC [2002] Code of Professional Conduct. NMC, London. 7

APPENDIX 1. NURSE-LED DISCHARGE COMPETENCY ASSESSMENT FRAMEWORK NAME OF CANDIDATE. PIN NUMBER/EXPIRY... WARD/AREA SUPERVISED PRACTICE UNDERTAKEN [Minimum of 5 supervised practice sessions must take place prior to assessment] DATE ASSESSORS NAME SIGNATURE DATE ASSESSED AS COMPETENT NAME & GRADE OF ASSESSOR SIGNATURE OF ASSESSOR SIGNATURE OF CANDIDATE [N.B. The candidate must have been registered with the NMC for a minimum of 1 year before Nurse-led Discharge Competency assessment can take place] 8

ASSESSMENT RATING LEVEL SCORE INDICATOR Novice 1 Either: Cannot perform this activity satisfactorily. Or: Can perform this activity but requires constant supervision and some assistance. Advanced Beginner 2 Can perform this activity satisfactorily but requires some supervision and assistance. Competent 3 Can perform this activity satisfactorily without assistance or supervision. Proficient 4 Can perform this activity satisfactorily with more than acceptable quality of work and with initiative and adaptability to special problem situations. Expert 5 Can perform this activity with more than acceptable quality, with initiative and adaptability and can lead others in performing this activity. Please score each competency contained within this booklet against the criteria above. The candidate must achieve a level of competent, i.e. a score of 3 or above, in all of the assessment criteria to pass the assessment. [N.B. The Assessor must be a Sister who has been assessed as competent to carry out Nurse-led Discharge and who has a recognised Assessors qualification] 9

MULTIDISCIPLINARY WORKING COMPETENCY 1. ASSESSMENT CRITERIA GRADE DATE ASSESSORS SIGNATURE Demonstrates the ability to co-ordinate and lead a team effectively. Demonstrates collaborative working and has the trust of senior colleagues. Communicates effectively with and involves the team, other healthcare professionals, patients and carers in the discharge process. Able to develop and implement clinical management plans for patients. Able to identify and achieve shared goals. Demonstrates good understanding of individual roles within the Multidisciplinary team and how they are involved in and contribute to the discharge process. Able to anticipate the information needed by the Multidisciplinary team in order for them to make decisions. Demonstrates a high level of knowledge of the discharge process and related legislation and policies e.g. the principles of informed consent, The Human Rights Act, The Data protection Act, The Community Care Act, Professional code of Conduct and the Trust Discharge Policy. Documents fully, accurately and precisely throughout the discharge process. 10

MULTIDISCIPLINARY WORKING COMPETENCY 1. To be completed for all assessment criteria where a score of less than 3 is achieved. ASSESSMENT CRITERIA: LEARNING NEEDS: ACTION PLAN: REASSESSMENT DATE:.. GRADE ACHIEVED:. ASSESSORS NAME:.. ASSESSORS SIGNATURE: 11

ESTIMATING EXPECTED DATE OF DISCHARGE COMPETENCY 2. ASSESSMENT CRITERIA GRADE DATE ASSESSORS SIGNATURE Demonstrates the ability to undertake a full assessment of the patient, which includes physical, physiological, social and functional assessment. Able to demonstrate excellent knowledge of the clinical conditions covered by the speciality of the ward or clinical area, and the investigations and interventions required for these conditions. Able to demonstrate excellent knowledge of the condition specific protocols used in the ward or clinical area that allow Nurse-led Discharge to take place. Able to use condition specific protocols and related guidelines to support the planning and implementation of care and discharge. Able to accurately estimate the length of stay needed for a patient to complete treatment to a level where they are clinically fit for discharge i.e. to accurately set Estimated Discharge Dates. Able to review and revise the Estimated Date of Discharge given to patients, based on further assessment of the individual patient or further data such as information provided by investigations or interventions or assessments carried out by other members of the Multidisciplinary team 12

ESTIMATING EXPECTED DATE OF DISCHARGE COMPETENCY 2. To be completed for all assessment criteria where a score of less than 3 is achieved. ASSESSMENT CRITERIA: LEARNING NEEDS: ACTION PLAN: REASSESSMENT DATE:.. GRADE ACHIEVED:. ASSESSORS NAME:.. ASSESSORS SIGNATURE: 13

DEVELOPMENT, IMPLEMENTATION AND REVIEW OF CLINICAL MANAGEMENT PLANS COMPETENCY 3. ASSESSMENT CRITERIA GRADE DATE ASSESSORS SIGNATURE Demonstrates the ability to develop clinical management plans based on the full assessment of the patient. Demonstrates the ability to review clinical management plans developed by other members of the Multidisciplinary team. Demonstrates the ability to review patient progress and adjust clinical management plans in response to assessment information and test results. Able to identify Estimated Dates of Discharge within Clinical Management Plans. Able to assess patients for discharge using criteria or protocols developed by the Multidisciplinary team. Demonstrates the ability to make effective discharge decisions. Demonstrates a high level of knowledge of the Nurse-led Discharge policy and is able to recognise which patients fall within and which patients are excluded from the framework of Nurse-led Discharge. 14

DEVELPOMENT, IMPLEMENTATION AND REVIEW OF CLINICAL MANAGEMENT PLANS COMPETENCY 3. To be completed for all assessment criteria where a score of less than 3 is achieved. ASSESSMENT CRITERIA: LEARNING NEEDS: ACTION PLAN: REASSESSMENT DATE:.. GRADE ACHIEVED:. ASSESSORS NAME:.. ASSESSORS SIGNATURE: 15

MAKING REFERRALS COMPETENCY 4. ASSESSMENT CRITERIA GRADE DATE ASSESSORS SIGNATURE Able to demonstrate an excellent ability to identify when patients need to be referred to other members of the Multidisciplinary team. Able to initiate referrals to other members of the Multidisciplinary team in an accurate and timely manner. Demonstrates the ability to actively follow up actions and results that are necessary following referrals. Able to co-ordinate and organise Multidisciplinary reviews of patients. Able to demonstrate the ability to use the outcomes of Multidisciplinary reviews to adapt the Clinical Management Plans and Estimated Discharge Dates of patients as necessary. 16

MAKING REFERRALS COMPETENCY 4. To be completed for all assessment criteria where a score of less than 3 is achieved. ASSESSMENT CRITERIA; LEARNING NEEDS: ACTION PLAN: REASSESSMENT DATE:. GRADE ACHIEVED:. ASSESSORS NAME:. ASSESSORS SIGNATURE: 17

INTERPRETATION OF TEST RESULTS AND INVESTIGATIONS COMPETENCY 5. ASSESSMENT CRITERIA GRADE DATE ASSESSORS SIGNATURE Refers for necessary tests in an accurate and timely manner. Proactively chases and accurately interprets the results of tests and investigations. Demonstrates the ability to adjust Clinical management Plans in response to the results of tests and investigations. Able to recognise and communicate as necessary abnormal test results in an effective and timely manner to the appropriate member of the Multidisciplinary team. Able to identify when the results of tests or investigations indicate that discussion of the patient s care and review by medical colleagues and other members of the Multidisciplinary team is needed. Able to take responsibility for discharge decisions based on the clinical assessment of the patient and the results of tests and investigations. 18

INTERPRETATION OF TEST RESULTS AND INVESTIGATIONS COMPETENCY 5. To be completed for all assessment criteria where a score of less than 3 is achieved. ASSESSMENT CRITERIA: LEARNING NEEDS: ACTION PLAN: REASSESSMENT DATE:.. GRADE ACHIEVED:. ASSESSORS NAME:. ASSESSORS SIGNATURE: 19

ACTION TAKEN WHEN A PATIENT DECIDES TO SELF-DISCHARGE AGAINST HEALTHCARE PROFESSIONAL ADVICE COMPETENCY 6. ASSESSMENT CRITERIA GRADE DATE ASSESSORS SIGNATURE Able to explore the reasons for self-discharge with the patient. Attempts to persuade the patient to remain in hospital if this is in the clinical interests of the patient. Able to explain the risks and potential consequences of self-discharge to patients and their carers. Demonstrates the ability to rapidly co-ordinate any necessary post discharge follow up and care if the patient agrees to it. Demonstrates the ability to document events fully and accurately within the patient s records. Communicates with the patient s General Practitioner as necessary, including ensuring that a discharge letter is sent to them. Informs the patient s consultant or medical team of the patient s intention to self-discharge at the earliest opportunity. 20

ACTION TAKEN WHEN A PATIENT DECIDES TO SELF-DISCHARGE AGAINST HEALTHCARE PROFESSIONAL ADVICE COMPETENCY 6. To be completed for all assessment criteria where a score of less than 3 is achieved. ASSESSMENT CRITERIA: LEARNING NEEDS: ACTION PLAN: REASSESSMENT DATE: GRADE ACHIEVED:... ASSESSORS NAME:. ASSESSORS SIGNATURE:.. 21

NOTES - Following successful achievement of this Competency Assessment, a copy of this Competency Assessment Book must be kept within the ward or clinical area where the assessment has taken place. - This assessment does not allow the candidate to carry out Nurse-led Discharge outside of the speciality of the ward or clinical area where the assessment has taken place. - This assessment only allows the candidate to carry out Nurse-led Discharge in the ward or clinical area where the competency assessment took place. - A further competency assessment will be required if the candidate moves to another ward or clinical area with a different speciality and wishes to continue to discharge patients under the Nurse-led Discharge framework. 22

APPENDIX 2. GUIDELINES FOR NURSE-LED DISCHARGE. [Only to be used in conjunction with the Trust Nurse-led Discharge Policy] Nurse-led Discharge can proceed where:- - Medical staff have indicated in writing that a patient is suitable for Nurse-led Discharge. - Medical staff have documented that a patient is clinically fit and that Nurse-led Discharge can go ahead. - Clinical and discharge criteria within a condition specific protocol that allows Nurse-led Discharge have been met. - Specific criteria for a patient, additional to those within their condition specific protocol, have also been met. - The clinical and discharge criteria set for a patient have been met, and the medical team have documented in the patient s notes that they are happy for Nurse-led Discharge to go ahead once these criteria have been met. CHECK LIST - Is the patient medically fit for discharge? - Does the patient fulfil the criteria for discharge under the Nurse-led Discharge framework, as specified in the Nurse-led Discharge Policy and summarised in the guidelines above? - Has the patient met all of the clinical and discharge criteria documented in their condition specific protocol or their notes? - Is the patient s condition unchanged from when a decision to allow Nurse-led Discharge to proceed was made? If the answer to any of the above questions is no, then Nurse-led Discharge should not proceed and the patient should be referred back to their medical team. 23

THE RESPONSIBILITIES OF THE MEDICAL TEAM - Even where a patient is identified as being suitable for Nurse-led Discharge overall legal responsibility for the patient remains with their Consultant. - The medical team are responsible for agreeing to a patient being discharged under the Nurse-led Discharge framework, either through prior agreement to this proceeding for patients on agreed condition specific protocols, or through documenting that a patient is suitable for nurse-led discharge in their notes. - The medical team are responsible for identifying and specifying any clinical or discharge criteria that they feel the patient must meet before Nurse-led Discharge can proceed, and documenting these criteria in the patient s notes. - The medical team will complete the patient s Discharge letter and prescribe the patients discharge medication once the nursing staff have informed them that the patient is to be discharged [preferably 24 hours in advance where possible]. THE RESPONSIBILITIES OF THE MULTIDISCIPLINARY TEAM. - The Multidisciplinary Team are responsible for identifying and specifying any clinical or discharge criteria that they feel the patient must meet before Nurse-led Discharge can proceed, and documenting these criteria in the patient s notes. The medical team caring for the patient must agree that discharge can go ahead once these criteria have been met. THE RESPONSIBILITIES OF THE NURSE CARRYING OUT NURSE-LED DISCHARGE Nurses who are extending their role and who are carrying out Nurse-led Discharge are bound by their Professional Code of Conduct [NMC 2002] and are accountable for their practice. Nurses who are undertaking the Nurse-led Discharge role must have:- - Been qualified and registered with the NMC for a minimum of 1 year. - Been identified by their Ward Manager as suitable to take on this extended role. - Received training, coaching and education and supervised practice [minimum 5 discharges] in Nurse-led Discharge. - Successfully completed a Nurse-led Discharge Competency Assessment. A good working knowledge of the Nurse-led Discharge Policy 24

APPENDIX 3. THE NORTH WEST LONDON HOSPITALS NURSE-LED DISCHARGE FLOW CHART Medical staff have documented that patient is medically fit Or Patient is on a condition specific protocol that allows Nurse-led Discharge YES NO Medical staff have indicated in writing that patient is suitable for Nurse-led Discharge Or Clinical and discharge criteria within a condition specific protocol have been met NO DO NOT PROCEED WITH NURSE-LED DISCHARGE YES Refer to Medical team and revert to Medicallyled Discharge. Specific clinical or discharge criteria for the patient have been met YES NO Patient s condition is unchanged from when the decision to allow Nurse-led discharge to proceed was made Refer to Medical team and revert to Medicallyled Discharge YES NO YOU MAY NOW PROCEED WITH NURSE-LED DISCHARGE Refer to Medical team and revert to Medicallyled Discharge 25