Contents
1 Aim
This procedure provides a description of the current recommended best practice for safe and successful discharge of patients from Hawthorn and Hazel wards of the intermediate care inpatients services at Tickhill Road Hospital.
2 Scope
The detail contained within this procedure applies to all levels and disciplines of staff that provide a service to the patients within Hawthorn and Hazel ward, intermediate care inpatient services.
3 Link to overarching policy, and or procedure
This procedure is overarched and to be used in conjunction with the admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures.
4 Procedure or implementation
4.1 Procedure for transfer and discharge planning and implementation for patients from Hawthorn and Hazel ward of the intermediate care inpatient services
- All patients will have an expected date of discharge (EDD) identified on admission by the admitting registered nurse (RGN).
- A board round will be undertaken daily by the multidisciplinary team (MDT) to discuss and highlight patients for weekly MDT meeting, a definite discharge date (DDD) will be given to all patients.
- At each board round no right to reside (NRTR) status is reviewed by the MDT and determined using the following 3 criteria:
- does the patient have clinical needs that must be met within the intermediate care bed base? yes or no
- are there any outstanding MDT assessments that need to be completed? (nursing, occupational therapy (OT), physio, pharmacy, social worker) yes or no
- does the patient require ongoing rehabilitation, which can only be completed within an intermediate care bed base? yes or no
NRTR status will be recorded after ward round on SystmOne and a daily report generated by the ward manager.
- Discharge will be discussed as part of the agenda at the MDT meeting for patients receiving care on Hawthorn and Hazel wards.
- Discharge planning will involve all active members of the rehabilitation team, the patient and, or their representative.
- The MDT meeting relating to the safe and successful discharge will consider individualised patient needs and as a minimum:
- preferred discharge location or suitability of this
- other needs relating to discharge location
- identified care needs beyond discharge
- identified representative, for example, family or friends
- support required from other agencies
- ability to administer own medications
- safety outside of the ward
- transportation outside of the ward
- equipment needs
- consent and capacity relating to discharge planning
- A home assessment or access visit will be carried out when appropriate based on clinically assessed individual needs of the patient. The purpose of this home assessment or access visit is specific to the individual patient and the assessors will differ depending on patients specific needs.
- When the patient is assessed as lacking capacity to make decisions about their discharge, decisions will be made in their best interest. On every occasion staff must complete MCA1 and MCA2 to ensure that a robust record of capacity assessment and best interest decision is available for scrutiny. If the person has appointed someone to act as their attorney for health and welfare, consent must be sought from them. In all cases a representative will be identified to consult with. The patient and, or representative will be fully informed and understand the action plans relating to discharge. (Mental Capacity Act (MCA) 2005).
- If there are any proposals which involve a change in the person’s accommodation and they lack capacity to make the decision and have no one to represent them, an independent mental capacity advocate (IMCA) must be appointed to represent them.
- All patients and, or their representatives will be encouraged and supported to identify their preferred discharge location, suitability of this preferred discharge location will be ascertained prior to the MDT meeting for the purpose of advising further discharge planning.
- If the property is deemed unsuitable, this will be discussed at the MDT meeting, to enable further discharge planning, and access visits as necessary.
Once discharge plans are made, the patient will continue to be discussed at the daily ward round to ensure all outstanding tasks completed in line with DDD.
- The registered nurse (RGN) will coordinate and facilitate a timely and individualised discharge planning process with the support of the full active MDT in line with the DDD.
- If the patient has an identified infection risk this must be discussed with the receiving service to allow them time to make any necessary arrangements for the management of the infection once the patient is discharged to their care. All relevant information must also be documented on the patient’s transfer or discharge letter and care records updated accordingly.
- A phased discharge (if applicable to patient requirements) process will include increasing periods of time spent at the identified discharge location, with specific care needs met through a process of care planning with or without the support of other appropriate agencies as agreed in the discharge planning meeting.
- Referrals to other agencies will be made as the need is identified for the purpose of safe and successful discharge, in line with the DDD and within the Mental Capacity Act 2005, ( MCA 2005).
- Where other agencies are to provide care beyond discharge; all active agencies or professionals will be notified of the DDD will be confirmed and agreed, ( MCA 2005).
- Patients identified as having on-going needs will require a formal assessment by the RGN and will be referred to the specific service prior to discharge and notified of discharge date. For example, community nursing, Community Mental Health team, drug and alcohol services.
- Professionals involved in providing care or treatment will ensure that all details are added to the discharge report or letter; the discharge report or letter will be completed, proof read, edited and finalised prior to the date of discharge.
- Any training required to ensure the continuation of patient care delivery beyond discharge will be co-ordinated by the RGN and action plans formulated in the safe and successful discharge goal.
- A copy of the discharge report will go with the patient on the date of leaving the ward and an electronic version sent to the registered general practitioner (GP).
- Discharge letter to include details of do not attempt cardio pulmonary resuscitation (DNACPR) or recommended summary plan for emergency care and treatment (ReSPECT) document.
- Patients and, or their representatives will have a clear understanding of the plans for future rehabilitative, social and continuing health care, its location, frequency and purpose. The plan for this will be communicated by the named professional.
- Follow up plans and details will be recorded by the MDT onto the patient’s discharge report or letter, to include:
- type of follow up, for example, physiotherapy
- point of contact, for example, name and contact number
- date of any appointment, if known
- contact details of who to contact in the case of an enquiry
- Patient and, or their representative will be provided with the contact details for any relevant equipment sources.
- All patients will receive information as to how to contact out of hours doctors and social services on the discharge letter.
- The original DNACPR order or RESPECT document should be given to the patient or carer. Staff should ensure that the patient or carer is aware of and fully understands the order.
4.2 If the patient is identified as having on-going care needs beyond discharge
- Allocated social workers will be invited to attend all case reviews and pre-discharge planning meetings for the purpose of supporting discharge planning ( MCA 2005).
- Any patient with complex moving and handling needs will have a moving and handling plan completed by their occupational therapist (OT). This will highlight specific handling or transfer techniques, equipment required and the number of people required to complete safe moving and handling of the patient. The moving and handling plan will be forwarded to relevant carers or care agencies and community OT (to enable future review).
- Assessment by the RGN and will be referred to the specific service prior to discharge.
4.3 If equipment or adaptation needs are identified as essential for discharge
- Any additional items of equipment or adaptations deemed essential for discharge will be in place on or prior to the DDD.
4.4 During the week of discharge
All discharge plans for those patients receiving care in Hawthorn and Hazel ward will be documented on the discharge planning template on SystmOne. To include:
- transport arrangements will be made and confirmed at least 48 hours prior to the DDD
- 14 days supply of all required medications and dietary supplementation will be provided (safe and secure handling of medicines manual and nutrition policy (promoting good nutrition for patients))
- the pharmacy team will highlight if the patient previously used boxed medication or NOMAD whilst in the community. All NOMAD’s to be ordered through a community pharmacy
- the registered nurse (RGN) will identify from the patient and, or their representative how, where and who will be responsible for obtaining further supplies of medications for the patient and include this detail in the discharge letter
- all medication required beyond discharge will be received by the ward 48 hours prior to the DDD, wherever possible
- supplies of all dressings, catheter supplies, continence aids will be arranged 48 hours prior to discharge
- the RGN will support the patient to apply for the return of any money or property stored in general office. Patients’ monies and property procedure
- final plans will be agreed and confirmed with the patient and, or their representative as arrangements are confirmed
- the RGN will ensure that the patient and, or their representative are provided with the contact details (and a link contact, where possible of all agencies providing care beyond discharge: in discharge letter
- the discharge co-ordinator will offer the patient, and, or their representative a your opinion counts form and provide support with completion as required
4.5 On the day of discharge
The discharge co-ordinator will agree a plan for post-discharge follow up with the patient and, or their representative, details of this plan will be entered into the discharge report, follow up section. This will include an identified date for post discharge phone call for patients on Hawthorn or Hazel ward.
An identified patient representative will be contacted within 10 minutes of patient leaving the ward to inform them of the departure, (if this is an identified need recognised during discharge planning process).
What the patient will be provided with:
- medication supply of 14 days. Which is either boxed medication or NOMAD trays. NOMAD trays will have been organised through patients own pharmacy. All medications dispensed will be checked by 2 registered nurses (RGNs) against the current prescription and the list of medications which will go with the patient
- NOMADs which are being organised through the patient’s own community pharmacy will be checked prior to discharge and pick up or delivery will be arranged
- all patients will take a signed copy of the discharge letter with them when they leave the ward
- ensure that the original DNACPR form or ReSPECT document goes with the patient if an order has been made
- any dressings, catheter supplies or continence aids that may be required
- a copy of the discharge letter will be sent electronically to the GP on the DDD, via SystmOne
4.7 Care beyond discharge
Post discharge follow up contact will be made by the discharge co-ordinator, at a time frame agreed with the patient and, or their representative prior to the DDD as part of the discharge plan; this will not be more than 2 days after discharge. This post-discharge follow up may consist of a telephone call or home visit depending on the patient’s individual needs.
The outcome of the post-discharge follow up contact will be recorded in the patient record and action plans completed relating to any event or issue arising from this contact before the patient’s care is formally concluded.
4.8 Delayed discharge
In the event of discharge being delayed beyond the DDD:
- a report will be published every day identifying patients who meet the NRTR criteria
- the ward manager will review the report daily and any escalations sent
- escalations are sent in accordance with the shared NRTR policy
5 Links to associated documents
- Admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures
- MCA Mental Capacity Act 2005 policy
- Safe and secure handling of medicines manual
- Nutrition policy (promoting good nutrition for patients)
- Copying letter to service users policy
Document control
- Version: 3.1.
- Unique reference number: 44.
- Approved by: Clinical policies review and approval group.
- Date approved: 6 September 2022.
- Name of originator or author: Ward manager Hawthorn ward or head of patient flow.
- Name of responsible individual: Executive director of nursing and allied health professionals.
- Date issued: 29 September 2022 (amendment)
- Review date: August 2025.
- Target audience: All staff within the Hawthorn and Hazel ward, in-patient ward.
Page last reviewed: April 23, 2024
Next review due: April 23, 2025