Discharge before noon takes persistence and planning
Each week, Lady Skinner ward at Charing Cross Hospital consistently manages to complete 80 per cent of their discharges before noon. This frees up space earlier in the day for new patients who need to be admitted and allows patients to go home when they are ready to. Overall, discharging before noon helps avoid bottlenecks in hospital flow and reduces length of stay overall. Here senior sister Diana Belshaw explains how her team makes this happen each week.
I’ve been the senior sister on Lady Skinner ward since September 2014. Usually our ward is a rehabilitation ward that looks after patients recovering from falls, medical problems, or surgery – but at the moment we’re seeing a lot of acute patients because the hospital is so busy. Still, we manage to complete most of each day’s discharges before noon.
I am extremely passionate about ensuring that each patient who needs to leave hospital has a smooth discharge. Its second nature to me and I’ve also made it a big priority for my team. When I’m away, Ivy Villa and Wendy Magleo Olivar, the band six nurses in my team, manage discharges in my place, and they are absolutely brilliant. The whole ward team works so hard to discharge our well patients before noon each day and free up space for new patients who really need our help.
There is a lot of admin involved – we spend a lot of time making phone calls, chasing up outstanding paperwork and reminding community partners that they have a patient coming in a few days and they need to be ready. But when we get it right, it makes the rest of our work easier.
It’s so demoralising to see patients stuck on the ward when they should be at home or in a community rehabilitation facility. You know that they aren’t getting the care they need and you feel helpless to improve their situation. This is how we prevent that feeling of helplessness – we plan ahead, we hit the phones to get plans in place, we escalate challenges quickly, and we do it all again the next day.
Anticipated date of discharge
When a patient arrives on our ward, we discuss their care needs and what we can do to help them get well enough to leave hospital. A consultant or senior decision maker and the MDT gives that patient an anticipated date of discharge (ADD) – the day we expect them to go home. As soon as we have that date, we contact social services in the community, as well as their family or regular carers, and start to put plans in place to help them transition to home or their next place of care.
From there, we work backwards to plan their care: what medications will they need? What rehabilitation goals will they need to meet? What tests or scans will we need to complete to ensure we feel confident that they are ready to leave hospital? This helps us plan care for each individual patient as well as plan our work across the ward each week. This forward planning helps ensure we’re using our time efficiently for all of our patients.
Discharge to assess
The discharge to assess (D2A) approach – where we assess a patient in their own home – is integral to the way we run our ward. Because the hospital environment is so different to home, it can be more effective to assess a person’s rehabilitation needs in their home environment. It gives us a better understanding of what they need to do each day and what is important to them. We encourage our therapists to do their D2A assessments as soon as possible and support them to do so if other work is getting in the way. If the patient requires a restart of care I sent the D2A as soon as I get an anticipated date of discharge – known as an ADD.
Transport
Once we have an anticipated date of discharge (ADD), we book transport and notify our discharge lounge team to let them know when they can expect our patients. Transport teams already have busy schedules supporting patients who come to hospital frequently, such as renal patients who need regular hospital dialysis. Booking transport early helps us minimise delays for patients when they are ready to go home. The discharge lounge is a great place for patients to wait for their transport and any final bits such as prescriptions while we make space for another patient on our ward.
Board rounds and multidisciplinary team meetings
In the morning we have a board round; these are quick handover meetings between the MDT to feedback any concerns that have arisen overnight and to discuss the day’s discharges. We have a multidisciplinary team meeting every day too. Sometimes it’s only 15 minutes, but it gives our whole team a chance to review and discuss each of our patients and collectively plan for their care. Discharge is always a focus at these sessions – we review care, confirm or revise ADDs, and ensure patients are progressing and improving. We address any blockers to progress and decide what to do next.
Persistence and planning
At the end of the day, planning and persistence are the magic ingredients: from daily multidisciplinary team meetings to repeated phone calls to community providers, we are persistent in planning for each patient’s discharge. This gives us a north star each day – we need to make sure that every day we’re doing something to help each patient’s care progress. Our whole ward team shares that goal. And by the end of each day, our colleagues beyond our ward do, too, if only so that we’ll stop calling them to help us progress discharges!
But that persistence helps the whole hospital, not just our ward. We all need to work together to send patients home as soon as they are ready to leave hospital, so that we can get patients out of A&E and onto our wards for care. I always think about how I’d feel if a relative of mine was stuck in A&E for 24 or 36 hours – I'd be frustrated with staff and so disappointed in my experience. We don’t want our patients to endure that, and we don’t want our colleagues to work under those conditions, so we should do all we can to help each other out.
Every patient is our patient – we can’t just focus on our own wards. We are here to care for everyone who comes through our doors. If we only focus on the patient in front of us, we’re not doing our jobs.
