Nurse Led Discharge Mater Misericordiae University Hospital Hilda Dowler, ADON Nursing Quality

Overview of today’s talk

Terminology Nurse led facilitated discharge

Definition Nurse or Midwife led discharge ‘Nurses leading the whole process of discharge planning following decisions made by nurses, using criteria, protocols or given set of principles’ (Lees, 2007) Commonly mis interpreted as: ‘the transference of total responsibility for the discharge decision from doctors to nurses’ (Lees, 2004)

Definition Nurse or Midwife led discharge Plan must be agreed by the consultant in charge of care, and nurse/midwife must be willing to accept the role and have knowledge and expertise to execute the plan (Lees, 2007; Dept of Health, 2004)

Definition Nurse facilitated discharge ‘A process where nurses adopt specific responsibilities (within a predetermined scope of practice) for the proactive management of activities aligned with a patients discharge plan’. (The plan will be multidisciplinary with nurses engaged to ensure it takes place in a timely manner). Reference: Lees L, (2012) Timely Discharge from hospital Section 1 Chpt 3 p.42; ISBN: M&K Publishing

Definition Nurse facilitated discharge Nurse assigned to the care of the patient, sources and co-ordinates patient information and links with families, carers, primary care teams, community care teams and voluntary agencies where appropriate (HSE 2008 p54).

Approaches to Nurse Led Discharge Criteria-led Used for disease or condition groups where the parameters for discharge are similar; one example is the British Thoracic Society guidelines for pneumonia, which clearly state parameters for discharge of these patients

Approaches… cont. Bespoke (emergency) An individual, tailored plan that is documented and agreed by the multidisciplinary team and executed by a registered practitioner (nurse or midwife). Can be used for patients admitted as an emergency, where advance planning for discharge could not take place and parameters for discharge may be multifaceted

Approaches… cont. Care pathway or protocol-led (elective) This tends to be used for patients admitted electively onto a pathway for their condition. Patients could be screened for suitability for criteria-led discharge before admission. The pathway or protocol must indicate where the discharge process begins and ends (e.g. does it include case management or follow up)

Implementation of nurse led discharge Critical Questions ( before, during and after implementation) Is your existing discharge process an efficient one ? Why do you want to introduce nurse led discharge? Where do you need to make changes in the process for it to be nurse led? Where do you need to add in support or training or competencies? What are the desired outcomes (measures of success)? Who is responsible for auditing the discharge process?

Implementation issues

Developing competencies: A continuum of practice Reference: Lees L, (2012) Timely Discharge from hospital Section 1 Chpt 3 p.42; ISBN: M&K Publishing

Developing competency framework

Developing competency framework

Developing competency framework Competency 2 Estimating a date of discharge

Developing competencies Registered practitioners must have: The ability to assess and make critical decisions regarding discharge with expertise & training and competency assessment. At least two years post registration clinical nursing experience. The support of the Ward Manager/ADON/DNM to confirm that:  Directorate/ward specific protocols and patient criteria have been developed, agreed and in operation.  Registered staff should only discharge patients from the ward or setting in which they hold clinical responsibility.

Areas of greatest impact Breast cancer service: (6.22 control and 3.96 intervention group) A&E & Community teams: (6.3 control and 1.7 intervention group) Gynaecological: (2.2 control to 1.7 intervention group) Day surgery in general: Reduction in cancelled operations 50% to 34 % Opted for same care again 88% v 69% (control)

Learning from experience Project nurse employed on a short term contract to lead the changes, responsibility for implementation not devolved to staff at ward level, so project ceased when project nurse or support was removed (Walsh, 2004) Staff recruitment and retention (skill mix, experience/competency), reason for lack of sustainability Nurses time away from usual duties to work on implementation

Measuring to improve Dashboard Outcome measures Average length of stay Discharge time in the day Use of EDD Patient & staff satisfaction rates Process measures Discharge plans Communication process

Overcoming organisational challenges Nurse led discharge should be introduced systematically in clinical areas that are prepared to embrace it Assessing and adapting the existing discharge process is vital to successful implementation Crucial that everyone involved (consultants, nurses, health and social care professionals and patients) is clear what outcomes measures are being used to monitor the impact and effectiveness of the changes Manage management’s ongoing expectations -‘ Winter Capacity’ initiative

Five key points (‘Top Tips’) 1.Nurse-led discharge should be integrated with and not separate from the usual discharge process 2.Bringing in nurse-led discharge requires a review of the whole discharge process 3.Outcome measures must be in place before a project starts so its effects can be evaluated 4.Implementation should help nurses to take charge of the revised discharge process through shared learning 5.Success will come to those who can show they can safely adapt elements of their existing discharge process for the new one

How will we know we have made a difference? The benefits!! Patient experience – increased discussion, compliance surrounding discharge from Hospital Reduced length of stay (Dashboard Outcome measure) Discharge earlier in the day (Dashboard Outcome measure) Improved communication Increase in the use of bespoke medical management criteria Increased and more effective use of EDD (Dashboard Outcome measure)

In conclusion….