1. Developing a Trust wide framework to support Nurse Facilitated Discharge to reduce length of stay Kate Pound and Sue Haines Service Redesign Manager Assistant Director of Nursing

2. 4 hour wait and cost improvement pressures Need to reduce LOS and increase pre noon discharges Pre April 2007 - Informal activity, ad hoc Initiated medical and HCOP wards April 07 18 week wait will have further implications for surgery Background and Context Nurse Facilitated Discharge

3. LOS data for C53

4. The size of the task Analysis of discharge data for: 28 medical wards 324 HRG’s were assessed 8,869 patients Later increased to 11,571 90% of patients discharged 28 surgical wards 651 HRG’s were assessed 31,972 patients Later increased to 35,234 90% of patients discharged

5. Key Projects to reduce LOS Discharge process –Discharge reporting –Weekly discharge review –Nurse Facilitated Discharge –Ward action plans Discharge pathways –Hip and Knee replacement –COPD –Cardiac

7. Nursing at NUH Discharge can be delegated to nurses when clearly documented with parameters, or with agreed protocols. ( NUH 2006) Recognition for nurse led activity Formalising existing practice – clinical governance

8. Models of NLD Management Plan Model, consultant defined and nurse facilitates. Protocol Led Model, patients with specific conditions, or have had specific procedures follow agreed care pathways.

9. Process Setting standards Looking at competencies of staff involved Flexible and responsive to local needs Formalising existing practice Not expansion to role Pilot project list number of wards Audit

10. Challenges Medics Documentation Workloads Culture and attitudes Leadership of ward manager

11. Enablers Trust priority empowered authority of project Weekly data performance monitoring Support / education Champions – in practice ward mangers and consultants driving change

12. Audit and evaluation The aim of the audit was to : Review the documented evidence in the case notes of medical management plans with specific criteria for discharges identified by consultant medical staff Assess the completeness of the documentation To identify what worked well and where improvements were required

13. Method –Data eg LOS, time of discharge –Content analysis of case notes, medical and nursing –Questionnaires by the users eg patients, nursing staff and consultants

14. LOS projects rolled out

15. LOS projects

17. Audit reviewed all medical weekend discharges 29 wards – 52 discharge, 37% were NFD (n=19)

19. Content Analysis – Medical Notes Where did medical staff record NFD NFD proforma 42% Case notes 32% Weekend handover stickers 26%

20. Completeness of the medical documentation Only 12.5% (n=1) of the documentation was incomplete when a NFD proforma was used When the handover sticker or the NFD was recorded in the case notes documentation was poor. Specific clinical criteria poorly defined eg ‘when patient is back to normal’

21. Completeness of the Nursing documentation Documentation was perceived as ‘good’ when the NFD proforma was used.6 out of the 8 patients had a record that they had met the clinical criteria for discharge Only 1 out of the 11 patients had any record in nursing documentation stating that they had met the clinical criteria to be discharge by nurse

22. Patient Questionnaires What work well? –Discharge was well planned –TTOs were ready –Able to go without seeing the Dr –It was quick Could be improved? –Transport –TTOs

23. Ward Managers Questionnaires What works well? –Improves team working –Improves communication,verbal and written –Improves discharge planning –Increases the number of morning discharge –Increases the number of weekend discharges –Reduces the LOS for patients as fewer patients are dependant on their doctors reviews for their discharges

24. Ward Managers Questionnaires How can we improve NFD? –Improve Drs training of NFD –Improve teaching / education around NFD –More nurses to be trained in NFD –NFD should be a integrated part of a consultant ward round

25. Doctors Questionnaires What works well? –Right patient information to support discharge –Improves patient safety –Stops unnecessary registrar review –Helps to maintain the focus on appropriate discharges –Increases morning discharges

26. Doctors Questionnaires How could it be improved? –Encourage junior doctors to action NFD –Nurses need to highlight NFD more –Senior medical staff should encourage more NFD –More wards need to be doing NFD

28. Data Current practice? Areas for development?

29. Future - next steps Maintaining momentum, embedding in ward and team culture Competence of nurses - staff turn over Ongoing performance monitoring Surgery and family health Weekly data collection

30. Contact Details Kate Pound – kate.pound@nuh.nhs.ukkate.pound@nuh.nhs.uk Sue Haines – sue.haines@nhu.nhs.uksue.haines@nhu.nhs.uk