The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [49]
The discharge planning process takes into account a patient’s physical, psychological, social, cultural, economic and environmental needs. It involves not only patients but also families, friends, informal carers, the hospital multidisciplinary team and the community health/social services teams (Maramba et al. 2004, Salentera et al. 2003), with the emphasis on health and social services departments working jointly. However, a new emphasis is being placed on personalized care in the community, with patients purchasing and managing their own care package (Darzi 2008). Giving patients greater control and choice over the services they need requires the professionals to ensure that they have provided information regarding all the possible alternatives for care open to the patient and their carers (Darzi 2008).
As well as patient experience, discharge planning is considered a factor in reducing the length of stay in hospital, which has a financial impact for the NHS (DH 2004a, Bull and Roberts 2001, Mardis and Brownson 2003, Nazarko 1998). Given the huge cost of inpatient care, it is financially sensible to ensure that procedures are in place, and complied with, to facilitate patients being discharged at the earliest opportunity. However, the notion of a seamless service may be idealistic because of increasing time constraints and the complex care needs of high-dependency patients (Smith 1996).
Occasionally the discharge process may not proceed as planned; a discharge may be delayed for a number of reasons and a system should be in place to record this (for example, see Figure 2.1). Patients may take their own discharge against medical advice and this should be documented accordingly (see Box 2.13). When patients are assessed as requiring care or equipment but decline these, this does not negate the nurse’s duty to ensure a discharge is safe. A discussion should take place with the patient and carer to assess how they intend to manage without the required care/equipment in place. It is crucial that the community services are aware of assessed needs that are not being met through patient choice or lack of resources. It is critical that the community team who will be supporting the patient when they return home are notified and where possible this should be in writing, such as sending them a copy of the patient refusal of equipment form. Some patients receiving news of a poor prognosis may prefer to go home to die and plans would need to be set up at short notice (Figure 2.2).
Figure 2.1 Discharge delay monitoring form.
Reproduced with kind permission of the Royal Marsden Hospital NHS Foundation Trust (2006).
Figure 2.2 Checklist for patients being discharged home for urgent palliative care.
Box 2.13 Patients taking discharge against medical advice
Nursing staff responsibility
If a patient wishes to take their own discharge, the ward sister/co-ordinator should contact:
a member of the medical team
the manager on call
the complex discharge co-ordinator.
The complex discharge co-ordinator will inform Social Services if appropriate. Out of hours, following a risk assessment, the manager on call will contact the local Social Services department, if appropriate, and inform the hospital Social Services department the following day.
Medical staff responsibility
The doctor, following consultation with the patient, should complete the appropriate form prior to the patient leaving the hospital. The form must be signed by the patient and the doctor and filed in the medical notes. The doctor must immediately contact the patient’s GP.
The role of informal carers
Engaging and involving patients and informal carers as equal partners is central to successful discharge planning (DH 2003a, Holzhausen 2001). The Picker