The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [51]
NB: This is not an exhaustive list and MUST BE DISCUSSED with the complex discharge co-ordinator/specialist sister, discharge planning, palliative care.
Complex discharge definition
A large package of care involving different agencies.
The patient’s needs have changed since admission, with different services requiring co-ordination.
The family/carer requires intensive input into discharge planning considerations (e.g. psychological interventions):
— patients who are entitled to Continuing NHS Funded Care and who require a package of care on discharge
— patients for repatriation.
1 Comprehensive assessment by nurse on admission and document care accordingly
(a) Provisional discharge date set. This will only be an approximate date, depending on care needs, equipment, and so on.
It should be reviewed regularly with multidisciplinary team.
Discharge should not be arranged for a Friday or weekend.
(b) Referrals to relevant members of multidisciplinary team. For example, occupational therapist, physiotherapist, Social Services.
(c) Referral to community health services (in liaison with multidisciplinary team). For example, District Nurse (who may be able to arrange for night sitters), Community Palliative Care Team.
(d) Request equipment from District Nurse and discuss with family. For example, hoist, hospital bed, pressure-relieving mattress/cushion, commode, nebulizer.
If oxygen is required, medical team to complete Home Oxygen Ordering Form (HOOF) and Home Oxygen Consent Form (HOCF) for oxygen cylinders and concentrators at home. Fax to relevant oxygen supplier.
2 Discuss at ward multidisciplinary meeting, arrange family meeting/case conference as required, and invite all appropriate healthcare professionals, including community staff
(a) Appoint discharge co-ordinator at the multidisciplinary meeting. To act as co-ordinator for referrals and point of contact for any discharge concerns.
To plan and prepare the family meeting/case conference and to arrange a chairperson and minute-taker for the meeting.
Primary team nurse to liaise with discharge co-ordinator.
(b) Formulate a discharge plan at meeting. At the meeting, formulate a discharge plan in conjunction with patient, carers, and all hospital and community personnel involved and agree a discharge date; an occupational therapist home visit may be required.
(c) Ascertain discharge address. Liaise with services accordingly.
It is important to agree who will care for patient/where patient will be cared for, for example ground/first floor.
Ascertain type of accommodation patient lives in so that the equipment ordered will fit in appropriately.
NB: If not returning to own home, a GP will be required to take patient on as a temporary resident.
(d) Confirm PROVISIONAL discharge date. This will depend on when community services and equipment can be arranged.
This must be agreed with the patient and family/informal carer/s.
3 Ascertain whether District Nurse is able to undertake any necessary clinical procedures in accordance with their primary care trust policy, for example care of skin-tunnelled catheters. Consider alternative arrangements if necessary
(a) Confirm equipment agreed and delivery date. NB: Family must be informed of delivery date and also requested to contact ward to inform that this has been received.
(b) Confirm start date for care. For example, Social Services/District Nurse/community palliative care.
(c) Confirm with patient/family agreed discharge date. Liaise with complex discharge co-ordinator for Community Services Arrangements Form.
Check community services are able to enter patient’s home as necessary.
4 Forty-eight hours prior to discharge, fax and telephone District Nurse with Community Care Referral Form and discuss any special needs of patient, for example syringe driver, oxygen, wound care, intravenous therapy, MRSA or other infection status. Give written information and instructions
(a) Arrange transport and assess need for escort/oxygen during transport.
(b) Ongoing review. Should be in place for