The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [55]
13 Where there is a designated discharge co-ordinator, they can act as a resource offering support and education to the ward team in the preparation of discharge plans, especially for those patients requiring a complex package of care. To facilitate effective discharge planning and utilize expertise appropriately. E
14 Formulate a discharge plan in conjunction with patient and carers and all involved hospital and community personnel and agree a discharge date. To collate information and co-ordinate planning (DH 2004a, C).
15 For complex discharges, a discharge planning meeting should be held. To co-ordinate continuity of care planning. E
16 The ward-based nurse is responsible for arranging and co-ordinating community nursing services (including the Community Palliative Care Team) in consultation with the discharge co-ordinator, if applicable. To facilitate continuity of care between hospital and community. E
17 Refer to the community nursing services with a minimum of 48 hours’ notice. If a complex package of care is being organized, more notice will be required. Invite community nurses to visit the ward where appropriate. Community nurses may wish to assess the patient’s nursing care needs and ensure preparation of the home prior to discharge. They need time to liaise with other agencies to co-ordinate care and to obtain any equipment required. E
18 Ascertain whether community nurses are able to carry out necessary clinical procedures in accordance with their trust policy, for example care of skin-tunnelled catheters. Consider alternative arrangements if necessary. Give written information and instructions. District Nurses may not have been trained in certain procedures or may be unfamiliar with particular equipment. E
19 Details of patient’s MRSA status (or other infections) must be given to community personnel and written in requirements. To reduce risk of cross-infection. Community staff require full knowledge of the patient’s history and nursing referral details (Halm et al. 2003, E; Smith 2003, E, C).
20 Complete the community care referral form or update letter. The form/letter should be completed and signed and a copy provided for all community services. Provide information for community staff to ensure that they have accurate information (Halm et al. 2003, E).
21 Ensure any essential medical/nursing aids or equipment have been obtained before discharge by community services, for example oxygen, nebulizers, commode, pressure-relieving mattress, hoist. Some equipment may not be available or may take some time to obtain. Equipment may be loaned from the community and appropriate legislation procedures must be followed for safety reasons (DH 2001c, C).
22 Home assessment by occupational therapy may be required prior to discharge.
23 Patients requiring community nursing, physiotherapy, occupational therapy, stoma care, speech therapy and/or dietetic support on discharge will be referred by the appropriate hospital-based healthcare professional to their equivalent in the community. To ensure continuity of specialist care. E
Leaving the hospital on discharge
24 Medical staff are responsible for assessing the patient’s medical fitness for discharge and for liaising with other members of the multidisciplinary team regarding arrangements for meeting the patient’s care needs in the community. To ensure that both health and social care needs are taken into consideration when formulating discharge plans (DH 2003a, C).
25 Ensure that patient and, with their agreement, carers have full information regarding the patient’s medical condition and care required. To prepare carers and to enable patient/carer support. E
26 Teach the patient and carers any necessary skills, allowing sufficient time to practise before discharge. This should include information on the safe use of equipment, for example a hoist, and identify