Introduction of Discharge

Pathways

Aims of the session – What Pathway is

your patient on ?

Explore key features of early discharge

planning assessment

Inform of the processes currently in

place to facilitate early discharges incl. referrals paperwork

Develop seamless approach in order to

assist with discharges

Analyse and discuss Issues related to pathways 0 – 3 ,

through real case scenarios Roles &

Responsibilities

Introduction of

pathways 0,1,2

& 3

Medway-

pathways

The Process

Discharge

Evaluation/Review of Progress – Discharge Planner

Implementing Care Plan – referrals as per Discharge Pathways

Care Planning with carers/NOK/patient

Discharge Plan-MDT daily with actions

MDT/Board Round with EDD & Discharge Pathways in place

Admission assessment - collateral

common causes of poor discharges

Gaps or lack of

referral – scant info (ward says

ref done but not on

the for community services)

Poor health

education and

instruction: to patient or informal

carers (Involving carers/NOK) meds

management

Inadequate supplies

with patient.

Eg: Dressings

(D/C on Friday )

Discharged with cannula in situ

Catheter in situ no

information supplied/ referral not

done

Lack of risk

assessment – MDT approach

– Collateral(scant info leading to poor/unsaf

e D/C planning & delays)(D/C with new

cath –no ref

made/sepsis)

Transport and TTOs – ongoing referrals such as district nurses

Poor communic

ation

Recent findings /Themes

Outlining roles and responsibilities – MDT • Silos working

• Culture -

• Documentation

Training • Quality of Admission initial assessment – social

aspects

• Duplication -

• Over – assessment

• Respecting professionals input

Fresh Thinking

“Discharge to Assess (D2A) aims to ensure that patients who are

‘medically optimised’, and no longer need a hospital bed, are able

to leave hospital and have their assessment in the most suitable

setting – usually their own home .”

Ward

led

IDT

led

Care options at discharge align to

preferred pathways Home with Responsive services (discharge to assess (D2A) ) - IPCT & H@H - P1

Responsive Services , rehab beds – P2

Joint Community re-ablement (JCR) East Sussex – P1

Community rehabilitation services such as CNRT – P1

Nursing & Residential care Homes – P3 for new placement & P 0 return to own residence

Live-In-CARER – P3

NHS funded care ( EOL/Palliative)Community Palliative Team , Hospice – P3

Case Study 1- Group Discussion

• 83 year old lady - D&V ?Viral gastroenteritis

• Deemed MFFD on ED – transferred to medical ward

• On ward- patient stable and no further outbreaks of loose bowels or vomiting

• Mobilizing with 1 x stick on the ward with little assistance

• No therapist over the weekend

• Handover on admission – needs stairs assessment prior to discharge

Discussion:

• What pathway will your patient be on?

• Therefore, how would you approach this discharge?

• Would you refer to any community services?

Case study 2- group discussion

Mr F is a 71 year old man attended A&E– found by police wandering, confused, called ambulance.

Patient unable to provide history but A&E was able to obtain some details of patients and a neighbour

called to say they have his flat key

• Confused with AMTS (Abbreviated mental test score) 3/10

• Unable to recall what had happened

• Keen to go home

• Independently mobile without aids

• Attends to own personal care and feeds himself on ward

• NEWS 0 – plan CT head/bloods – get collateral history and NOK.

Discussion :

1. What discharge pathways will this patient be on?

2. What are the key issues from this scenario?

3. As a nurse , how would you start discharge planning? Further info? Bloods what are we looking for?

4. Who would you refer to both in hospital and community on discharge?

11

Case study 3- group discussion

• 94 yr old female – admitted on 2/6/20 with fall – vaso-vagal episode sepsis ?source. COVID

negative

• PMH – dementia , Angina , AF , TIA .

• On ward – needing 1 x to transfer – now has a new catheter for retention

• Social - has QDSX 1 POC in place

• MRFD – 4/6/20

Discussion

• Which Pathway your patient will be on ?

• Depending on the pathway, what assessment do you think is required prior to discharge?

Mrs F 96 year old admitted with dehydration-diagnosed with

CAP(Community Acquired Pneumonia) – reduced oral intake due to

dysphagia and frailty

Plan

• IV Abs to OABs

• Bloods , IVI , Sats low CTPA – NAD , O2 -? Evidence of malignancy ?throat but no further investigation due to

frailty– wean off O2

• Sats targets : 88-92 % OA

• Social – lives alone in house with stairs- 75 year old daughter main carer but lives in Worthing and been

supporting with all care such as feeding- not coping Normally mobilises short distance indoors- finds stairs very

difficulty. Boiler not working at home. Incontinent at night on ward. Reduced oral intake on ward.

Discussion:

1. Any thoughts on the discharge pathways ?

2. What are the key issues to consider with this patient, in regards to discharge planning?

3. Types of referrals & MDT to trigger and why?

4. Possible destination?