Nurse led discharge: Leading the way to improve patient flow and care transfer

Since 2004 in the UK, nurse led discharge has featured and been slowly developed as part of NHS Policy initiatives to improve discharge planning. It has been a reactionary process to policy pressure rather than a clinically led development. Hence the imperative to improve discharge planning has been very broad and to this end the increasing older population, Intermediate Care and Ambulatory care have probably featured equally, as initiatives, in parallel with nurse led discharge.

Nevertheless, in 2010 nurse led discharge was revisited through a new NHS Policy in a document called ‘Ready to Go’ (Department of Health, 2010) in a bid to tackle several ongoing NHS bed capacity issues namely; to achieve a reduction in the length of patient stay, to embed nurse led services and as part of new nursing roles.

Early adopters of the concept were found to have continued their nurse led discharge, but this is best described as ‘pockets of excellent practice’ spread throughout the UK, rather than a consistent approach or change in practice. The developments that continue to present can be located in surgery (Gynaecology and day case) and specialist areas of practice where leaders of a service have embedded this new way of working (Paediatrics, clinical decision units and psychiatric services, to name a few).

Liz Lees, Consultant Nurse (acute care and doctoral student), Heart of England NHS Foundation Trust, joined us to elaborate on the topic.

Your interest in nurse led discharge has evolved over 14 years. Do you still encounter people who are anxious about the process of nurse led discharge?

In a word, yes. However, I think that the nature of the anxieties has changed over time (14 years).

For example, instead of worrying about whether it is politically correct to call ‘nurse led discharge’ – nurse led, by its name, i.e. there was a move to call it Criteria led Discharge. I argue strongly that ‘a criteria’ does NOT lead discharge, on autopilot, it is nurses (or other staff) that lead the process! So, that argument gets silly.

I realize Criteria Led Discharge is used in Australia, so please don’t be offended. Criteria will guide; intelligence will lead. Parameters are good, but people (humans) must make the judgement call on whether these are reductionist and too simplistic. I think the current anxieties are created by how best and where best to integrate nurse led discharge with existing organizational processes. For example, there cannot be two (or ore) parallel processes for discharge planning; it should be one process with a clear adjustment,, if the process is to be nurse led. I often refer people to look at some of the Theory that underpins organizational change, such as Normalization Process Theory or Critical Realism Theory. The former argues that when staff adopt an idea it gradually becomes normal, but understanding the process by which this happens is crucial. The latter argues that staff will adopt contingencies and behaviours according to the context where they work; so if nurse led discharge is not suitable or not possible in a particular circumstance it will not be adopted. So, this is where attention needs to be focused.

What indicators are used to measure the impact of this process?

Currently in the UK, we are drowning in indicators (usually these are presented as a set known as Metrics or Dashboards or Safety barometers)! I think in the early days patient satisfaction was a commonly used measure. In the acute areas where I work we use the ‘time of discharge’, because our patients are either discharged home after 48 hours stay (40%) or transferred to other in-patient wards for further ongoing care. The idea being that every hour counts especially to achieve the four-hour national target set for Emergency Care and improve the flow of patients from A&E.

In day case surgery, they have measured throughput of cases, i.e. can they clear the day-case area in a day or are patients being moved for overnight stays (when they should not be)? I have also seen the length of stay measurement given in comparison (nurse led to none nurse led areas); sometimes the length of stay (depending on specialty) is less in nurse led areas, especially rehabilitation areas, where medical dependency is less and therapeutics (Physiotherapy) are a large part of the care.

In summary, a one size approach to measures, does not fit all.

What has been the patient’s experience?

In studies of nurse led discharge where satisfaction has been the measure, patients were asked ‘if they would opt to receive nurse led care again’ and 96% of those asked said, ‘yes’. Issues only seem to arise where care upon discharge is fragmented and patients have to wait for aspects of the discharge process to be completed, i.e. transport home and medications to take home. These two aspects are no different to ‘the usual discharge process’. Patients commented upon ‘feeling involved in their care’, ‘being empowered through joint decision making’ and ‘having confidence in nurses’.

You’re currently undertaking a research project on risk assessment tools for discharge and transfer of patients. What do you mean by risk and discharge planning?

The categorisation and appropriate weighting/stratification of a problem that is regarded as a risk, in particular risks related to discharge planning have been explored from many perspectives in the discharge planning literature (Westra et al, 1998, Holland et al, 2003, 2006).

Definition:

‘Risk’ in discharge planning is a characteristic, or set of characteristics that are assessed as risky such that they may impede the discharge from Hospital or result in an unwanted outcome (Lees, unpublished Thesis work, 2014).

In addition to the key authors work, sub elements of ‘risk assessment’ have been identified from the literature review, namely;

(1) Risk and readmissions
(2) Risk and extended (perceived as prolonged) length of stay
(3) Risk and predictive use of resources post discharge
(4) Risk and adverse outcomes (excluding readmissions, e.g., functional decline).
(5) Risk and the early identification of discharge planning needs (x2 articles).

Yet, these risk assessments are quite unlike risk assessments used for condition specific illnesses, e.g., cardiac failure; by contrast, discharge planning spans an enormous breadth of interrelated aspects (Lees, 2012, Holland et al, 2006). They extend beyond physical components of risk to those that manifest in relation to social, emotional, psychological and functional aspects of a person’s life (Atwal, 2012, Wenger, 1997, Langdon et al, 2013).

How an individual and their reaction to the issues that comprise risk(s), actually experiences risk, seems to be entirely individual depending upon their perception of risk, life experience/situation. For example, whether the person has had multiple visits to hospital as a ‘last’ resort or whether the person views hospital as the ‘first and only’ solution to the risk (Lees, 2012, Holland et al, 2003).

Moreover, risk is viewed differently in different settings, and by professionals with different expertise, for example the advent of intermediate care promoted the support of independence, often at home which meant that ‘healthy risk-taking’ became popularized (Vaughan, 1999, Atwal, 2012).

In conclusion, risk is asserted to be a dynamic and evolving issue and while the literature does not explore this specifically, risk is not a static phenomenon (Rodgers, 1989).

What are the practicalities of assessing risk in discharge planning?

If you ask staff (any type of health or social care professional)who has a responsibility to assess risk in the context of discharge planning, they will groan because risk assessments are seen as form filling exercises. Nevertheless, compliance is essential for services to work collaboratively. My interest in risk arises from working in a busy acute medical setting where risk assessment is a core part of our role as nurses, in the process of admitting patients to hospital. This said, risk assessment for discharge has largely been driven from a corporate negligence perspective – such as, the introduction of discharge checklists.

I am interested in the preparation of patients for discharge and what core perspectives (in limited time) would we best to concentrate our efforts upon? And then the question arises (a subject of much debate…): who should do the assessment and what training do they need?

The evolutionary cycle of knowledge development in discharge planning has a tendency to be pragmatic, dynamic and context dependent (NHS IMAS, 2012, BGS, 2012, RCN, 2010). What is regarded, as a risk by an assessing professional may not actually represent a risk or the greatest risk for a patient when asked directly or assessed (Atwal et al, 2012). Equally, depending upon which professional (therapist, nurse, social worker) undertakes the patient assessment and the context of such, will affect the perception and scoring of risks and thereby the subsequent decisions made (Rhudy et al, 2010, Dunn et al, 1994).

For example, where some patients have adapted to a particular ‘risk’ (e.g., living alone, using a wheelchair) others maybe limited by the same issue (Grimmer et al, 2004). Additionally, the impact upon the carers to assume a new role is not well connected to the development of discharge risk assessment tool, especially for patients going home to be cared for by their families (Huby et al, 2004, Grimmer et al, 2004).

The literature explored has illuminated the difficulty of understanding what comprises risk in the context of discharge planning. I have thematically organized some aspects frequently encountered to demonstrate risk through a conceptual model, Conceptual Analysis, Walker and Avant, 2002. The model attempts to demonstrate what aspects of risk may occur before the actual problems are detected (antecedents), what is most important to the actual situation namely, being discharged from hospital (critical attributes) and what is likely to be the result (consequences). Furthermore, the antecedents, critical attributes and consequences (Rodgers, 1989) of risk are symbiotic and dovetail, which makes the assessment of risk and weighting of individual items of risk, notoriously difficult to measure (Textbox, 1).

Lees, L., analysis of risk (in relation to discharge planning):

Liz will be speaking on the topic of “Improving Patient Flow and Care Transfer through Risk Assessment” at the upcoming Transfer of Care Conference in June.