1 Criteria Led Discharge - CLD Some examples - #Red2Green #homefirst #endPJparalysis “Patients time is the most important currency in health and social

2 Why criteria led discharge - develop a compelling story#Last1000days #Red2Green #endPJparalysis “Patient time is the greatest currency in health & social care” Prof Brian 48% of people over 85 die within one year of hospital admission Imminence of death among hospital inpatients: Prevalent cohort study David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med 10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80 Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity. Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:1076–1081.

3 #Red2Green days = giving patients back their time Criteria Led Discharge will help

4 Clinical (and functional) criteria for discharge

5 Red2Green should be combined with the SAFER Patient Flow BundleS - Senior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A – All patients will have an Expected Discharge Date and Clinical Criteria for Discharge. This is set assuming ideal recovery and assuming no unnecessary waiting. F - Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10am. E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R – Review. A systematic MDT review of patients with extended lengths of stay ( 7 days or greater – ‘stranded patients’) with a clear ‘home first’ mind set.

6 Questions patients and their loved ones should know the answer toQuestions patients and their loved ones should know the answer to. Informed patients will help CLD e.g. enhanced recovery programme. 1. Do I know what is wrong with me or what is being excluded? This requires a competent senior assessment and discussion. 2. What is going to happen now, later today and tomorrow to get me sorted out? The ‘inputs’ needed (diagnostic tests, therapeutic interventions etc.) with specified timelines. 3. What do I need to achieve to get home? The ‘clinical criteria for discharge’ (CCD), a combination of physiological and functional parameters. ‘Back to baseline’ is rarely a useful phrase. 4. If my recovery is ideal and there is no unnecessary waiting, when should I expect to go home? This is the ‘expected date of discharge’ (EDD) which should be set along with the CCD at the point of admission.

7 Nurse Facilitated Discharge Project- Neutropenic Oncology PatientsObjectives To reduce the amount of time oncology patients are in hospital (LOS reduction) To increase the number of patients we can discharge home before lunch (Pre-noon) To produce a competency framework to support Nurses knowledge and skills To design and implement a criteria led proforma to determine those suitable for this method of discharge To improve discharge planning through board rounds (exemplar board rounds) Key Principles Not target focused, no KPI’s set on amount of patients each ward discharges via NFD Buy in from all members of multidisciplinary team (including Consultants) Only nurses who meet the competency criteria can undertake NFD Use patient stories of what it means to them to get home for their lunch to motivate staff Involve patients/relatives and careers in the process from the start

8 Nurse Facilitated Discharge- ResultsStart of the project

9 For further information please contact…Scott Purser- Deputy Divisional Nurse- Sharon Leighton- Project lead- Annie Walton- Matron Oncology-

10 Criteria led dischargeSouth Warwickshire NHS Foundation Trust experience Dr Jyothi Nippani

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12 Criteria Led DischargeSupported by Director of Nursing Standard operating policies ratified in the governance committees before being rolled out in specific areas Well established on Day Surgery Unit where it is routine practice and delivered by qualified nurses Also in 23 hour, Surgical wards, Urology, Gynaecology, Orthopaedic wards and some medical wards Criteria for discharge are multidisciplinary and can be ANP led discharge on frail patients. Clear instructions on when to escalate and seek advise

13 Examples of clinical criteria given by teamsHome if or when (can be a combination of any of these) Bowels opened Passing urine –or residuals of xxxx Eating and drinking Mobilising without supervision Pain under control Wound looks clean –(no ooze, swelling or redness) Apyrexial for 24 hours Bloods (U&Es, Hb etc) are normal or improving Stoma nurses happy TTOs done NEWs of xxx or less Pt asymptomatic with lying /standing drop of BP Changed from IV to oral treatment and stable for 24 hours

14 Safety-netting methods used at discharge (varies with each team)Verbal discharge advice given by nurse Speciality advice leaflets given on what to expect and care at home Access to a point of contact in the hospital for queries, advise and reassurance – (not to default to GP or ED) Telephone calls to patient to check if they are OK after a GA Nurses can access consultants /team out of hours for any queries Nurses can book into urgent consultant OP slots/ hot clinics

15 Advantages Patients can be discharged timely and earlier on in the morning Nurses can plan the transport etc. accordingly Patient flow is maximised Frees up doctors

16 Sandra Steeples – Discharge Manager & Red2Green LeadPlanning ahead the Southend Way with the Clinical Criteria for Discharge sticker 528 beds by the sea The longest pier! Good DTOC rate Good MDT working Poor weekends discharge rate Struggle to plan ahead for EDD`s Late decisions on discharges Sandra Steeples – Discharge Manager & Red2Green Lead

17 Benefits of CCD Many patients stay in hospital unnecessarily “waiting for something to happen”. This is often because there is no clear idea of what is needed to leave hospital. The senior Dr will know when the patient can go home – he / she just needs to share that knowledge! If the Dr documents clear clinical criteria for discharge, then discharge will happen! Patients benefit from improved care co-ordination Patients benefit from a good clinical plan with a timely planned discharge If the team understand what needs to happen to get a patient home, it is more likely to happen Benefits to the Trust Real time accurate bed management Improved patient flow through the organisation Meaningful information for capacity and demand to be managed Less complaints about delays Happier patients

18 How Southend introduced CCDStarted with training sessions to Drs on improving patient flow and the importance of the CCD Developed simple guidance on how to document CCD Developed a `sticker` to go in the notes so that the CCD was visible, and the Drs felt they were adding value! Trialled the sticker on one ward with a champion Drs ! Rolled out the sticker on Fridays to help weekend flow. Stickers provided to all wards. Matrons pushed the stickers across their areas

19 Clinical Criteria for dischargeThis sticker is inserted in medical notes to allow safe discharge once patient is medically stable. Clinical Criteria for Discharge (CCD) written on (DATE)  …………………………/ Aim home on (DATE) ………………………… If the following safe clinical criteria is met the patient can be safely discharged home with no further medical review required. If patient deteriorates the patient should be escalated to the appropriate team 1. 2. 3. 4. Name of Consultant in charge of care: ____________________________________ Name of Dr planning CCD: PRINT _________________________SIGN ___________________________ IF THESE CRITERIA ARE NOT MET BY (DATE) : …………….  The patient must be reviewed by the Medical team  ………… Date: ___________________Time:__________________________________ Nurse in charge is signing to agree that the above criteria is met and patient will be discharged. Print Name ________________________           Signature_________________ Date: ___________________Time : __________________________________

20 What we found with the CCD trialWard managers pinned the stickers to every set of notes to `encourage` the medical staff to write down `what was in their heads to plan a patient home` We increased weekend discharges that weekend by 52%. The clinical site team reported that identifying medically optimised patients became much clearer with the use of the criteria. Ward staff reported that they were able to plan discharge earlier in the day as they now knew what they were working towards. The sticker improved visibility of the plans. We progressed to using it immediately before a BH weekend, and flow was greatly improved. We are currently embedding our vision that this becomes BAU every day for every patient. We have a way to go, but have proved the sticker helps increase earlier discharges.

21 The Problem – UHNM Dr Rhys BenyonLack of junior doctors on ward Short Foundation and CMT rotations (4months) lead to poor department organisational memory Overall discharges from the ward were slow and ‘flow’ sluggish Junior doctors if available have with very limited experience and very limited organizational understanding Many patient who could be discharged to rapid access clinics are admitted unneccesarily With the increasing sub-specialisation of medicine acute physicians struggle to manage the wide range medical problems resulting in multiple referrals to sub-specialities for in patient opinions leading to delays in decision and treatment

22 UHNM solution Cardiac nurse practitioners on the ward coordinating discharges and encouraging flow Experienced senior nurses recruited from Cardiology wards – Average 15 yrs cardiology experience 6 months course in generic health assessment Prolonged specialty specific training program for 18 months with consultant mentor throughout Prescribing course for allied health professionals – at least 60 hours of 1:1 consultant training for each team member

23 UHNM solution Rigorous assessment processNationally recognised cardiology specific masters program MINICEX’s as designed for SPR assessment Patient surveys 360 appraisal Team reviews

24 UHNM summary The major gain will be when the cardiac nurse practitioners can complete the discharge letters and this requires them to have been through a nurse prescribing course. 6 of them will complete this in September 2017   Departmental view - we can no longer rely on the SHO grade. 4 vacancies out of 10 slots has been the norm for the last 18 months. The deaneries simply cannot fill their slots. We are going to try to move to a hybrid of specialist nurses and junior doctors in about equal numbers. The feeling from everyone including the junior doctors is that this is a great success when we piloted it for shifts on the ward.

25 You either believe you can or you can’tSummary / Key Points Needs to be MDT Involve patients – the 4 questions Development of roles to ensure competency, merge boundaries – not just nurse led Use multiple PDSAs & improvement measures (we are still poor at this) to prove the positive effect e.g. reduced LOS, earlier discharge time and reduced complaints Use patient stories focussing on saving patients time Link to the SAFER patient flow bundle and Red2Green days Develop a proforma Link to 7 day services – increase weekend discharge rates Don’t aim for perfection – start somewhere You either believe you can or you can’t