Patient care - daily dynamic discharge approach: guidance

Daily Dynamic Discharge

Forming an evidence base

The Royal College of Physicians, in 'Right Patient, Right Place - Right Time' ^[3] dictates that 'transfer of care planning should commence at the point of entry to acute care and involve the appropriate components of the multi-professional team at the earliest opportunity'.

The NHS Institute for Improvement ^[4] , concurs, and adds that 'planning for discharge with clear dates and times reduces a patient's length of stay, emergency readmissions and pressure on hospital beds, and that there are key elements when planning for discharge, regardless of whether a patient is receiving emergency or elective (inpatient or day case) care. These are:

• specifying a date and/or time of discharge as early as possible
• identifying what a patients discharge needs are and how they will be met
• deciding the identifiable clinical criteria that the patient must meet for discharge'

The institute bases its view on evidence of the commonly observed phenomena of periods of mismatched demand and capacity in hospitals. This occurs when the total number of new admissions necessitates patient discharge so that their beds become available.

The recently published Scottish Government Emergency Department Capacity Management ^[5] Guidance states that 'while the most visible and widely publicised example of pressure and patient care delays are cited as patients on trolleys in EDs, this is not just an ED problem; crowding in the ED affects various parts of the hospital in different but interrelated ways. We recognise the multi-disciplinary issues and we must do more to minimise the risk to patients on a whole-system, integrated basis.

At times of peak demand, hospitals are, to all intents and purposes, 'gridlocked' until patients are discharged ^[6] as there are often a few hours each day when admissions are likely to outpace discharges. The evidence states that moving even 30% of discharges ahead of admissions would reduce the maximum peak of bed requirement, and concludes that planning discharges before the peak in admissions is an effective way to smooth the total demand for beds.

In addition, models used to determine bed capacity management and short-stay emergency care indicate that, if a patient's discharge is facilitated by 1 pm, the hospital has sufficient capacity to carry out elective work and accommodate patients admitted as an emergency without waits and delay or breaching the four-hour emergency access standard. To realise and sustain this discharge performance indicator at ward level, nurses are encouraged to take individual responsibility and ownership of the discharge processes. ^[7]

The Royal College of Physicians' 'ward rounds best practice' guide ^[8] states that the wider multi-disciplinary team - doctors, nurses, pharmacists, therapists and allied health professionals - must be given dedicated time to participate, with clarity about individual roles and responsibilities during and after ward rounds. This includes:

• structuring ward rounds: preparation, scheduling and post-round review with allocation of tasks
• ensuring nursing involvement, sharing information about the patient and being informed of all key decisions about their care
• discharge planning: setting a date for discharge and giving patients a detailed plan on how to manage their care outside hospital.