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Paving the way for safe discharge

A nurse-led ward at Yeovil District Hospital NHS Foundation Trust has supported patients who are ready for discharge but cannot be found community places. Work on the ward is rewarding and eases pressure elsewhere in the trust. The iCare team was recognised in this year’s Nursing Standard Nurse Awards and named runner-up in the Enhancing the Experience of Care category.

A nurse-led ward for patients who are medically fit for discharge but unable to leave hospital because of pressure on community places has reduced the time patients spend in hospital.

Some patients transferred to the ward while waiting for a care home place have improved so much that they have been discharged to their own homes instead, and fewer patients have needed rehabilitation at community hospitals.

The achievements of the iCare team at Yeovil District Hospital NHS Foundation Trust were recognised by the Nurse Awards 2015 when the team was named runner-up in the Enhancing the Experience of Care Award, sponsored by NHS England.

Associate director of nursing, Maddie Groves, suggested to senior colleagues that they bring all medically fit patients together as one cohort in a nurse-led environment where resources could be focused on rehabilitation and preparation for appropriate discharge.

This was because of the growing number of patients who were fit for discharge but still in hospital because of pressure on places in the community to care for older people.

Associate director of nursing Maddie Groves: ‘The focus is on one shared goal – a return to maximum independence’

Inevitably, medically fit patients on acute wards received less attention from staff than those who were seriously unwell, which delayed and compromised their rehabilitation. In addition, the hospital leadership was pressing for more timely discharges, while nurses were highlighting their increasing workloads.

Fostering an atmosphere of normality

The medically fit for discharge ward at Yeovil Hospital not only offers its patients intensive rehabilitation, but also a wide range of therapeutic activities, including visits by dogs.

‘This improves patients’ quality of life,’ says associate director of nursing Maddie Groves. ‘It is especially important for patients with dementia.’

Ward staff work closely with the dementia team, which regularly holds sessions for all patients, including dance and massage sessions. ‘It is noticeable how therapeutic these are and the patients have given positive feedback,’ says ward sister Alison Dowd. ‘All staff are urged to bring forward ideas so we can discuss them as a team.’

Patients are guided to be as independent as possible and to work towards their own recovery to enable them to go home. They are all encouraged to get dressed in their day clothes and sit out of bed as much as possible. Meals are served round a dining table. This has seen a reduction in wastage and an increase in the amount of food consumed.

‘It has also helped with hydration and this has been noticeable with our patients who are living with dementia,’ Ms Dowd says. ‘They appear to eat and drink more when sitting with people who are eating and drinking well too. This also encourages functional mobility and socialising skills. Mealtimes are more relaxed and not rushed.’

Ms Groves explains: ‘We wanted to create a ward in which care of these patients became a priority, where they were offered extensive rehabilitation before safe and appropriate discharge. At the same time the nurse-led ward has released medical staff to concentrate on the acute ward.

‘I realised that cohorting patients with teams that could manage care would focus on one shared goal – a return to a level of maximum independence. What we do is truly holistic nursing, but that’s difficult on a busy acute ward.’

Ms Groves approached staff about secondments to the ward and discussed the idea with colleagues, including those in physiotherapy, occupational therapy, dementia care, social services and pharmacy.

A 30-bed ward was designated for medically fit patients. A multidisciplinary team was assembled and a protocol developed to define who would be transferred and how they would be managed on arrival. A transfer process was established and a patient information leaflet produced.

The multidisciplinary team includes a band 7 senior ward sister, a band 6 sister, band 5 nurses, two assistant practitioners, healthcare assistants, occupational therapists, physiotherapists and social workers.

‘The ethos of the ward is to have a multidisciplinary approach that ensures all patients have a safe discharge home,’ explains ward sister Alison Dowd. ‘It is nurse-led, with no routine visits from medical staff, but they are easily contactable if required. Patients have to have completed their episode of acute care and require no further medical input. Their only care needs should be nursing or therapy input.’

Discharge checklist

At first, medical staff and consultants were concerned they would not review the patient every day. ‘We overcame this by making sure they understood the ethos of the ward and commented on and then signed off procedure and admission policy, as well as the policy on deterioration,’ says Ms Groves.

‘Now there is a “medically fit for discharge” checklist that has to be completed before the patient is added to the transfer list. Physiotherapy, occupational therapy and medical teams complete the transfer summary. This ensures continuity of care.’

She says it was initially impossible to transfer all the patients suitable for care on the new ward because the hospital was full, and so patients were waiting several days for a place. This has been resolved – and another six beds added – so the transfer wait is now no longer than 24 hours.

Heathcare assistant Betty Beasley and discharge facilitator Michelle Ivens with a patient.

Ms Groves says: ‘At first we went round the wards and reviewed patients for transfer, but now the nurses know when patients reach the appropriate stage and write in the medical notes that they can be transferred.’

Music and movement teacher Rachelle Green and a patient work together

Issues such as staffing levels have been tweaked, the discharge facilitator is now used more effectively and social workers are available to nurses and patients.

‘Ward teams are much slicker at managing discharge for those who have had the rehabilitation they need,’ says Ms Groves.

The team gets together to start or agree discharge planning and continuing rehabilitation places when the patient is transferred. The senior nurse walks the ward every day to help expedite discharges.’

‘In the first three months, the average length of stay fell from 14 to 11 days despite the winter pressures, and that has now fallen by another two days,’ Ms Groves says. ‘In some cases, patients have continued their rehabilitation while waiting for their care home and we have, in fact, discharged them back to their home.’

Close working

Ms Dowd adds: ‘This is primarily a positive outcome for them and their families, which is the most important factor. However, it also ensures resources are available in care homes for those who need them.’

Close working with other healthcare professionals has given opportunities to share skills.

‘We are continually teaching each other,’ says Ms Dowd. ‘The physiotherapy team takes opportunities to teach staff how to mobilise patients safely so their mobility can be improved when the physiotherapy team is not on the ward. It is also essential that patients are functionally independent. This is aided by joint working.’

Director of nursing and clinical governance Helen Ryan is proud of the team. She says: ‘This small, dedicated team has transformed the discharge process for our patients. It was done at short notice during the height of the winter pressures and with little time to plan. However, Ali and the team took the initiative, using their experience and judgement to create a positive, patient-centred care environment. Everyone who has visited this ward has been impressed.’

Patients rate their care highly – something noticed by the Nurse Awards judges – and nurses working on the ward like it, too. ‘This is holistic nursing,’ says Ms Groves, who is developing a new specialty based on preparing medically fit patients for discharge.

‘Nurses have permission and time to give good care, with opportunities to spend one-to-one time with patients and their families. It helps nurses develop their decision-making skills as they work as autonomous practitioners.’

Transfer protocol

Consultant assesses patient as medically fit.

Ward nurse completes medically fit for discharge (MFFD) criteria checklist.

Patient is added to transfer list.

MFFD discharge facilitator or sister visits patient, meets family/carers, and provides information.

Physiotherapist/occupational therapist/medical team completes summary transfer.

Pharmacy completes medication for discharge.

Patient transferred to ward and met by physiotherapy/occupational therapy to agree rehab plan.

Seen by ward social worker to complete discharge plan.

Ms Dowd agrees. ‘The ward has a relaxed atmosphere. The patients thrive. We all work together to achieve a common goal – discharge the patient safely as soon as possible. I find it extremely satisfying and enjoyable’.

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