Discharge Planning Policy
Version
8.1
Name of responsible (ratifying) committee
Patient Safety Working Group
Date ratified
16 February 2012
Document Manager (job title)
Matron for Discharge Services
Date issued
27 February 2012
Review date
01 July 2015
Electronic location
Management Policies
Related Procedural Documents
See Section 8
Key Words (to aid with searching)
Simple Discharge Policy; Discharge Planning; Leaving
Hospital Policy; Going Home Policy; Patient discharge;
Interagency relations; Patient transport services; Home
care of patient; Primary care teams; Pharmacy;
Occupational therapy; Physiotherapy; Speech and
language therapy; Social services; Nutrition; Dietetics;
District nurse services; Clinically Stable Discharge Read;
PDD; CDT; IDB
Version Tracking
Version
Date Ratified
8.1
03.02.2015
Brief Summary of Changes
Author
Minor changes and extension of review date
R Davies
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 1 of 21
CONTENTS
INTRODUCTION ................................................................................................................................ 3
PURPOSE .......................................................................................................................................... 3
SCOPE ............................................................................................................................................... 3
DEFINITIONS ..................................................................................................................................... 3
DUTIES AND RESPONSIBILITIES ..................................................................................................... 5
This should be used in conjunction with the Safer Bundle which each CSC has agreed to, please
refer to Appendix D. ..................................................................................................................... 5
Complex Discharges .................................................................................................................. 11
1.1. Rapid Discharge ................................................................................................................ 13
1.2. Self Discharge ................................................................................................................... 13
1.3. Discharge from Children’s In-Patient Areas ....................................................................... 13
1.4. Discharges from Day Surgery ............................................................................................ 14
1.4.1. Physical Assessment Criteria ............................................................................... 14
1.4.2. Documentation to be provided to the patient/relative/carer ................................... 14
TRAINING......................................................................................................................................... 15
REFERENCES AND ASSOCIATED DOCUMENTATION ................................................................. 15
EQUALITY IMPACT STATEMENT ................................................................................................... 16
MONITORING COMPLIANCE .......................................................................................................... 17
Appendix A ....................................................................................................................................... 18
Discharge Checklist .......................................................................................................................... 18
Appendix B ....................................................................................................................................... 19
List of Documentation to Accompany Patient on Discharge .............................................................. 19
Appendix C……………………………………………………………………………………………………..20
The Discharge and Transfer Planning Process for Simple and Complex Discharges………………20
Appendix D…………………………………………………………………………………………………..21
10-Step Plan………………………………………………………………………………………………….21
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 2 of 21
INTRODUCTION
Portsmouth Hospitals NHS Trust (the Trust) recognises that to facilitate a smooth discharge
from care in hospital to care in the community, the discharge plan must be well defined,
prepared and agreed with each individual patient. To allow sufficient time for suitable and safe
arrangements to be made, discharge planning should begin on admission, or at pre-admission
clinics, with a predicted date of discharge being identified within 48 hours of admission and
communicated to patients and, if appropriate, their carers/relatives.
This policy is written in accordance with the NHS and Community Care Act 93/98, the
Department of Health Discharge from Hospital: Pathways, Process and Practice 2003, The
Community Care Act (Delayed Discharges) 2003, NHS Continuing Care 2004 and Achieving
Simple, Timely Discharge from Hospital 2004 (refer to Section 8). ‘Ready to go?’ - Department
of Health, 2010 and Transforming Social Care – Department of Health, 2008
The principles of discharge apply to all patients who have stayed, for however long, in the
Trust. However, there are some departments such as the Children’s unit that have specific
processes.
PURPOSE
The purpose of this policy is to set out the process requirements and staff responsibilities to
support well-organised, safe and timely discharge for all patients. It aims to fully involve
patients and their carers/relatives in the discharge process and ensure that patients receive
appropriate assessment, planning and information about their discharge and after care.
SCOPE
Patient discharge must be seen as an interdisciplinary and/or multidisciplinary issue.
Therefore, this policy applies to all permanent, locum, agency and bank staff of Portsmouth
Hospitals NHS Trust and the MDHU (Portsmouth), including doctors, nurses, allied health
professionals, social care professionals and managers. Whilst the policy outlines how the
Trust will manage effective discharge implementation it does not replace the personal
responsibilities of staff with regard to issues of professional accountability for governance.
Recognising that discharge should be working on a “7 day” system. It is expected that most
discharges will take place between the hours of 09.00 and 19.00, however in some
circumstances a discharge may take place outside of these times. This is usually self
discharges and some end of life care discharges.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that
it may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety’
DEFINITIONS
 Simple discharge: Patients with simple discharge needs make up at least 80% of all
discharges. They are defined as patients who:
- will usually be discharged to their own home
- have simple ongoing care needs which do not
require complex planning and delivery.
Many of these patients will be discharged from medical assessment units, short stay wards,
or even A&E itself as well as medical and surgical wards. Time in hospital does not
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 3 of 21
determine whether a patient has simple discharge needs. The key criterion is the level of
ongoing care required – and therefore the complexity/simplicity of the discharge
arrangements.
 Complex discharge: The remaining patients in hospital who have more complex needs (
approximately 20% ) require referral for assessment by other members of the
multidisciplinary team.
Complex discharges relate to patients:
- who will be discharged home or to a carer’s home, or to intermediate care, or to a
nursing or residential care home, and
-
who have complex ongoing health and social care needs which require detailed
assessment, planning, and delivery by the multi-professional team and multi-agency
working, and whose length of stay in hospital is more difficult to predict
Please refer to Appendix C for information on simple and complex discharges.
NHS Continuing Health Care (CHC)
Consideration for NHS CHC
Funding will need to determined for health care requirements on discharge for all patients with
rapidly deteriorating health problems.
Consent and a CHC checklist is completed when a person is medically fit for discharge and
have reached their optimum level.
The consideration for eligibility for continuing healthcare and NHS funded care needs to form
part of the discharge planning in line with requirements in the National Framework (revised
November 2012). It is essential that patients, their families and/or carers are fully engaged
throughout the process according to best practice as stated in CHC National Framework. Full
assessment for CHC. Using the DOH Decision Support Tool (DST) will be completed prior to
discharge however this should ideally not take place in the acute setting. The patient should
be transferred to an alternative setting for the assessment to be completed. There are
continuing care assessments beds available for both Hampshire and Portsmouth, were the
assessment can take place in a more suitable environment – should the client have no
challenging non compliant behaviours.
Patients with an End of Life Care Plan
This applies to patients with specialist palliative care needs, however input may be from a
single or multi-disciplinary team depending upon the place of discharge. Specialist advice
may be required to ensure prompt access to and availability of equipment or services.
An estimated date of discharge is not used for palliative care, these patients who have been
admitted as part of for end of life care and management.
Where the patient’s condition is rapidly deteriorating, the responsible clinician for the patient
can use the DoH Fast Track tool to provide evidence to support rapid response to care needs
in the community. Patients can be discharged to existing community services not provided
through CHC for end of life care support.
Discharge Lounge
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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Non-ward environment on both Trust sites which accommodates patients prior to leaving
hospital, where care needs can be completed and any communications regarding discharge
can be actioned.
Please refer to the Discharge Lounge Standard Operating Procedures for more detailed
information on the process.
 Rapid discharge and transfers to community hospitals and care homes: may be simple
or complex and usually as a result of pressures to place patients in appropriate care
environments as a result of the escalation process.
 Predicted [Planned] Discharge Date - PDD: a target discharge date to which all agencies
can work whilst recognising that the date may change according to the patients
needs/clinical status
 Self discharge: related to patients wishing to self discharge against medical advice
 ‘To Take Out’ Medicines (TTOs): medicines which the patients take away when they leave
hospital
 Out of Hours Discharge: a discharge that takes place after 1700hrs and before 0800hrs
Monday to Sunday
DUTIES AND RESPONSIBILITIES
This should be used in conjunction with the Safer Bundle which each CSC has agreed
to, please refer to Appendix D.
Medical Staff
The consultant or other appropriate doctor with delegated authority has responsibility for:
Please refer to appendix D for the 10 Step Plan.
 Determining a planned discharge date (PDD) that is communicated to the patient,
relatives/carer on admission and recorded in the patient’s notes and on the board within the
ward area.
 ALL patients to have a PDD based on medical and functional suitability for discharge
 The PDD must be realistic and set within 24 hours of admission
 Decision Maker review of patients following Board Round
 SICKEST patients first THEN potential discharges THEN new patients THEN ward round of
remaining patients
 Ensuring that the Patient Journey Board is updated and agreed post consent of the patient
and relative details being incorporated in this format
 Confirming the PDD on the first senior clinical review and ensuring that date is
communicated to the multi-disciplinary team (MDT), the patient and their relatives/ carers in
relation to Section 2’s for relevant OT or ASC needs.
 Keeping the patients/relatives/carers fully informed of their progress and treatment in order
to progress assessment needs.
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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 Liaising with the MDT on a regular basis to enable co-ordination of the agreed discharge
date.
 Ensuring any change in the patient’s PDD is communicated to the MDT/patients/relatives
and recorded in the medical notes without delay.
 Documenting clearly in the medical notes when a patient is medically fit for transfer.
Pharmacy
 Ensuring all TTO medication is prescribed at least 24 hours before discharge.
 Ward Pharmacist to be informed of any changes immediately, and patients with NOMADs to
be identified earlier if possible
 Patients transferring under End of Life (with an End of Life care plan) should have
anticipatory medications written and dispensed accordingly. Patients with a syringe driver
should have the pump logged with the hospital equipment library or MOPRS End of Life
Team for return and ensure that the process for return is followed (Large addressed padded
envelope with instructions to be sent with pump) and that medical engineering are aware of
this for return.
 Ensuring that when a patient is to be discharged with medication prescribed via injection or
an infusion pump an authorisation letter is written to the district nurse confirming details of
the prescribed medication to accompany the patient on discharge.
 Completing medical summary of treatment/ medical management plan for on-going care
needs for patients transferred to community hospital, care home or social care facility
recognising the Electronic Discharge Summary should be completed if unable and a hand
written then to ensure concise and legible.
 Ensuring the General Practitioner receives a written Discharge Summary within 24 hours of
discharge. This should be legible i.e. printed or electronic and contain the following
information as a minimum:
-
Initial reason for admission
List of investigations carried out and all available results
Summary of procedures/treatment carried out during current stay in hospital
If necessary, the summary should also include
Definitive primary diagnosis or reason for not being available
Medication commenced and to be continued following discharge, including duration
Medication changed or stopped, including reason
Management plan post discharge
Escalation plan, if problems occur (i.e. who to contact)
If using AMBER Care bundle in hospital suggest use of EPaCCS register and/or Gold
Standards Framework in the community.
- Current follow up arrangements
-
Recognising the Electronic Discharge Summary should be completed if unable due to IT
breakdown then a hand written should be legible on all copies provided.
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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 Providing a further discharge summary to be sent to the General Practitioner within 10
working days if the preliminary letter has been handwritten or the GP needs to be informed
of additional information (e.g. test results received post discharge).
 Issuing a sickness certificate for any anticipated period of incapacity.
 Reviewing the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). If a DNACPR
decision is to remain in situ/valid on discharge then the doctor (Grade ST3 or above) must
discuss this decision and the implications, with the patient or, if they lack capacity, the
patients relative/ advocate and/or main carer.
Senior Nurse /Nurse in Charge has overall responsibility for:
 Ensuring that all patients have a PDD recorded in their notes, detailed on the Visible Ward
Board and that this date has been communicated to the patient, relatives/carer, as
appropriate.
 Ensuring that systems are in place so that patient discharge is co-ordinated and progresses
according to plan.
 Ensuring that information required to plan and manage patient discharges is gathered, and
recorded accurately, especially in respect of conversations with the patient, their family
and/or carers: including the date and times of those conversations
 Continuously monitoring the discharge progress of all patients and, if necessary, ensure
positive action is taken to expedite discharges for those who are medically fit and have
exceeded their PDD.
 Any delays to patient progress (diagnostics, tertiary opinion, ASCOT) to be reviewed and
escalated as per CSC pathway ie through Matron or General Manager
 Ensuring the collection and submission of weekly delayed transfers of care monitoring
information
Ward Nurse is responsible for:
 Discharge planning commences within 24 hours of admission and that progress is
appropriate to achieve the PDD.
 The patient and relatives / carers are fully involved in the discharge planning process, their
needs and wishes are taken into account and they have at least 24 hours notices of the
discharge date, whenever possible
 Patients with complex needs are referred to the Integrated Discharge Bureau (IDB) as early
as possible
 Prompt referrals to the relevant agencies are made, using the appropriate referral criteria
and documentation and if the discharge is complex, giving the district nurse / care home
staff the opportunity to attend the ward to discuss and organise a package of care.
 Consideration of the need for continuing health care assessment for all patients with ongoing
care needs before referral to Social Services using the continuing care check list located in
the discharge planner.
 The patient’s medication is ordered 24 hours before the discharge
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 7 of 21
 Appropriate transport arrangements are made and that all pertinent information regarding
the patient’s condition is given to the ambulance service transporting patients. (e.g. Do Not
Resuscitate [DNAR] status, infections, issues regarding transferring and in respect to
manual handling). When arranging transport for discharge it is vital that the discharge
address including Post Code is confirmed and checked as correct, as it may differ to the
patient's home address. It is equally important to check that the patient can access their
destination address e.g. do they have a key, can they manage any steps at the property.
 Transport should be made via the On-Line Transport system through the current provider.
 Transport should only be provided for discharge when there are no family or friends to
transport. Transport can be booked 24/7 and all staff should access this system to book
accordingly to the patients needs and mobility status.
 If your patient is not eligible you will be signposted to a directory of alternative transport.
.
 The receiving hospital, care home or social care facility (or community nurse team, if the
patient is returning home) is notified of any known infection and the current infection control
practices in place e.g. antibiotic therapy, dressing regime, barrier nursing.
 The patient has the necessary medication, dressings and relevant information about post
discharge care.
 All arrangements and referrals in relation to discharge planning are clearly documented,
signed and dated within the discharge planning documentation
 All healthcare professionals involved with the patient are notified of any change in the
patient’s ward placement and or condition/suitability for discharge with a request for a review
as appropriate.
 To improve the quality of patient admission, discharge and transfer between health and
social care providers PHT have signed up to 10 Standards which fits with the CQUIN targets
as well as other markers. Local of seamless care – improving patients safety and experience
at admission, transfer and discharge (ADT) across the Portsmouth and South East
Hampshire area.
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The targets are:
Person Centred Approach
The process of Interprofessional – inter organisational handover
Written and verbal communication
Care Plans
Record Keeping
Risk Management
Safeguarding
Whole Systems /Partnership working
Managing and learning from Incidents
Transport and Escort
Special Considerations
To ensure all Healthcare Professionals are involved ensure the standards are recorded
within the relevant document and completed. Current documents are not inclusive of
standards as PHT to revalidate current documents which area in line with NMC and
professional standards.
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 8 of 21
 Any potential delays in discharge are referred immediately to the IDB as soon as they
become known outlining the reasons for the delay or potential delay.
 A Discharge Summary is completed by medical staff and sent to the GP within 24 hours
 All necessary information for discharge/transfer of care and management is gathered,
recorded and communicated appropriately
Integrated Discharge Bureau [IDB] will:
 Coordinate, monitor and ensure patients are discharged from Portsmouth Hospital safely,
as far as possible, in line with their planned discharge date [PDD]
 Provide specialist advice and support, including signposting to other specialist services, to
all ward and MDT staff on complex hospital discharges
 Act as a point of contact for colleagues within community hospitals, primary care, social
services and voluntary agencies in relation to people with complex discharge packages or
concerns related to the hospitals discharge procedure and process.
 Facilitate and support staff with discharge planning of patients whose care is being provided
on outlying wards
 Maintain a list of all patients that have
-
Been in hospital for longer than 14 days
Have just been declared medically fit
Have been flagged by the ward/discharge MDT as being complex and potentially
requiring the assistance of the Discharge Planning Team
 Monitor progress and advise on the discharge process including identifying and reporting the
reasons for any delayed discharges.
 Monitor, progress, advise and provide training to the organisation in regard to discharge
systems and processes including monitoring and reporting all Delayed Transfer of Care
[DTOC] issues to local commissioners/ Strategic Health Authority.
Discharge Planning Team [DPT] will:
 Provide specialist advice and support to wards and the multidisciplinary team on complex
hospital discharges.
 Act as a point of contact for colleagues within community hospitals, primary care, social
services and voluntary agencies in relation to people with complex discharge packages or
concerns related to the hospitals discharge procedure and process.
 Provide informal and formal teaching and education packages to members of the
multidisciplinary team on current issues relating to discharge planning
 Maintain an up to date database on staff trained to undertake continuing care and funded
nursing care assessments.
 Facilitate the CHC Fast Track discharge process ensuring that patients, who have been
identified by a hospital clinician that they are in a terminal phase with a rapidly deteriorating
condition, an increased dependency and who have expressed a desire to die at home, are
processed immediately and given a facilitated discharge involving MDT, community health
and social care rapid response teams, as required [NB: CHC Fast Track Process for
Hampshire has changed – refer to DPT intranet site].
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 9 of 21
Infection Prevention and Control will provide ward staff with additional infection prevention
and control advice/input as required, including for those patients who are being transferred or
discharged to another facility, including to home
Note: if MRSA screening is required before transfer to another healthcare provider, (e.g.
transfer to an alternative hospital for specialised treatment) staff should be aware that it could
take up to 3 working days for results to be obtained.
Further information regarding patients with MRSA, Vancomycin Resistent Enterococci (VRE),
CDIFF can be found on the Infection Prevention and Control departmental website
Continence Service will provide advice, support and education to wards on all aspects of
continence care: addressing such issues in a timely manner will support appropriate discharge.
Reasons for referral include:

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Reversible causes of bladder problems that have been addressed on the ward
Bladder problems e.g. urgency, frequency, straining etc.
Urinary and/or faecal incontinence
Urinary catheter, indwelling or intermittent self catheters (ISC), is causing significant
problems.
 Bladder and/or bowel diary commenced
Frailty Pathway
 A Consultant Geriatrician and Older Persons Nurse Specialist will be present on the AMU
8am-12 365 days per year. Frail patients should be allocated to the Geriatricians Post take
ward round list, and will then be reviewed by the Geriatrician and OPNS.
 The Geriatrician and OPNS will liaise with on-site community matrons, Integrated Discharge
Bureau and OPMH Liaison Team, Therapy and Social Services staff regarding the
implementation of a community response to support the patient back out of hospital into a
community setting, if appropriate, and in preference to a hospital admission. They may make
an onward referral to a community virtual ward if needed.
 Advise relatives/carers of patient condition and capabilities and to recommend action in
support of the patient’s current condition
 Facilitate rapid access to out patient assessment and diagnostic clinics and, when
appropriate, in preference to a hospital admission
Community Discharge Team
The team came into post October 2013 under CQUIN initiative.
The role of In-reach Team will be to support and facilitate the safe and timely discharge of
patients back out into a community setting. Individual patient discharge, whether simple or
complex, remains the responsibility of ward staff to coordinate and expedite.

Ensure that patients with likely complex needs on discharge are identified on admission. This
includes pursuing discussions with patient and families as early as possible in their treatment
pathway regarding likely needs on discharge so that patients experience a minimal delay
once identified as clinically stable by Portsmouth Hospital’s clinical teams.
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 10 of 21

Provide background information to wards on the known clinical and social history of the
patient and as it relates to discharge from hospital.

Provide daily support to ward teams around the planning and undertaking of effective and
safe discharge planning
Referral Pathways
The Community Discharge Team will work with elderly patients with complex needs for discharge
and will case manage certain patients out of hospital – where it appropriate for them to do so.
However, ward staff will retain responsibility for coordinating all internal discharge planning activities
including setting EDD’s, drafting TTO scripts, producing Discharge Summaries, daily liaison with
families regarding progress, booking transport and coordinating internal transfers to Discharge
Lounge
Patient referrals to Community Discharge will be via several routes.
a) Individual members of the Community Discharge Liaison Team will attend daily
whiteboard rounds to identify patients that are both complex and likely to require community
in-reach assistance and planning to leave hospital. They will contribute to the setting of the
Expected Discharge Date for all patients on the ward and will prioritise their activities to
ensure patients are able to safely leave hospital on that date.
b) From the Hospitals PTL - Patient Transfer List [IDB list] complex elderly patients will be
identified for community in-reach support as they have recently been flagged as clinically
stable by the ward via the green cross notification procedure. This process will capture
complex frail elderly patients who may have been outlied from MOPRS recently or are
currently under the care of AN Other specialty
c) Patients specifically referred to either service by ward staff via bleep or telephone to hub
offices. NB: Ward referrals for patient review the OPMH Liaison Team should be faxed to
Ext 6591 [02392 286591 - if faxing from outside the hospital]
Complex Discharges
The health professional coordinating the discharge must ensure all points relating to complex
discharges have been considered, as follows:
 The Discharge Planning Team should normally be involved in the discharge of
complex patients and can provide expert advice to ward/ staff and department
managers to:
Assist ward staff in the identification of patients with ongoing care needs.
Support ward staff in assessment of patient discharge needs and assist ward
staff in making alternative discharge plans, as appropriate
- Advise ward staff about suitability for and availability of Community Hospital
beds
- Advise ward staff about eligibility and process for accessing Continuing
Health Care funding
- Provide an ongoing programme of education around CHC matters for
ward/department staff.
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 The patient and home carer (including informal carers) must be central to the
Discharge Plan. They must be kept informed of progress on a regular basis by all
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
Page 11 of 21
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members of the multidisciplinary team (MDT). Where appropriate the patient and
carers will be invited to attend multidisciplinary meetings, discharge planning and
case conferences.
Any concerns regarding a possible Vulnerable Adult, must be advised to the senior
nurse on duty.
Any concerns regarding a patient with mental health needs or learning disabilities
must be taken into account and the discharge planning process must involve the
appropriate specialists, to ensure the discharge is appropriate and that the patient
is discharged to the right environment for their safety and on-going care needs
If the patient has been deemed not to have capacity following a capacity
assessment (refer to the Mental Capacity Act 2005 or Consent policy) a referral to
an Independent Mental Capacity Advocate (IMCA) 12 should be considered before
making any discharge plans.
When patients are transferred to a community hospital/ care home the nurse in
charge of discharge must ensure:
-
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All notes and X-rays are sent with the patient if they are being transferred to a
Community Hospital or photocopied notes if they are being transferred to a
hospital out of area. Care homes should not receive medical notes.
The doctor caring for the patient must complete a medical transfer letter and
document in the notes that the patient is fit for discharge.
The nurse in charge of discharge should complete and send a nursing
transfer letter.
The community hospital or care home should be contacted and be given a full
handover prior to discharge.
A record of what each Hospital requires with the notes and drug charts
Transport should be arranged at the earliest opportunity, with the aim that the
patient will arrive at their destination no later than 1400hrs on the day of
discharge
 Staff must ensure that information about infections and any particular care needs
related to those infections and their control are communicated when a patient
moves to the care of another organisation, e.g. community nurse, GP, nursing
home or community hospital. This information should include:
MRSA status and whether the patent is currently receiving decolonisation
treatment
- The date of the next MRSA screen
- Contact with other patients with known or suspected infections
- Any recent history of diarrhoea and/vomiting
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 Communication with care providers must be documented in the patient’s health
records and the Discharge summary must highlight any infection risks and
associated care needs.
1
2
Independent Mental Capacity Advocacy [IMCA] - Role
IMCA Referral Form
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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1.1. Rapid Discharge
Rapid discharge3 should only occur when it is essential to discharge a patient urgently
to prevent a bed crises and to achieve emergency care standards. Rapid discharges will
be directed by the Business Executive, the Operations Centre Manager or the Hospital
Duty Manager
 When rapid discharges are necessary the nurse in charge of discharge must ensure
a safe discharge, by ensuring all of the criteria for simple and/or complex discharges
are met
 Rapid discharge must not occur as a result of poor discharge planning
1.2. Self Discharge
Patients may decide to discharge themselves from the hospital against clinical advice. If
a patient wishes to self discharge:
 Staff must advise the patient why it is in their best interest to remain in hospital;
 The doctor on duty must be informed;
 The doctor on duty must inform their consultant as soon as possible;
 Any medication required on discharge must be provided. If the patient refuses to
wait for their medication then all reasonable steps must be taken to ensure that the
patient receives it, e.g. using a courier service to deliver the medications to their
domiciliary residence
 Relatives and Social Services must be contacted, if relevant;
 The patients GP must be contacted at the time the patient leaves the hospital;
 A discharge summary must be sent to the GP within 48 hours of the patient leaving
hospital;
 All actions and discussions must be recorded, dated, timed and signed in the
patient’s health records.
1.3. Discharge from Children’s In-Patient Areas
 Children are only ever admitted to hospital if the care they require cannot be delivered
in the community. They are discharged from in-patient care at the first possible
opportunity at which community services and their families are able to manage any
ongoing care required. Preparation for discharge often includes significant levels of
education to accommodate care being continued in the community by a child’s care
givers.
 Discharge planning must begin on admission with a multi-professional and family
involvement focus, to ensure all needs are met. The focus of discharge planning is
always that the safety and developmental needs of the child are maintained on
discharge, supported by and giving support to, those whom they live.
 The general processes of the Trust apply equally to children as to adults. However,
specific community services exist for the support of children requiring ongoing care.
These include:
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3
Community children’s services – medical and developmental
Peripatetic and school based education services
Children’s and adolescent mental health services
Health visiting
Community Children’s Nursing Team
Discharge Lounge – Major Incident Plan
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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Community Dental Children’s services
Social Services Children’s Team
Tertiary units and community staff
 It is essential that Communications with all relevant services is documented.
 Discharge can only be facilitated once there is agreement of the multi-professional
team that the child is medically fit for discharge and that their ongoing needs can be
met in the community. Having achieved such agreement, nurse facilitated discharge
is acceptable except in cases of children for whom there are Safeguarding concerns.
 Children for whom there are Safeguarding concerns can only be discharged by the
Paediatric Consultant responsible for the child’s episode of care, or the consultant’s
paediatric registrar. A decision to discharge the child must be documented in the
child’s medical and nursing notes, along with any plan for follow-up after discharge.
This is in line with the Laming recommendations 2002.
 When children are discharged, particularly if they have undergone an operation, it is
important that the parents, carers or guardians are aware of what they can expect
when the child gets home. To ensure the parents, carers, guardians are fully
informed a number of leaflets are provided on discharge.
1.4. Discharges from Day Surgery
 To achieve a high-quality service discharge planning in day surgery should begin
before the adult or child is admitted to the unit. Pre-operative assessment has
become essential to the development of day surgery planning. For children and adults
alike it provides an opportunity to discuss the patient’s needs and to address any
fears or anxieties of the patient, family or carer.
 Discharge planning must embrace physical, psychological and social aspects of
individual patient care. This framework can then be used to develop guidelines for
patient discharge following day surgery
 Discharge criteria should be relevant to the aims and objectives of each individual
unit. However, the following aspects must always be assessed when developing
discharge criteria for both adult and paediatric patients, irrespective of who takes
responsibility for this.
1.4.1. Physical Assessment Criteria
 Conscious level should be consistent with pre-operative state
 Cardiovascular and respiratory assessments should be stable
 Alimentary – input and output assessment should be undertaken
 Patients should be conscious and orientated
 Pain, nausea and vomiting should be minimal and controlled
 Wound site – surgical bleeding should be minimal, i.e. not requiring a dressing
change
 Mobility of the patient – patient should be able to walk at a pre-operative level.
1.4.2. Documentation to be provided to the patient/relative/carer
 Information, both verbal and written, about the patient’s recovery at home in
relation to their procedure: the patient’s and the parent’s/carer’s level of
understanding should be checked
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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 Information about any required follow-up appointments must be provided
 Any required medication to take home must be provided and any required
support and guidance on administration
 Contact telephone for emergency and continuing care
 Copy of the discharge summary
TRAINING
 The Discharge Planning Team
provides a monthly programme of education for
ward/department staff on discharge Continuing Health Care – systems and processes. This
is part of the PHT training plan with Learning and Development incorporated within the
setting direction and patient safety day.
 Discharge planning training is provided to all relevant new staff as part of the hospital’s
induction processes as part of setting direction.
 The discharge Competency is part if the generic competencies to be completed by all staff
working at PHT
REFERENCES AND ASSOCIATED DOCUMENTATION
http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/
External Ready to go? - Department of Health, 2010.
Transforming Social Care - Department of Health, 2008.
Local Authority circular LAC (DH)(2009) 1 - Department of Health, 2009.
User-led Organisations Project Policy - Department of Health, 2007.
Urgent Care Pathway for Older People with Complex Needs - Best practice guidelines.
Department of Health, 2007.
Carers (Equal Opportunities) Act 2004. Office of Public Sector Information.
Implementation of Direction of Choice of Accommodation
Achieving timely "simple" discharge from hospital - Department of Health, 2004,
Supporting people with long term conditions - Department of Health, 2005.
 Discharge from Hospital: Pathway Process and Practice: Department of Health (2003)
 Active Timely ‘Simple’ Discharge from Hospital – A Toolkit for the Multidisciplinary
Team: Department of Health
 Ensuring the Effective Discharge of Older Patients from NHS Acute Hospitals. The
National Audit Office
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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 Ready to Go? : Dept of Health
Internal




Patient Identity Policy
Discharge Planning Team [intranet site]
Transfer Policy
Standard operating procedure for safe patient use of the discharge lounge
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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10. MONITORING COMPLIANCE
As a minimum the following elements will be monitored, to ensure compliance
Minimum requirement to be
monitored
Lead
Tool
Discharge requirements which are
specific and relevant for each
patient group: 100% of discharge
requirements met
Patient Experience of discharge:
100% of user surveys
demonstrate a positive response
to discharge arrangements
Quality of documentation and
information provided to patients
on discharge from PHT: 100% of
patients have appropriately
completed documentation
Senior Nurse –
Discharge Services
Audit of discharge planning
documentation completed
by ward staff in individual
patient records
Telephone survey of
random inpatients within 1
week of discharge
Process for discharge out of
hours followed in 100% of cases
Senior Nurse –
Discharge Services
Senior Nurse –
Discharge Services
Senior Nurse –
Discharge Services
Audit of documentation for
patients leaving hospital via
the Discharge Lounge
Review of discharge check
lists to ensure process
followed to include
evidence of dialogue with
Community Support Teams
Patient Transport Service
conveyance log
Frequency of
Report of
Compliance
Annually
Reporting arrangements
Lead(s) for Acting on
recommendations
Policy Audit Report to:
 Nursing and Midwifery
Advisory Committee
CSC Heads of Nursing /
Senior Nurse –
Discharge Services
Annually
Policy Audit Report to:
 Nursing and Midwifery
Advisory Committee
CSC Heads of Nursing /
Senior Nurse –
Discharge Services
Annually
Policy Audit Report to:
 Nursing and Midwifery
Advisory Committee
CSC Heads of Nursing /
Senior Nurse –
Discharge Services
Annually
Policy Audit Report to:
 Nursing and Midwifery
Advisory Committee
CSC Heads of Nursing /
Senior Nurse –
Discharge Services
.
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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Appendix A
Discharge Checklist
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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Appendix B
List of Documentation to Accompany Patient on Discharge
 PHT ‘Leaving Hospital’ leaflet
 If patient leaving hospital via Discharge Lounge – PHT Discharge Lounge - Patient Leaflet
 X2 copy of (Electronic) Discharge Summary
 Patient Discharge Information sheet (refer Appendix C)
 Care plan – if ongoing treatment/care will be required post discharge
 Nurse Transfer of Care letter (if going to Residential or Nursing Home)
 If the patient is employed - the patient may require a sick certificate. A MED10 certificate
stating the patient has been an inpatient may be completed by the nursing staff coordinating
the discharge. The medical/surgical team will need to complete a MED3 certificate if the
patient requires time off after their hospital admission.
 A validated on discharge DNACPR agreement – if appropriate
 PHT Residential Placement Information leaflet– for >65 patient who are either:
o awaiting placement
o leaving hospital to complete Continuing Health Care application process
o leaving hospital to wait elsewhere for a vacancy to arise in nursing home of choice
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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Appendix C
Ready to Go? – Department of Health, 2010
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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Appendix D
10 Step Plan
Ready to Go? – Department of Health, 2010
Discharge Planning Policy
Version: 8.1
Issue Date: 27 February 2012
Review Date: 01 July 2015 (unless requirements change)
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