RCHSG Clinical Procedure
Title Short Stay Surgery Criteria Led Discharge
Document Registration Number
Applicable to: LBH, Ballina and Casino Hospitals
Author/s: Dr Austin Curtin VMO General Surgeon, Dr Shehnarz Salindera
General Surgery Registrar
Clinical consultation: (positions/groups)
Clinical Authority: RCHSG Quality and Safety Committee
Management Authority: Executive Director RCHSG
Issue Date:
Last Review Date: New procedure
Next Review Date:
_________________________________________________________________
Richmond Clarence Executive Endorsement & Sign Off
Approved: (signature of manager endorsing)
Date discussed & approved:
Date Signed off by RCHSG Executive Director:
_______________________________________________________________________
1. Title
Short Stay Surgery Criteria Led Discharge
2. Related Policy
3. Purpose
The purpose of this procedure is to provide a framework for the
implementation and utilisation of criteria led discharge (CLD) for short
stay surgical admissions.
4. Risk Management (Outline the possible risk being managed by the procedure
ahead of the following statements and then remove this italic type.)
Current Risk Rating:
Targeted Risk Rating:
CONSEQUENCE
LIKELIHOOD
Serious
Major
Moderate
Minor
Minimum
Frequent
A
B
J
P
S
Likely
C
D
K
Q
T
Possible
E
H
L
R
U
Unlikely
F
I
N
V
X
Rare
G
M
O
W
Y
Generic information on Risk Management for use in documents can be accessed
at: http://int.ncahs.nsw.gov.au/riskmanagement/index.php?pageid=4473&siteid=310
5.
Procedure
Efficient discharge of patients improves access to elective and emergency
surgery in High Volume Short Stay Surgical Units. Efficiency can be
achieved through the use of agreed discharge criteria for short stay surgical
procedures. To this end clinical pathways have been developed for certain
Short Stay Surgical procedures. The pathways include discharge criteria
that have been agreed upon by the interdisciplinary team (IDT). These
consist of specific criteria relevant to the surgery/procedure and the
Modified Post Anaesthetic Discharge Scoring System (MPADSS). When the
patient meets the criteria as assessed by a competent Registered Nurse
(RN) or Junior Medical Officer (JMO) they may be discharged thus avoiding
unnecessary delays.
Inclusion criteria for CLD:

Undergoing a suitable elective procedure

Expected LOS less than 48 hours

Fit and well with few co-morbidities

Coordination with community services/General Practice can
be arranged as required

Post-Operative accommodation/transport pre-planned and
support available for 24 hours post discharge.
Exclusion Criteria for CLD:

Patient assessed as not suitable for CLD.
5.1
Procedural Statement:
The consultant proceduralist will identify eligibility for CLD in consultation
with the patient/family when completing the Recommendation for Admission
(RFA) form. The proceduralist will discuss the CLD process with the
patient/family and their expectations for discharge. This will include the
provision of standardised written information. The proceduralist will
determine any changes to the discharge criteria.
5.2
The appropriate clinical pathway will be commenced at the pre-admission
assessment.
5.3
The IDT will agree on estimated date of discharge (EDD) with a maximum
of 48hrs and document this on the clinical pathway. This can be reviewed
depending on patient condition.
5.4
EDD and CLD will be clearly identified on the patient journey board.
5.5
The admitting surgical team must have reviewed all patients on CLD at
least daily.
5.6
The nurse caring for the patient will monitor the criteria for discharge and
once all criteria are met, the patient is reviewed by a CLD competent nurse
to confirm the discharge can proceed without a final medical review.
5.7
The Junior Medical Officer (JMO) must ensure a discharge summary is
completed and scripts are available before discharge.
5.8
A full set of observations must be performed and recorded within one hour
of discharge. In addition, any nursing observations that have been regularly
recorded during the previous 48 hours should also be performed.
5.9
If the CLD competent nurse is satisfied the observations are within normal
limits for the patient, and the patient has met the criteria for discharge they
may be discharged.
5.10 Parts A, B and C must be completed on the Clinical Pathway.
5.11 A list of CLD patients will be kept on the ward to facilitate auditing.
5.12 A follow-up telephone call will be made to the patient and the outcomes will
be documented in the post discharge phone call section of the clinical
pathway.
6.
Responsibilities
Executive Director
Executive and authorising sponsor of project implementation
Lead Surgical Consultant
Ensure all Perioperative Care Unit/A5/Surgical Short Stay Unit
medical staff are aware of and understand the CLD project and their
expectations.
Director Anaesthesia
Ensure all anaesthetics staff aware of and understand the CLD
project and their expectations
Nurse Unit Manager
Ensure all Perioperative Care Unit and Surgical Short Stay Unit
nursing staff are aware of and understand the CLD project and their
expectations.
Ensure all relevant nursing staff are deemed competent in CLD
Ensure CLD procedure is adhered to
Engage all disciplines in CLD during interdisciplinary rounds
CNE
Provide education to all relevant staff in use of clinical pathway/CLD
Undertake clinical competency staff assessments in CLD
Staff
Ensure a basic understanding of CLD and willingly engage and
participate in implementation
7.
Education
What
CLD process, including
competency
Orientation
Agreed processes
Relevant staff
NUM
Senior RN / Nurse in
charge
JMO
Perioperative staff
VMO staff
Responsibility
Project Lead
implementation
NUM
Lead Surgeon
CNE
Lead Surgeon
•
Nurse competency assessment must be completed prior to conducting
CLD: attached in Appendix D
8.
Monitoring, Evaluation and Review
This procedure will be reviewed 12 months after implementation.
Evaluation measures will include:
8.1
Pre and post implementation Patient and Staff Experience will be collected
using Patient Experience Trackers (PETs)
8.2






Patient Flow Data will be reviewed as follows:
Discharge by day of week
Ward Length of Stay
Surgery cancellations due to inadequate preparation
Re-admission within 28 Days/ Unplanned Readmissions
Rapid Response Calls (Between the Flags)
EEDD: Expired Estimated Date of Discharge





Clinical Pathway Audit
Utilisation and documentation
% of completed forms
% of patients discharged
% patients not discharged on CLD
% completed transfer of care checklists
8.3
9.
Key Words
Criteria led discharge
10.
Definitions
Criteria led discharge
11.
References
ACI Criteria Led Discharge Toolkit, Kate Lloyd, 2nd December 2013
12.
Acknowlegements
ACI Acute Care Taskforce
ACI Criteria Led Discharge Working Group
Acute Care Taskforce Improving the Medical Inpatient Journey
Bega Hospital (Surgical Ward)
Calvary Mater Hospital (Haematology Unit)
Children’s Hospital at Westmead
Clinical Excellence Commission
Nepean Hospital
Queensland Health
Royal Children’s Hospital Melbourne
Wollongong Hospital (Cardiology Step Down Unit and Neurology
Wards)
Auckland District Health Board
Department of Health/NHS UK
13.
Appendices
Appendix A: Day Only Template for Criteria Led Discharge
Appendix B: Overnight Template for Criteria Led Discharge
Appendix C: Transfer of Care/Discharge Checklist
Appendix D: Staff Education Tool
Appendix E Surgery Specific Criteria
Appendix 1: Checklist
Richmond Clarence HSG Procedure Development Checklist
Title of Draft Procedure:
Richmond Clarence HSG sites where document is to be utilised:
Replaces Existing procedure:
Registration Number of Superseded Documents:
yes
no
Related Legislation, Dept. of Health Policy or Circular, or other Area Documents:
Author:
Contact Details:
Implementation Requirements (e.g. equipment, training):
Review & Consultation
Consumer/carer consultation?
Brief description of consumer/carer consultation:
yes
no
HSG Committee consultation:
yes
no
Drugs and Therapeutics Committee:
Infection Prevention and Control Committee:
Blood and Blood Products Committee:
RCHSG Quality and Safety Committee:
Other:





Additional subject matter expert/s consultation?
Position title of subject matter expert/s:
yes
no
APPENDIX A: Template for up to 23 Hour Short Stay Unit
NNSW LHD
LISMORE BASE HOSPITAL
Criteria Led Discharge
23 Hour Clinical Pathway
Lap Chole/Hernia Repair
MRN:___________________________________
SURNAME: _____________________________
GIVEN NAME:
___________________________
DOB: __________________________________
Affix patient label
PART A: PRE-ADMISSION
RT B: NURSING CA
PRE-ADMISSION ASSESSMENT
Review: £ Anaesthetic £ Nursing £ JMO
£ Observations / Weight /Allergies recorded
£ Pre-Op tests as per protocol
£ Medications ordered
£ Information given re cessation of smoking
Name/Designation:
DATE:
£ Patient information given
£ Consent complete
£ Mobility Pre-op
£ Discuss discharge plan / transport home
Signature
Time/date:
PART B: ADMISSION
PROTOCOL ELIGIBILITY: Is this patient suitable for Criteria Lead Discharge Protocol?
Suitable:
Unsuitable:
£ Expected Stay < 48hrs
£ Flagged at Pre-Admission to have
significant medical issues, cardiac or other
£ Fit & well with few co-morbidities
£ Drug, Alcohol or Mental Health Problems
£ Surgeon sign off on RFA
£ Any Other Concern(s)
£ If required coordination with community
services/GP arranged
£ Post discharge accommodation/support 24 hours
arranged?
£ Patient signature to confirm ________________
PRE-OPERATIVE – DAY OF OT
£ Pre-operative checklist
£ Confirm discharge/ transport plans
£ EDD Date/Time
£ Patient has read anaesthesia information
and will discuss any questions with
anaesthetist
Name/Designation:
£ Routine medications taken as instructed
£ Baseline observations recorded
£ Post discharge GP appointment arranged
Signature
Time/date:
RTW:
POST
PROCEDURE
Tests/Surgeons
Orders:
ADLs:
Nutrition:
Observations:
Medication:
Treatment:
0–2 hours
£ Post op void
£ Diet – Light
£ I/2
Hourly
£ Regular
analgesia as
ordered
£ Antiemetic PRN
£ Observe wound
dressings
£ Check
drain output
Patient
Education:
Initial
2-4 hours
Initial
4–23 hours
£ Mobilize
£ IV therapy
ceased
£ Q2 H for 2 hrs
then Q4 H
£ Analgesia PRN
£ Independent
£ Cannula
removed
£ Q4 H
£ Check
dressings
£ Check
drain output
£ Post-op
care
£ Remove
drain
Follow
Up:
£ Discharge
medications
£ Post-op
complications
£ Wound care
£ D/C
Information given
£ Patient
aware & f/u
appt. booked
Signature Log Every person documenting in this care plan must supply a sample of their initials and signature
below
Initials
Signature
Print Name
Role
Concise and complete clinical handover provided. Should include but not limited to:
I Identification
Correct patient identification
S Situation
SAGO chart and calling criteria checked. CERS discussed
if relevant. Medication chart checked and complete
B Background
Diagnosis
Surgery/Procedure/relevant history
A Assessment & Actions
Clinical pathway checked. Variances, Interventions &
Outcomes discussed.
R Responsibility
Responsibility transfer
Recommendations
Relevant risk management discussed.
AM-PM
PM-ND
ND-AM
Date:
Nurse handing over care:
Nurse accepting care:
Initial
PART C: DISCHARGE CRITERIA (Patient must meet all discharge criteria to be discharged without
a medical review)
Anaesthetic Discharge Criteria: Modified Post-Anaesthetic Discharge Scoring System
(MPADSS)
1. Vital Signs
2. Ambulation
The patient
2 = within 20% of pre-operative value
2 = Steady gait / no dizziness
is clinically
1 = 20 – 40% of pre-operative value
1 = with assistance
fit for
0 = >40% of pre-operative value
0 = none / dizziness
discharge
3.
Nausea
/
Vomiting
4.
Pain
5. Surgical Bleeding
when the
2 = Minimal
2 = Minimal
2 = Minimal
MPADSS
1
=
Moderate
1
=
Moderate
1 = Moderate
score is ≥9
0 = Severe
0 = Severe
0 = Severe
SCORE:
Nurse Print:
Nurse Signature:
N/A
Nurse Designation:
Date/Time:
Discharge when patient is:
£ Mobilising independently
£ MPADSS score is ≥9
£ Patient Between the Flags
£ Transfer of care checklist completed
£ Tolerating light diet
£ Voiding
£ Wounds clean and dry
£ Drain removed if required
Medical review prior to discharge if:
£ Unstable vital signs/ febrile
£ Pain uncontrolled by oral analgesia
£ Vomiting
£ Bleeding from wounds / red wounds
£ Drain output >50mls Bile or Blood
I confirm that the nursing care in PART B
and criteria in PART C have been met by
the patient
Patient discharged home @____________hrs.
Patient accompanied by:
Patient did not meet criteria in PART C
and was not discharged under CLD (circle
reason)
1. Post op complication
Specify
2. Comorbidities
4. Mobilisation - late
6. Unplanned return OR
Nurse Print:
Nurse Signature:
Nurse Designation:
Date/Time:
3. Delay in IVC removal
5. Non-compliance
7. Other
Specify
APPENDIX B: Template for OVERNIGHT Short Stay Unit
NNSW LHD
LISMORE BASE HOSPITAL
Criteria Led Discharge
Overnight Clinical Pathway
Lap Chole/Hernia Repair
MRN:___________________________________
SURNAME: _____________________________
GIVEN NAME:
___________________________
DOB: __________________________________
Affix patient label
PART A: PRE-ADMISSION
PRE-ADMISSION CLINIC
DATE:
Review: £ Anaesthetic £ Nursing £ JMO
£ Observations / Weight /Allergies recorded
£ Pre-Op tests as per protocol
£ Medications ordered
£ Information given re cessation of smoking
£ Patient information given
£ Consent complete
£ Mobility Pre-op
£ Discuss discharge plan / transport home
Name/Designation:
Signature
Time/date:
PART B: ADMISSION
PROTOCOL ELIGIBILITY: Is this patient suitable for Criteria Lead Discharge
Protocol?
Suitable:
£ Expected Stay < 48hrs
£ Fit & well with few co-morbidities
£ Surgeon sign off on RFA
£ If required coordination with community
services/GP arranged
£ Post discharge accommodation/support 24 hours
arranged?
£ Patient signature to confirm ________________
Unsuitable:
£ Flagged at Pre-Admission to have significant
medical issues, cardiac or other
£ Drug, Alcohol or Mental Health Problems
£ Any Other Concern(s)
PRE-OPERATIVE – DAY OF OT
£ Pre-operative checklist
£ Confirm discharge/ transport plans
£ EDD Date/Time
£ Patient has read anaesthesia information and will
discuss any questions with anaesthetist
Name/Designation:
Signature
£ Routine medications taken as instructed
£ Baseline observations recorded
£ Post discharge GP appointment arranged
Time/date:
RTW:
POST
OPERATIVE
CARE
0 –6
hours
Initial
Initial
6-12
hours
12 – 18
hours
18 – 23+
hours
£ Mobilise
£ Independ
ent
£ Cannula
removed
£ Q4 H
Tests/Surgeons
Orders:
ADLs:
Nutrition:
Observations:
Medication:
Treatment:
£ Post op
void
£ Free fluids
£ Post op
wash
£ Light Diet
£ I/2 hrly for
2 hours
£ Q 1 H for 2
hours
£ Regular
analgesia as
ordered
£ Antiemetic
PRN
£ Observe
dressing
£ Monitor
Drain
£ Q4 H
Patient
Education:
£ IV therapy
ceased
£ Q4 H
£ Discharge
medications
£ Record
drain
output
£
£ Post-op
care
£ Check
dressings
£ Monitor Drain
£ Remove
drain
£ Post-op
complic
ations
£ Education
given
£ D/C info
given
£ Appt
booked
£ Pt aware f/u
appointment
Follow
Up:
Signature Log Every person documenting in this care plan must supply a sample of their initials and
signature below
Initials
Signature
Print Name
Role
Concise and complete clinical handover provided. Should include but not limited to:
I Identification
Correct patient identification
S Situation
SAGO chart and calling criteria checked. CERS discussed
if relevant. Medication chart checked and complete
B Background
Diagnosis
Surgery/Procedure/relevant history
A Assessment & Actions
Clinical pathway checked. Variances, Interventions &
Outcomes discussed.
R Responsibility
Responsibility transfer
Recommendations
Relevant risk management discussed.
Date
AM-PM
PM-ND
ND-AM
Nurse handing over care:
Nurse accepting care:
Nurse handing over care:
Nurse accepting care:
Initial
PART C: DISCHARGE CRITERIA (Patient must meet all discharge criteria to be discharged without
a medical review)
Anaesthetic Discharge Criteria: Modified Post-Anaesthetic Discharge Scoring System
(MPADSS)
1. Vital Signs
2. Ambulation
The patient
2 = within 20% of pre-operative value
2 = Steady gait / no dizziness
is clinically
1 = 20 – 40% of pre-operative value
1 = with assistance
fit for
0 = >40% of pre-operative value
0 = none / dizziness
discharge
3.
Nausea
/
Vomiting
4.
Pain
5. Surgical Bleeding
when the
2 = Minimal
2 = Minimal
2 = Minimal
MPADSS
1
=
Moderate
1
=
Moderate
1 = Moderate
score is ≥9
0 = Severe
0 = Severe
0 = Severe
SCORE:
Nurse Print:
Nurse Signature:
N/A
Nurse Designation:
Date/Time:
Discharge when patient is:
£ Mobilising independently
£ MPADSS score is ≥9
£ Patient Between the Flags
£ Transfer of care checklist completed
£ Tolerating light diet
£ Voiding
£ Wounds clean and dry
£ Drain removed if required
Medical review prior to discharge if:
£ Unstable vital signs/ febrile
£ Pain uncontrolled by oral analgesia
£ Vomiting
£ Bleeding from wounds / red wounds
£ Drain output >50mls Bile or Blood
I confirm that the nursing care in PART B
and criteria in PART C have been met by
the patient
Patient discharged home @____________hrs.
Patient accompanied by:
Nurse Print:
Nurse Signature:
Patient did not meet criteria in PART C
and was not discharged under CLD (circle
reason)
1. Post op complication
Specify
2. Comorbidities
4. Mobilisation - late
6. Unplanned return OR
Nurse Designation:
Date/Time:
3. Delay in IVC removal
5. Non-compliance
7. Other
APPENDIX C TRANSFER OF CARE CHECKLIST
APPENDIX D: Staff Education Tool
Competency Assessment for Criteria Led Discharge:
APPENDIX E: SURGERY SPECIFIC CRITERIA
Elective Laparoscopic Cholecystectomy- Day Only Criteria
Elective Laparoscopic Cholecystectomy- Overnight Criteria
Elective Laparoscopic Hernia Repair- Day Only Criteria
Elective Laparoscopic Hernia Repair- Overnight Stay Criteria
Elective Open Hernia Repair- Day Only Criteria
Elective Open Hernia- Overnight Stay Criteria
Discharge when patient is:
Medical review prior to
discharge if:
£ Mobilising independently
£ Tolerating light diet
£ Voiding
£ Wounds clean and dry
£ Between the Flags
£ Drain removed if present
£ Pain uncontrolled by oral analgesia
£ Vomiting
£ Shoulder tip pain
£ Bleeding from wounds / red wounds
£ Unstable vital signs/ febrile
£ Drain output >50mls Bile or Blood
Elective Vascular Angioplasty Criteria
Discharge when patient is:
£ Mobilising independently
£ Puncture site dry
£ HPU
Elective ERCP Criteria
Discharge when patient is:
£ Mobilising independently
£ Pain free
£ HPU
£ Tolerating Diet
Closed Reduction of Fracture Criteria
Discharge when patient is:
£ Normal neurovascular status
£ Good range of motion
£ Tolerating Diet
£ Pain well controlled
£ Plaster comfortable
£ Stable Vital Signs
Medical review prior to
discharge if:
£ Unstable circ obs
£ Haematoma or oozing puncture site
£ Unstable vital signs
Medical review prior to
discharge if:
£ Pain uncontrolled by oral analgesia
£ Vomiting
£ Unstable vital signs
£ Febrile
Medical review prior to
discharge if:
£ Abnormal Limb Obs or NV status
£ Pain uncontrolled by oral analgesia
£ Pain or swelling in Limb
£ Plaster abnormality
£ Nausea, Vomiting or Drowsiness
£ Unstable vital signs/ febrile
ORIF- Upper Limb- Overnight Stay Criteria
Discharge when patient is:
Medical review prior to
discharge if:
£ Normal Neurovascular status
£ Good Range of Motion
£ Tolerating Diet
£ Pain well controlled
£ Plaster comfortable
£ Stable Vital Signs
£ Abnormal Limb Obs or NV status
£ Pain uncontrolled by oral analgesia
£ Pain or swelling in Limb
£ Plaster abnormality
£ Nausea, Vomiting or Drowsiness
£ Unstable vital signs/ febrile
ORIF- Lower Limb Criteria- Overnight Stay Criteria
Discharge when patient is:
Medical review prior to
discharge if:
£ Normal Neurovascular status
£ Good Range of Motion
£ Tolerating Diet
£ Pain well controlled
£ Plaster comfortable
£ Stable Vital Signs
£ Abnormal Limb Obs or NV status
£ Pain uncontrolled by oral analgesia
£ Pain or swelling in Limb
£ Plaster abnormality
£ Nausea, Vomiting or Drowsiness
£ Unstable vital signs/ febrile