Transcript Document 7357141

Developing a Trust wide framework to
support Nurse Facilitated Discharge
to reduce length of stay
Kate Pound and Sue Haines
Service Redesign Manager
Assistant Director of Nursing
Background and Context
Nurse Facilitated Discharge
•4 hour wait and cost improvement pressures
•Need to reduce LOS and increase pre noon
discharges
•Pre April 2007 - Informal activity, ad hoc
•Initiated medical and HCOP wards April 07
•18 week wait will have further implications for
surgery
Wards
C53
LOS data for C53
No. of
beds
Specialty specialty
Mean IP exp
Top HRGs for
LOS
mean IP ward
LOS
24
5.57
5.71
number
of
patiens
Cardiac Catheterisation
and Angiography
w ithout complications
LOS
ELOS
(PIANO)
Variance Beds lost
between due to
current
variance
LOS and
141
8
3
5
Acute Myocardial
Inf arction w /o cc
59
5
6.69
1.69
Pacemaker Implant
except f or AMI, Heart
Failure or Shock
45
6
7.17
1.17
Ischaemic Heart
Disease w ithout
intervention >69 or w
cc
34
5
5.13
0.13
Arrhythmia or
Conduction Disorders
>69 or w cc
33
4
5.12
1.12
Ischaemic Heart
Disease w ithout
intervention <70 w /o cc
705
32
5
3.51
1.49
Cardiac Pacemaker
Replacement/Revision
31
2
3.45
1.45
Acute Myocardial
Inf arction w cc
30
6
10.57
4.57
Complex Elderly w ith a
Cardiac Primary
Diagnosis
29
11
14.52
3.52
Heart Failure or Shock
>69 or w cc
29
8
10.46
2.46
Other Cardiothoracic or
Circulatory Procedures
>18
19
17
9.04
7.96
151.24
Invalid Primary
Diagnosis
17
10
7.46
2.54
43.18
15
4
2
2
30
13
9
6.96
2.04
26.52
12
13
9.92
3.08
40.04
Arrhythmia or
Conduction Disorders
<70 w /o cc
Heart Failure or Shock
<70 w /o cc
47.68
Cardiac Catheterisation
and Angiography w ith
complications
Readmission Specialty
s from ward readmission
discharges
%
%
6.5
5.61
Exp
readmission
%
4.8
The size of the task
Analysis of discharge data for:
• 28 medical wards
• 324 HRG’s were assessed
• 8,869 patients
• Later increased to 11,571 90% of patients discharged
•
•
•
•
28 surgical wards
651 HRG’s were assessed
31,972 patients
Later increased to 35,234 90% of patients discharged
Key Projects to reduce LOS
• Discharge process
–
–
–
–
Discharge reporting
Weekly discharge review
Nurse Facilitated Discharge
Ward action plans
• Discharge pathways
– Hip and Knee replacement
– COPD
– Cardiac
Ward information
Week ending
18.11.07
Wards
ELOS
Average
based on LOS
top HRG weekly
05-06
Expected
no of
discharges
per day
Ashwell
Beeston
Berman 1
Berman 2
Bramley
Carrel
Fleming
Fletcher
Fraser
Gervis
No of
beds
28
19
16
12
16
12
32
18
18
18
10.8
25
9.9
45
2
0.5
3
6
25
18
36
25
13
26
27
28
22
Tue
Wed
Thur
Fri
Sat
Sun
%
discharged
before
12:00
(weekly)
nurse
lead
disch
arges
21%
0
14
2
2
1
4
2
0
3
1
0
0
0
1
0
0
0
100%
0
2
3
2
0
0
1
0
0
0
0%
0
44.5
0.5
2
0
2
0
0
0
0
0
100%
0
8
4.9
2
18
2
2
5
6
1
2
0
78%
0
9.6
6
1
5
0
0
0
1
3
0
1
40%
0
10
11.8
3
20
4
3
1
7
3
0
2
65%
0
9.8
11.6
2
5
2
1
1
0
0
1
0
100%
5
8.1
5.7
2
13
1
2
3
1
2
1
3
23%
0
8.1
5.4
2
10
1
2
1
2
2
2
0
20%
0
8.7
14.6
9.3
2
6
13
0
3
1
3
1
1
2
2
1
2
1
2
0
0
17%
50%
0
1
Hayward Hse
Hogarth
Morris
Newell
Nightingale
Patience 1
Patience 2
Southwell
Toghill
Current no Mon
of
discharges
per week
6.8
25
3.8
5
1
37
5
8
7
3
5
7
2
49%
0
44
4
0
2
0
1
0
0
1
50%
4
8.5
5.5
1
3
0
3
0
0
0
0
0
100%
1
10
7.3
2
10
4
2
1
2
1
0
0
30%
0
9.5
9
2
17
3
3
4
2
5
0
0
29%
0
8.4
10.2
3
16
3
3
2
1
1
6
0
59%
1
8.6
7.4
2
12
2
2
2
3
1
1
1
67%
0
1
EAU
1.2
32
7
1
5
6
7
4
2
34%
ESSU
1.1
78
18
8
7
20
6
8
11
23%
0
B3/AMU
14
14
1.0
8
18
2
2
54
11
13
6
1
1
10
4
2
6
1
3
11
2
0
11
3
3
6
0
3
4
0
1
22%
55%
62%
16
0
1
14
13
1
12
2
4
0
1
5
0
0
33%
0
10
9
2
11
0
1
4
1
5
0
0
18%
7
8.7
7
3
21
6
2
2
3
4
4
0
24%
1
6.3
6
3
22
4
3
4
3
7
1
0
18%
0
8
12
3
12
1
2
2
1
4
1
1
17%
1
2
2
87
12
14
11
13
13
12
12
21%
4
10
9
3
23
0
6
6
4
4
3
0
22%
1
14
16
1
13
3
1
2
2
2
3
0
38%
0
21
17
1
11
6
1
1
0
2
1
0
55%
609
101
100
84
106
105
69
44
B47
B48
B49
C51
C52
C53
C54
D57
D58
F20
F21
TOTAL:
28
28
23
18
30
24
24
42
28
27
28
0
44
Nursing at NUH
• Discharge can be delegated to nurses
when clearly documented with
parameters, or with agreed protocols.
( NUH 2006)
• Recognition for nurse led activity
• Formalising existing practice – clinical
governance
Models of NLD
• Management Plan Model, consultant
defined and nurse facilitates.
• Protocol Led Model, patients with
specific conditions, or have had specific
procedures follow agreed care
pathways.
Process
•
•
•
•
•
•
•
Setting standards
Looking at competencies of staff involved
Flexible and responsive to local needs
Formalising existing practice
Not expansion to role
Pilot project list number of wards
Audit
Challenges
•
•
•
•
•
Medics
Documentation
Workloads
Culture and attitudes
Leadership of ward manager
Enablers
• Trust priority empowered authority of
project
• Weekly data performance monitoring
• Support / education
• Champions – in practice ward mangers
and consultants driving change
Audit and evaluation
The aim of the audit was to :
•Review the documented evidence in the case
notes of medical management plans with
specific criteria for discharges identified by
consultant medical staff
•Assess the completeness of the
documentation
•To identify what worked well and where
improvements were required
Method
– Data eg LOS, time of discharge
– Content analysis of case notes, medical and
nursing
– Questionnaires by the users eg patients,
nursing staff and consultants
80% LOS
Mean
UPL
Month/Year
LPL
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
Dec-05
Nov-05
Oct-05
Sep-05
Aug-05
Jul-05
Jun-05
May-05
Apr-05
LOS (Days)
80% LOS for Elective and Emergency Patients
Nottingham University Hospitals NHS Trust
(All Specialties, Excludes Daycases)
LOS projects
rolled out
7
6.5
6
5.5
5
4.5
4
Jun-06
Jun
Jul-06
JulAug-06
Aug
Sep-06
Sep
Oct--06
06
Oct
Nov-06
-06
Nov
Dec-06
Dec
Jan-07
Jan
Feb-07
-07
Feb
Mar-07
Mar
Apr--07
07
Apr
May
May-07
Jun
Jun-07
JulJul-07
Aug
Aug-07
Sep
Sep-07
Oct
Oct--07
07
Nov
Nov-07
-07
Apr--06
06
Apr
May-06
May
%%Discharged
Discharged
City Campus
Campus
City
% Discharged
before
12pm (Surgery/Medicine)
% Discharge
d be
fore 12pm
(Surge ry/M e dicine )
55
55
50
50
45
45
40
40
35
35
30
30
25
25
20
20
LOS projects
15
15
Month Discharged
Discharged
Month
Medicine
Medicine
Surgery
Surgery
Medicine
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
45
40
35
30
25
20
15
10
5
Feb-07
Mar-07
Apr-07
May -07
Jun-07
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Apr-06
May -06
Jun-06
Jul-06
Aug-06
% Discharged
QMC Campus
% Discharged before 12pm (Surgery/Medicine)
LOS projects
Month Discharged
Surgery
Audit reviewed all medical weekend
discharges
• 29 wards – 52 discharge, 37% were NFD (n=19)
5
3
2
1
Wards
at
ol
og
y
H
ae
m
st
ay
ho
rt
S
nd
oc
rin
E
C
ar
di
ol
og
y
ro
G
as
t
H
C
O
E
0
R
es
pi
ra
to
ry
number of patients
4
Number of nurses identified as competent to undertake NLD 2007
180
160
140
120
100
80
60
40
20
0
March
April
June
Content Analysis – Medical
Notes
Where did medical staff record NFD
• NFD proforma 42%
• Case notes 32%
• Weekend handover stickers 26%
Completeness of the medical
documentation
• Only 12.5% (n=1) of the documentation
was incomplete when a NFD proforma
was used
• When the handover sticker or the NFD
was recorded in the case notes
documentation was poor. Specific clinical
criteria poorly defined eg ‘when patient is
back to normal’
Completeness of the Nursing
documentation
• Documentation was perceived as ‘good’
when the NFD proforma was used.6 out of
the 8 patients had a record that they had
met the clinical criteria for discharge
• Only 1 out of the 11 patients had any
record in nursing documentation stating
that they had met the clinical criteria to be
discharge by nurse
Patient Questionnaires
What work well?
– Discharge was well planned
– TTOs were ready
– Able to go without seeing the Dr
– It was quick
Could be improved?
– Transport
– TTOs
Ward Managers Questionnaires
What works well?
– Improves team working
– Improves communication,verbal and written
– Improves discharge planning
– Increases the number of morning discharge
– Increases the number of weekend discharges
– Reduces the LOS for patients as fewer
patients are dependant on their doctors
reviews for their discharges
Ward Managers Questionnaires
How can we improve NFD?
– Improve Drs training of NFD
– Improve teaching / education around NFD
– More nurses to be trained in NFD
– NFD should be a integrated part of a
consultant ward round
Doctors Questionnaires
What works well?
– Right patient information to support discharge
– Improves patient safety
– Stops unnecessary registrar review
– Helps to maintain the focus on appropriate
discharges
– Increases morning discharges
Doctors Questionnaires
How could it be improved?
– Encourage junior doctors to action NFD
– Nurses need to highlight NFD more
– Senior medical staff should encourage more
NFD
– More wards need to be doing NFD
7/
8/
20
07
7/
15
/2
00
7/
7
22
/2
00
7/
7
29
/2
00
7
8/
5/
20
8/
07
12
/2
00
8/
7
19
/2
00
8/
7
26
/2
00
7
9/
2/
20
07
9/
9/
20
07
9/
16
/2
00
9/
7
23
/2
0
9/
30 07
/2
10 0 07
/7/
10 20 0
7
/14
/2
10
0
/21 07
/
10 2 00
7
/28
/2
11 007
/4/
11 20 0
7
/11
/
2
11
0
/18 07
/
11 2 00
7
/25
/2
12 007
/2/
2
12 0 07
/9/
12 20 0
7
/16
/2
00
7
Number of patients
Nurse Faciliated Discharges
250
200
150
100
50
0
Date
Data
Current practice?
Areas for development?
Future - next steps
• Maintaining momentum, embedding in
ward and team culture
• Competence of nurses - staff turn over
• Ongoing performance monitoring
• Surgery and family health
• Weekly data collection
Contact Details
Kate Pound – [email protected]
Sue Haines – [email protected]