path to home overview & education 6e and 6w...

Path to Home Overview & Education

6E and 6W Orthopaedics

What is Path to Home?

Path to Home is an integral access and flow initiative to

address acute care service delivery and proactive

discharge planning. It is based on service re-design

and integration to create seamless transitions from

admission to discharge.

Our Path to Home goal is to provide our patients,

their families and care team/service providers with

a consistent experience via standardized

processes, communication strategies, and

supporting technologies.

Path to Home Goal

Path To Home Patient Journey

Zone Transition Unit

Daily Care

-Home Care

-Supportive Living

-Long Term Care

-Mental Health

-Primary Care

Community

Decision to Admit (Disposition)

ED

In-patient Acute Unit

ED Consultation

Disposition to In-

patient BedCare Team Activities

Patient

Orientation

to UnitBed Management

Patient Bedside

Whiteboards

Restorative Care

/ Sub-acute

Review

-Communicate to family of patient discharge-Next day “Green Flag call to MD -Care management notification of transition

-Consultant sign off-I-request Pre-Booking prior to 1400h

-Preliminary ETD id. for EMS transfer by 1700-Notify/confirm next day d/c

3 Days Prior to Discharge

ADOD=2 days: Notify Patient /

Family for Planned Family Arrival

Daily Patient Experience

Breakfast/Receive Morning Meds

Assessments/Treatments

In patient team updates patient

on plan of care

Lunch/Receive Afternoon Meds

Assessments/Treatments

In patient Care Team Updated on Care Plan

Dinner/Receive Evening Meds

Patient

Information

Package

Day of Discharge

Triage ED Physician Assessment

Disposition to

Departure

Covenant Health

Path to Home Model

Allied Health and Clinical Support Services

• Lab: timely specimen collection and

results availability for d/c decision

making.• DI: order will require date/priority, test

requested, relevant history and clinical

reason/expected findings.

• Inpatient units will receive a DI schedule

for pt’s with times for next day exams• Allied Health: Prioritize work activities

based on clinical needs, ADOD, resource

requirements and availability.

• EVS: Preplanning resource requirements

based on ADODs and ETDs.• Portering: On time arrival and portering

back up systems.

Access and Flow

• CTC: centralized management and real-time

monitoring.

• Staff utilization: centralized deployment of staff based on site needs.

• Transition Services: Care Coordinator /

Social Work Dyad model..

Care Management Physician declares and updates ADOD

-Early A.M. lab results by program-Discharge order -Confirmed Patient Departure by 1100h

-Inititate room turnover-D/C checklist reviewed & given to patient /

family upon discharge

Care

Management

Care

Management

Day Prior to Discharge

Interprofessional Discharge Checklist

Zone

Transition:

Acute to

Home Care

and LTC

Daily Care

A.M. & P.M. Rapid Rounds

Patient Bedside Whiteboard Update

Bedside Shift Report

A key component to the patient experience is effective

communication between our team members (Physicians,

Nurses, Allied Health, Clinical Support

Services, patients/families, and others).

Formalizing the communication is the key strategy we use

in Path to Home.

Communication is Critical

Path to Home Model

Key Framework Components

1. Inpatient Care Team 2. Allied Health & Clinical

Support Services

3. Patient Access & Flow

Anticipated Date of Departure (ADOD)/Estimated Time of

Departure (ETD)

Lab

(Early AM Lab Results)

Care Traffic Control

(Bed Management)

Rapid Rounds Diagnostic Imaging

(Pre-Booked Imaging Times)

Staff Utilization

(ESP)

Whiteboards

Chart Order & Standardization (Flagging System/Order)

Environmental Services Transition Services

(Care Coordinator/Social Work)

Change of Shift (Bedside Shift Report)

Allied Health

Meals & Breaks (UAS) Portering EMS/IFT

(IRequest & Prebooking)

Discharge Orders/Checklists

We introduce an Anticipated Date of Discharge (ADOD) which anchors our discharge pre-planning activities

It is the foundation to all activities leading up to a patient’s discharge

Anticipated Date of Discharge (ADOD)

Physicians declare ADOD within 24 hours of admission

For Elective Surgery the ADOD will be found on:

Care Pathways

Booking Form

* The Unit Clerk/ Charge Nurse are to transcribe the date from these forms onto the patient Kardex

For Non Elective Surgery ADOD is declared within 24 hours post-operatively for trauma patients :

Physician/ designate

Date to be documented on the patient order sheet

For Medicine Off-service the ADOD will be written on the patient care order sheet as:

ADOD is greater than 5 days ADOD is less than 5 days Or actual date when known


General Principles


Booking Form

During Shift Introduction today’s discharges will be

identified

Written on the Kardex

Rapid Rounds

Written on the Bedside Shift Report Form and

communicated between the outgoing and incoming

bedside nurse during “Bedside Shift Report”

Written on the Bedside Whiteboards and communicated

to the patient

How will ADOD be communicated?

Rapid Rounds are:

Structured interprofessional rounds that bring the team together to review the patients’ plan of care

Rapid Rounds are key in creating the consistent daily communication that is imperative in providing quality and safe patient care.

What are Rapid Rounds?

• A.M. Rapid Rounds starting 0730h

• At the patient bedside with the Charge Nurse, Clinical Associate, Care Coordinator, Pharmacist

• P.M. Rapid Rounds 1300h

• Touch down at the desk with the Charge Nurse, Physical Therapy Lead

• Review next day discharges and identify any potential discharge date “Move-ups”

• Ensure Discharge Checklist is signed of for next day discharges

Rapid Rounds Weekdays

Rapid Rounds Weekends

• A.M. Rapid Rounds starting 0730h

• At the patient bedside with the Charge Nurse, Clinical Associate

• P.M. Rapid Rounds 1300h

• Touchdown at the desk with the Charge Nurse, Physical Therapy Designate

• Review next day discharges and identify any potential discharge date “Move-ups”

• Ensure Discharge Checklist is signed of for next day discharges

Discharge Activity Tracking Tool (DATT)

Family/facility notification is to be documented on the

DATT

Family/facility Notification of Next Day

Discharge

Admission Brochure

The purpose of the Path to Home

brochure is to identify key unit

processes.

All patients when admitted to the

inpatient unit will receive the Path to

Home brochure.

The nurse will quickly review what the

patient will expect as part of the unit

orientation.

This will ensure that the patient is

aware of the use and purpose of the

whiteboard, shift change process etc.

The Discharge Checklist and all discharge

information will be kept in the chart under the

“Discharge Planning” section.

At discharge the Bedside Nurse reviews the

discharge checklist and discharge pamphlets

indicated on the checklist with the patient.

During the P.M. Rapid Round the Charge

Nurse is to identify next day discharges to

ensure discharge instruction is completed.

Discharge instructions identified by the Allied

Health team member will be reviewed prior to

discharge.

Follow unit process-Discharge envelope?

Discharge Checklist

Discharge Instructions after Hip and Knee Replacement

* Follow these instructions at home. If you have any questions refer to your Alberta Hip & Knee Clinic teaching booklet or call your Case Manager, ABHK Clinic 780 433 3155 Monday to Friday.*

Post-operative teaching:

Nursing staff/PT/OT to complete and review with patients. (Refer to ABHK Booklet) Follow up:

Staple removal – Make an appointment for staple removal and to book your follow-up\appointment with your surgeon @ Alberta Hip and Knee Clinic (780 433-3155) upon arrival home immediately after discharge

from hospital. Staple removal is usually 2 weeks after your date of surgery. Surgical follow-up is at 6 weeks. *Out of town patients please check with your nurse for instructions.

Appointments: Staple removal Surgeon follow-up

Basic Wound/Incision Care: (pg 29) □ completed Aquacel: □ Not applicable: □ Handout: □ Call your case manager: (pg 34)

if your incision starts to drain or if you notice increased drainage, remove the dressing and clean the incision with sterile saline (salt) solution DAILY then apply a new sterile dressing. *Saline can be purchased from a pharmacy or homemade.*

Observe for signs of INFECTION: Chills, fever >38.5, redness, area warm to touch, increased pain

* Sterile saline solution: Boil 2 cups of water and add 1 tsp of salt. Let cool, store in a clean container. Solution is good for

24 hours.

Call your family doctor: (pg 34)

if you have diarrhea for more than 2-3 days

for pain medication refills

any other medical concern NOT related to your surgery

Hygiene: (pg 25) Keep wound dry. No tub baths but may shower. Diet: (pg 19) Follow the Canada Food Guide.

Medications: (pg 17, 18) Prescriptions provided: □

Pain medication: Type: Dose: How often: Blood thinner: Type: Blood work: Date due: □ N/A

Transfusion Tags: given: □ N/A □ Goals of Care: given □ N/A □ Belongings given: □ N/A □ Home Care referral: 780-496-1300 self □ nurse □ faxed □ Rehabilitation Review: Physio/OT information provided: □ yes □ N/A

Weight Bearing Status ___________________________ Signature (Physiotherapy)

Appropriate exercises (pg 9) _________________________________

Mobility precautions (pg 22) __________________________________

Treatment of swelling/pain ie rest, ice and elevation (pg 21)

Activities of Daily Living (pg 23-28) Signature (Occupational Therapy) I reviewed with hospital staff and understand the preceding discharge instructions: Patient Signature or Legal representative (specify) Nursing Staff: Signature

Date: Day/Month/Year

Covenant Health Logo

Patient Label

*Call 911 if you have sudden

chest pain or trouble breathing!*

If you have concerns after office hours and cannot reach your family doctor, or the ABHK Clinic, return to the Emergency Department (pg 8) of

your surgery hospital.

On discharge the written discharge

summaries should be faxed by the Unit

Clerk to the Family Physician if known.

Discharge Summary

Components of Change of Shift

Unit Assignment Sheet

•Incoming Bedside Nurse reviews

patient assignments and identifies who

to give report to

•Sign in & out for breaks(3 breaks) so

the Charge Nurse knows who is

on unit for patient safety

reasons

•Provides information such as “Clinical

Associate” and “Surgeon on Call”

•Charge Nurse Assigns HCA duties

Shift Introduction

•Completed by the Outgoing

Charge Nurse each shift

•Read by the Outgoing Charge

Nurse in the report room at shift

change

•Program information may also

be shared as part of Key

Messages

•Takes 2-5 minutes

The Inpatient Bedside Shift Report/Change of Shift provides

a formalized process for how we transfer essential patient

information safely and hand off responsibilities between our

staff members.

This allows us to:

Provide quality and continuity of patient care during

change of shift activities

Maintain a safe patient environment

Allows patients and families opportunities to participate in care and decision-making.

Bedside Shift Report

The Bedside Nurse will:

complete their bedside shift report forms for each

assigned patient

provide the Charge Nurse with any patient updates for

next shift report in order to provide the Charge to

Charge unit report

Patient Status Updates for

Next Shift Report

Bedside Shift Report Form

•Will be completed by the

bedside nurse

•Will be kept in the bedside

binder

•Ensure that the top portion is

updated and pertinent

•Patient Safety checks are

critical

We have a standardized flagging system on all inpatient

units

The “Discharge Planning” section is at the back of the

chart

Chart Order & Standardization

The Patient Bedside Whiteboard is a tool placed near each patient’s bedside to support communication between the care team, the patient and their family.

Bedside whiteboards have proven to be tools that enhance the patient and family experience.

Ensuring consistent updating and sharing of information with our patients and families allows them to become active participants in their plan of care.

Bedside Whiteboards

On admission verbal consent is obtained from the patient

prior to use of the Patient Bedside Whiteboard.

The Bedside Nurse will update each of their patient’s

whiteboards daily at shift changes and when there are

any additional changes throughout the day.

PT/OT will also update the whiteboards with any changes to the mobility.

Bedside Whiteboards

Bedside Whiteboard Example

Lab collection times will be adjusted to provide results of

next day morning routine tests by defined times.

Collections for the surgical program are:

At 0600h 1 medical lab assistant starts collections on 5E

then 6E

At 0600h 1 medical lab assistant starts collections on 5W

then 6W

Laboratory Services

The ordering physician/designate will ensure orders for all DI exams are complete and include:

Procedure requested

Date/

Time

Priority required

Clinically relevant history

Clinical Reason/expected findings for the test

Diagnostic Imaging

What the Radiologist Receives

At 1930h daily a next day Diagnostic Imaging Report will

print to the Inpatient Unit with Pre-booked Exams.

Before 2030h the Charge Nurse will verify that the times

do not conflict with other tests/appts etc.

At 0555h a complete report will print with scheduled and

unscheduled exams.

Scheduled times will facilitate patient care and

communication.

Next Day Diagnostic Imaging Report

Diagnostic Imaging Report

Diagnostic Scheduled Exam Report

•All DI Exams that have a time

between 0700h and 1700h are pre-

booked

•Times with a 0001 require more

information so they are not pre-

booked (i.e. Radiologist approval,

interventional procedure form

completed)

•If a patient has 2 or more procedures

DI will try to coordinate exams

•On the unit computer desktops a icon

for Radiology has been added to

review preparations etc.

Portering

Porters will check in with the Inpatient units on unit arrival

when transporting a patient, and notify dispatch on

completion of a transport.

Dispatch will notify sending unit if unable to send a porter

within a defined period of time.

All Pre-booked Diagnostic Imaging times require the

patient to be ready for transport 30 minutes prior to the

time given

Shift Preparation by Charge Nurse

Days Evenings Nights


(UAS) with HCA Assignment

Shift Introduction Form

1930h DI Schedule Exam

Printed/Times Confirmed

Discharge Activity

Tracking Tool (DATT)

VAX census



Shift Introduction Form


Printed/Times

/Isolation/Confirmed

Discharge Activity


VAX census



Shift Introduction Form &

DI Scheduled Exams Read

EMS Patient Transfer

Form & Documents Bundled


Posted

Discharge Activity


VAX census

Room Turnover Using Citipage

Room Stripping Prior to Citipage

Patient Room Stripping Guidelines

The patient room will be stripped within 10 minutes of notification of the patient being discharged. This must be completed before the arrival of Environmental Services and is a shared responsibility of the Bedside Nurse and or designate. Ensure the following is completed prior to Environmental Service arrival to the room:

• All equipment and supplies are removed from the patient room.

This includes IV poles and fluids, basins, measuring cans, bed pans, oxygen tubing, scissors, tape, medications, and any patient care supplies.

• All bodily fluids MUST be removed by a nurse.

Inner canister linings must be removed even if there is no visible drainage in them

• All linen/personal belongings must be removed from the patient room:

from bed

bedside table

closet

over bed table & washroom

Remember:

•Prior to requesting the

room clean in “Citipage” ensure

the room has been stripped

•With centralized dispatch

notification via text pagers

arrival of environmental services

staff to clean a bed has been

quicker

Citipage Screen

Remember:

•The “Icon” is on the desktop of the

unit computers

•From 0730-2330h enter the

number

7804010474 on the

Screen

•After 2330h call

780-445-7086

For all anticipated discharges, a request is submitted in

IRequest by 1400h on the day prior to discharge

Pre-booking of potential next day discharges is also

recommended prior to 1400h to ensure timely transfers

(better to book and cancel)

IRequest Pre-booking

For transfer requests made prior to 1400h, “Dispatch/IRequest” will

input a next day transfer time at 1700h

The Unit Clerk will check for the next day confirmed time at 1700h

The Estimated Time of Arrival will be written on the Discharge

Activity Tracking Tool (DATT) and whiteboard

For transfers that are confirmed back to a facility, the facility can

also be notified and document on the DATT

IRequest 1700h Confirmed Times

Patient Transfer Summary

Must be completed on all

transfers using a EMS/IFT crew

Please sign both pages

For next day transfers please

initiate the form when the request

is made and place per unit

process

The Care Coordinator & Social Worker Dyad Model is a

shared and complementary decision-making relationship.

The Care Coordinator and Social Worker develop plans

and make recommendations jointly that impact the patient

discharge plan.

Responsibilities and accountabilities overlap significantly,

but each partner also has his/her own focus as mutually

determined according to role definitions and distribution of

workload.

Transition Services

Principle: The right patient, in the right bed, at the right time, cared

for by the right provider

Bed management consistently anticipates bed capacity and resource needs

for the hospital through coordinated responsibilities and tasks.

The Bed Manager, Bed Coordinators, and associated teams (Staffing Office,

Environmental Services, and Portering) oversee the overall hospital

performance and ensure backup systems are activated at defined thresholds

to avoid crisis or over-capacity.

Bed management works collaboratively with all teams and stakeholders to

provide safe, appropriate, and timely placement of patients within the hospital

Bed Management Model

We will be asking for front line staff feedback throughout the Path to Home journey.

A combination of weekly audits and on unit monitoring will occur during the test phase.

Covenant Health process and outcome measurement will be used. Organizational Access/Flow

Unit and Site Level Feedback Loops

Patient Satisfaction and Workforce Engagement Scores

How will we know if we are successful?

What supports are available to you?

Questions?