policy & procedure for discharge practices version 6

Policy & Procedure for Discharge Practices Version 6.0

Policy Statement: This policy is support the discharge of adult’s patients across HEFT, incorporating patients who self-discharge and the development of nurse/therapy facilitated discharge

Key Points: Quick Reference Guide • Definitions of simple/ complex discharges (FAQ’s) pg 6-8 • Use of Estimate Date of Discharge (E.D.D) see Key Principles of Effective Discharge pg 12 • Discharging patients without Mental Capacity (use of IMCA) pg13 • Providing written information to Care/Residential Homes (a copy of ongoing care plans to

accompany patients) pg 14 • Patients who wish to self discharge (who should be informed, how to manage patients who do not

have mental capacity and wish to self discharge) pg 15-16 • Patients who refuse to be discharged (how to manage patients or their relatives who refuse to

accept discharge arrangements to either their own home or care/ residential placements) pg 16 • Discharge Medication/TTO (who can collect medication, why medication cannot be placed in

envelopes, use of taxi’s to send medication out) pg 17 • Responsibility of discharging patients out of hours (identification of appropriate adult to meet the

patient, what constitutes out of hours discharge) pg 18

Key Changes:

• Choice Policy. • Invite to Social Work, Revised CHC Guidelines are the most significant changes and support will

be given by the central point and CDNs staff.

Paper Copies of This Document

• If you are reading a printed copy of this document you should check the Trust’s Policy website (Hhttp://sharepoint/policiesH) to ensure that you are using the most current version.

Ratified Date: 21st April 2011 Ratified By: Professional Governance Nursing Forum Review Date: 21st April 2013 Accountable Directorate: Corporate Nursing Corresponding Author: Head of Capacity & Corporate Nursing


©Heart of England NHS Foundation Trust 2007 View/Print Date: 22 September 2011 of 46

Meta Data Document Title: Policy & Procedure for Discharge Practices v6.0 Status Approved

Document Author: Ian Donnelly Head of Logistics & Capacity, Margaret McLaughlin Lead Nurse for Complex Discharges, Maria Mackenzie Lead Nurse for Clinical Innovation & Professional Practice maria.mackenzie@ heartofengland.nhs.uk

Source Directorate: Corporate Nursing Date Of Release: 1st June 2011 Ratification Date: 21st April 2011 Ratified by: Professional Governance Nursing Forum Review Date: 21st April 2013 Related documents Choice Policy 2009

Infection Control Policies 2009 Nursing & Midwifery Council Code of Conduct The Scope of Professional Practice

Superseded documents

Discharge Policy (2008) v5.0 Self-Discharge Policy (2005) v1.0

Relevant External Standards/ Legislation

Achieving Timely Simple Discharge from Hospital (Department of Health) 2004 The NHS & Community Care Act 1990 The Community Care (Delayed Discharge Act) 2003 Sitrep Definitions & Guidance 2010 Continuing Healthcare Framework 2007 / Revised 2009 New CHC Checklist 2009 Mental Capacity Act 2005 NHS Institute for Innovation 2010 High Impact Actions, Ready to Go No Delays. DH 2010 Ready to Go? *Note, this is not an exhaustive list.

Key Words Discharge/ self discharge/



Revision History Version Status Date Consultee Comments Action from

Comment 2 October 2006 Rosemary Gardiner Update

3 April 2007 Rosemary Gardiner HEFT & GHH

4 April 2008 Rosemary Gardiner HoEFT

5 July 2008 Rosemary Gardiner HoEFT

5.1 November 2010

Deputy Chief Nurse & Corporate Nursing

Review action cards to incorporate in main body of policy to include both self-discharge and nurse / therapy led discharge. To include FAQ page. To agree an exec sponsor for the policy. Have suggested the policy is under nursing

5.2 Draft January 2011 Matrons Business Meeting, Lorraine Longstaff – Matron for Safeguarding, Liz Lees – Consultant Nurse for Acute Medicine, Mary Ross – Clinical Director for Therapies, Group Medical Directors, Peter Moon – Governance Improvement Manager, Ian Donnelly – Head of Logistics & Capacity, Margaret McLaughlin – Lead Nurse for Complex Discharges

Updated Q/A added in patient information leaflet, section on TTO’s and Documentation provided at point of discharge

5.3 Draft March 2011 Rachel Blackburn Compliance Manager Safety and Governance

To create a more defined process for monitoring

Table added

5.4 Draft March 2011 Matrons Business Meeting, Lorraine Longstaff – Matron for Safeguarding, Liz Lees – Consultant Nurse for Acute Medicine, Mary Ross – Clinical Director for Therapies, Group Medical Directors, Peter Moon – Governance Improvement Manager, Ian Donnelly – Head of Logistics & Capacity, Margaret McLaughlin – Lead Nurse for Complex Discharges

Add in reference list, review FAQ’s, Review section7.8 re discharging pts to residential /care homes

Reference list added. FAQ’s reviewed by Lead Nurse for Complex Discharge Section 7.8 reviewed and amended



Table of Contents 1. Frequently Asked Questions to Support Implementation of New Discharge Policy................................ 6 2. Circulation ............................................................................................................................................... 9 3. Scope ...................................................................................................................................................... 9

3.1 Includes ............................................................................................................................................ 9 3.2 Excludes .......................................................................................................................................... 9

4. Definitions ............................................................................................................................................... 9 4.1 Simple Discharge ............................................................................................................................. 9 4.2 Complex Discharge or Transfer of Care .......................................................................................... 9 4.3 Complex Discharge Nurse Specialists (CDNS) ............................................................................... 9 4.4 Continuing Healthcare 2007 (Revised 2009) ................................................................................. 10 4.5 Continuing Healthcare Assessments ............................................................................................. 10 4.6 Social Work Referral / Invite .......................................................................................................... 10 4.7 Care Package ................................................................................................................................ 10 4.8 Residential Care Home .................................................................................................................. 10 4.9 Out of Hours Discharge ................................................................................................................. 11 4.10 Self-Discharge ............................................................................................................................... 11 4.11 Nurse or Therapist Facilitated Discharge ....................................................................................... 11

5. Reason for Development ...................................................................................................................... 11 6. Aims and Objectives ............................................................................................................................. 11 7 Standards ............................................................................................................................................. 12

7.1 Key Principles of Effective Discharge (for all discharges) .............................................................. 12 7.2 Patient Groups ............................................................................................................................... 12 7.2.1 Simple Discharge ................................................................................................................... 12 7.2.2 Complex Discharge ................................................................................................................ 13 7.3 Discharge Medication/ Tablets to Take Out (TTO) ........................................................................ 17 7.4 Documentation for Discharge ........................................................................................................ 18 7.5 Provision of Hospital Transport ...................................................................................................... 18 7.6 Equipment Required for Home Discharge ..................................................................................... 18 7.7 Discharging Patients Out of Hours ................................................................................................. 19 7.8 Nurse / Therapist Facilitated Discharge ......................................................................................... 19

8. Responsibilities ..................................................................................................................................... 20 8.1 Individual Responsibilities .............................................................................................................. 20 8.1.1 Chief Executive ...................................................................................................................... 20 8.1.2 Chief Nurse ............................................................................................................................ 20 8.1.3 Matrons .................................................................................................................................. 20 8.1.4 Senior Sisters / Charge Nurses .............................................................................................. 20 8.1.5 Medical Staff .......................................................................................................................... 20 8.1.6 Nursing Staff .......................................................................................................................... 21 8.1.7 Multi-Disciplinary Team .......................................................................................................... 21 8.2 Board and Committee Responsibilities .......................................................................................... 21 8.2.1 Approval Committee............................................................................................................... 21 8.2.2 Ratifying Board and Committee ............................................................................................. 21

9. Training Requirements ......................................................................................................................... 21 10. Monitoring and Compliance .................................................................................................................. 22

10.1 Monitoring ...................................................................................................................................... 22 10.2 Compliance .................................................................................................................................... 22

11. Implementation ..................................................................................................................................... 22 12. References ........................................................................................................................................... 22



13. Appendices ........................................................................................................................................... 23 Appendix 1: Patient Information on Discharge .......................................................................................... 24 Appendix 2: Pre Discharge & Discharge Checklist .................................................................................... 27 Appendix 3: Criteria for Discharge Lounge ................................................................................................ 28 Appendix 4: NHS Continuing Healthcare Checklist ................................................................................... 29 Appendix 5: Best Interest Checklist ........................................................................................................... 35 Appendix 6: Self-Discharge Notification .................................................................................................... 38 Appendix 7: Choice Directive / Delayed Transfer of Care ......................................................................... 39 Appendix 8: Home Oxygen Order form ..................................................................................................... 41

14. Attachments .......................................................................................................................................... 23 Attachment 1: Equality and Diversity - Policy Screening Checklist ........................................................... 44 Attachment 2: Equality Action Plan/Report ................................................................................................ 46



1. Frequently Asked Questions to Support Implementation of New Discharge Policy Q. What are the key changes within the new Discharge Policy, and where do I find it? A. The Discharge Policy can be found on the Trust intranet page under Policies and Procedures.

The key changes involve combining self-discharge and nurse/therapist led discharge into one policy. The policy also provides guidance on delayed transfers of care and Patient Choice

Choice Policy:

(i) If a patient is referred to Social Services for care in the community – letter 1 is issued by the Discharge Office following a Social Work assessment outlining the care options available and advising them of the interim care facility, this could be nursing or residential beds.

(ii) If a patient is delayed in hospital, then letter 2 is sent to the patient / relatives advising

them of the need to have made the necessary arrangements for discharge (for example: at home – environment not ready, nursing / residential – home not identified), etc.

(iii) This will be followed by letter 3 which is issued from the Chief Executive’s Office informing

the patient / relatives that they are expected to leave the Trust and the patient will be discharged (3 nursing homes will have been identified by the Trust with vacancies). The relatives have the choice, or the patient is discharged to a safe place until the agreed final destination becomes available.

Support will be available from by the central point and Complex Discharge Nurse Specialist staff.

Q. What are my responsibilities as a nurse to safely discharge a patient from our Trust? A. To ensure the transfer of care is safe, all necessary agencies are alerted, all documentation is

fully complete, family are aware, all risk assessments have been completed, medication is supplied and the patient / relatives understand the timings and necessity of concordance to medication / treatment regime. The ultimate aim is to ensure that the discharge is timely and safe with the best interest of the patient at all times.

Q. What is the difference between a simple and a complex discharge? A. Simple Discharge: The patient can be discharged home, or to another place, without any multi-

agency support. Usually executed at ward level without the need for funding. E.G., a care package may be restarted but usually not increased as this would require a review of funding or referral to private agencies.

Complex Discharge: The patient has care needs, may need placement, needs specialist

funding, or specialist nursing care. Best described as having needs that require the intervention of other agencies to support future health and well being and provide effective continued quality of life after discharge. This will ensure the discharge from the hospital is safe. End of life care is part of this complex discharge area with set protocols and time limits to prevent delays in discharge and final place of choice to be accessed within 48hours



Q. How do I refer my patient for ongoing social care? A. Try to give Social Services as much notice as possible by raising an invite to social care

electronically from Electronic Patient Handover (EPH) this can be done as soon as you know there may be a need for social care. When the patient is medically fit you must carry out a Continuing

Health Care checklist (CHC) if this does not indicate that the patient needs a full CHC assessment you can issue a section 2 to confirm to the Social Worker that the patient is now medically fit for assessment. A Social Worker is expected to carry out all social work assessments within 3 days of a section 2 being raised.

Advice can be given by ringing Central Point on extension 41622. Q. How do I refer my patient who needs physiotherapy, occupational therapy, speech and

language therapy or dietetics? A. Refer through your ward MDT to Physiotherapy, OT or SLT. Dietetic referrals are now electronic

and are made via EPH. Other therapies will be using the electronic system in time. If you have any problems contact the relevant department for further information.

Q How do I refer my patient for on-going rehabilitation that cannot be supplied by the ward? A If your patient needs intermediate care, enhanced assessment or rehabilitation on one of the

wards within HEFT, please contact your ward allocated therapist who will advise you on the appropriate form to complete.

At GHH the pilot Transfer of Care link on the EPH is the quick and easy way to refer your patients to the clearing house where all the ongoing health care teams can pick up the referrals for South Staffordshire, Birmingham and HEFT internal beds.

Q. How do I refer my patient who has ongoing health care needs? A. Via the same process as described above for ongoing social care, you will complete a CHC

checklist which can be found on the intranet home page, under ward census. If the patient meets the checklist it will be sent to the Complex Discharge Nurse Specialists (CDNS). You are to immediately contact the CDNS and discuss this referral. If the checklist does not meet for further assessment, then a section 2, the (Referral to Social Work) needs to be completed

The patient may also need referral to the Palliative Care Team if end of life is diagnosed. Q. Who can I contact for guidance with complex discharge needs? A. For all complex discharge care needs, your first point of escalation is via the Senior Discharge

Co-ordinator on each site as follows: BHH –Ext: 40842 GHH –Ext: 47870 SH –Ext: 44120 Update all discharges in the Electronic Patient Handover (EPH) discharge section please review

here first. Failing this via central point and the Lead Nurse for Complex Discharges You can always discuss with the ward allocated CDNS and / or Social Worker.



Q. Where do I escalate any blocks to discharge that are out of my control? A. For all complex discharge care needs, your first point of escalation is via the Senior Discharge

Co-ordinator on each site on contact numbers listed above Electronic Patient Handover (EPH) discharge update in the discharges section please review

here first. Failing this via central point ask for Margaret McLaughlin. You can always discuss with the ward allocated CDNS and / or Social Worker. Any concerns on day of discharge transport and pharmacy issues with CSP. For long-term complicated issues refer to Head of Capacity, Ian Donnelly.

Q. What do I do if my patient or their family refuse discharge? A. Follow the Choice Policy:

(i) Raise concerns internally to Matron and Ward Manager to try and resolve with effective communication with the patient.

(ii) Escalate to Directorate Manager. (iii) If it is a refusal to discharge into complex care, the Choice Policy can be followed using

the letter 3. Early communication with patients and relatives will help this. Escalate to Lead Nurse for Complex Discharge 40084/ or via switch

Q. When is it appropriate to use the discharge lounge? A. When the patient is ambulant / semi-ambulant (not bed bound) in a stable condition, has the

capacity to make decisions, patients who can sit safely in a chair. Seek advice from your Matron if unsure or refer to the site operational policy.

Q. How do you transfer patient information upon discharge? A. The discharge summary is given to patients / relatives. Any information that needs to be given to

areas such as nursing homes or community staff is sent via safe haven faxes – the fax receiver body needs to ensure us that they have a similar system to receive the information. If email is used, only the patient’s initials and NHS number should be given. These safeguards are to ensure data protection legislation is met. Some necessary information may need to be given in the interests of public safety, e.g. Schedule 1 offenders, violent and aggressive patients / relatives.

Q The role of Complex Discharge Nurse at Solihull is different can this be explained? A At Solihull Hospital, the discharge nurses are at present employed by Solihull Care Trust. They

will complete nursing assessments, order equipment and lead on C.H.C. issues. They will not become actively involved in delayed discharges. The C.L.N. will only deal with

Solihull G.P. patients. (This may change in light of the Transferring Community Services to HEFT)



2. Circulation This Policy is applicable to all healthcare professionals, whether employed on permanent, temporary or honorary contract, who are involved in the discharge of patients from Heart of England NHS Foundation Trust (HEFT). 3. Scope 3.1 Includes This Policy applies to the discharge of all patients cared for within an adult setting at HEFT. 3.2 Excludes

• Paediatrics: Covered by the Paediatric Discharge Policy 2008 • Neonatal: This Policy does not cover neonatal patients – Neonatal work within National

Guidelines. 4. Definitions 4.1 Simple Discharge Approximately 80% of discharges from hospital can be classified as simple discharges. This can be deemed to be patients discharged to their own homes or permanent place of residence, met with simple planning, without ongoing healthcare needs (DH Ready to Go 2010). A simple discharge is a patient who:

• may be discharged directly from A&E, ward areas, assessment areas, and day procedure units; • is usually discharged to their own home, or usual place of residence; • has simple ongoing care needs which do not require complex planning or delivery.

4.2 Complex Discharge or Transfer of Care A transfer of care is deemed to be complex when several members of the Multi-disciplinary Team are required to carry out comprehensive assessments in order to facilitate a safe, appropriate and timely transfer for the patient. This will involve co-ordination between Primary and Secondary Care and Community Care Services may require home or site visits with the provision of specialist equipment which may be organised by the Occupational Therapist, Tissue Viability Nurse, or Complex Discharge Nurse Specialists. D.H Achieving timely ‘simple’ discharge from hospital - a toolkit for the multi-disciplinary team (2004) 4.3 Complex Discharge Nurse Specialists (CDNS) Complex Discharge Nurse Specialists (CDNS) provide support and advice to staff in the management of complex discharges. Referral criteria for CDNS involvement includes:

• Complex transfers of care • Patients who require provision of nursing equipment • Patients who require a nursing assessment (for nursing home placement)—all patients who have

nursing needs are entitled to financial support from their PCT to cover nursing costs and this is



• deducted from the total cost of the placement. This will not be given unless a CDNS has assessed and recommended Funded Nursing Care. This is then given to social worker to accompany funding application. In the case of a self funder it is given to the nursing home to claim the money directly .A CDNS will also assess to determine if patient has minimal nursing needs that could be dealt with by District Nurses at home or in a Residential Home.

• Patients who require continued healthcare assessments / Fast Track • Patients who are considered a delayed transfer of care

4.4 Continuing Healthcare 2007 (Revised 2009) ‘Continuing care’ means care provided over an extended period of time to a person aged 18 or over to meet physical or mental health needs which have arisen as the result of a disability, accident or illness. ‘NHS continuing healthcare’ means a package of continuing care arranged and funded solely by the NHS. 4.5 Continuing Healthcare Assessments All persons aged 18 or over are entitled to consideration for a continuing healthcare assessment. An initial checklist will be completed by the healthcare professional. The result will have one of two outcomes:

(i) They meet the criteria for full consideration for an NHS continuing healthcare assessment – this patient is to be referred to the Complex Discharge Nurse Specialist Team / Community Liaison Nurse;

(ii) A full consideration for NHS continuing healthcare is unnecessary - this information

should be communicated clearly to the patient and their carer where appropriate. This results in completion of a section 2, which is a formal referral for a social work assessment.

4.6 Social Work Referral / Invite This is to inform the Social Worker that a patient may have ongoing needs that will require a formal Social Worker referral. Section 2: Assessment Notification (electronic via Central Point). The generation of a section 2 is a social work referral – an electronic referral and requirement of the Community Care Act (2003). Section 5: Is a formal notification that is submitted 24 hours prior to discharge to inform the Social Worker that the patient is medically safe to be discharged, and the only reason for delay is awaiting social service input. 4.7 Care Package A care package is care provided from more than one provider, e.g. Health and Social Care. Daily visits can be set up for social and functional needs to care for activities of daily living - long term. 4.8 Residential Care Home A residential care home provides personal care only to patients who require non nursing support. If a dressing or catheter is required by the patient, District Nurses will visit the Residential Home to provide this care A Nursing Home provides 24 Hour Nursing Care.



4.9 Out of Hours Discharge Out of hours discharge refers to discharges which occur after 20:00 hours. 4.10 Self-Discharge This refers to patients who have made an informed choice to leave hospital against medical advice. 4.11 Nurse or Therapist Facilitated Discharge A Nurse or Therapist facilitated discharge policy provides a framework and directive for the safe and effective provision of nurse or therapist led discharge and sets out the steps for implementation, audit and evaluation. Nurse Facilitated Discharges is one of the National High Impact Actions for Nursing and Midwifery (2010). Nurse Facilitated Discharges will enable HEFT to facilitate the discharge of each patient to their home, or transfer to an appropriate level of care as soon as the patient is clinically stable and fit for discharge. Nurse/Therapist facilitated discharge provides a process for non medically led discharge of patients where appropriate and agreed with the Consultant in charge of the patients care. . 5. Reason for Development Heart of England NHS Foundation Trust (HEFT) has a duty of care to ensure all patients have a safe and timely discharge from hospital. HEFT will facilitate the discharge of each patient to their home, or transfer to an appropriate level of care as soon as the patient is clinically stable and fit for discharge. This process will be undertaken in consultation with the patient, family or main carer, and in collaboration with the multi-disciplinary team to ensure the safe transition to primary or community care aiming for a person-centred, whole system and integrated approach. 6. Aims and Objectives

• To provide a process, that is patient centred and empowers the patients to work proactively with nurses and the wider multi-professional healthcare team to facilitate safe and timely discharges from HEFT.

• To ensure all healthcare professionals involved in the discharge process can differentiate

between a simple and a complex discharge. • To ensure patients and relatives / carers are involved in the discharge planning process from the

earliest opportunity and throughout the process. • To ensure patients and relatives / carers are provided with written / verbal information in relation

to their discharge. • Comprehensive records are maintained within the patients’ medical notes of the discharge

planning. • To provide a structured mechanism for out of hours discharges. • All staff involved in the discharge process understands the sequence of escalation for a delayed

discharge. • Discharge checklists are completed for all patients following an in-patient stay.



7 Standards 7.1 Key Principles of Effective Discharge (for all discharges)

• Discharge arrangements should be discussed with the patient and their relatives within 24-48 hours post admission.

• All ward based patients will be provided with access to written information relating to discharge within 24-48 hours post admission. (see attachment 1)

• Patients who do not have capacity to make decisions about their discharge or ongoing care needs should be assessed under the Mental Capacity Policy (see Policy on Trust intranet).

• Patients should be informed of their estimated date of discharge (EDD) as soon as confirmed by the medical team responsible for the patient’s care. EDD should be recorded in the patient’s medical notes and on the electronic nursing documentation.

• The clinical management plan should be reviewed daily with the wider multi-professional team and the patient to ensure a timely discharge is achieved.

• The Registered Nurse is responsible for completing the invite to the Social Worker as soon as it is identified that the patient may have ongoing care needs. The invite is completed via the Electronic Patient Handover system (EPH).

• When patients have pre-existing care packages, a minimum of 24 hours notice must be given to re-instate the services.

• Discharges will take place over the full seven days. • A discharge checklist must be completed for every in-patient discharge (N.B the checklist within

the surgical care/elective pathway or attachment 2 is accepted). • All patients will receive a copy of the discharge letter. Indicating diagnosis, treatment/ significant

investigations, medication and any further follow up whether in Out-Patients or via the patients G.P.

• A copy of the discharge letter will also be sent to the patients G.P • The discharge lounges will be utilised across all three sites to support the ethos of timely

discharges. • The Registered Nurse (RN) is responsible for identifying and escalating any problems which may

prevent the patient achieving a timely discharge. • Tablets to take out (TTOs) should be ordered 24 hours in advance of discharge. • Patients requiring TTOs will be provided with a maximum 28 day supply of medications to take

home. The medication must be checked by the Registered Nurse with the patient and against the patient’s current in-patient prescription.

• The clinical staff must plan to return all patients property in a timely fashion. This should include keys for access to the property if the patient lives alone.

(Adapted from DH 2010 Ready to Go 10 Steps)

7.2 Patient Groups There are two main types of patients groups for discharge arrangements: 7.2.1 Simple Discharge

• Relatives / carers, where able to, should bring in suitable clothing for patients’ discharge. When this is not possible, patients will be dressed to ensure privacy, dignity and warmth is maintained.

• Patients and their relatives / carers will be informed that HEFT supports morning discharges and aims for patients to go home before 13:00 hours. All patients who meet the criteria will be transferred to the discharge lounge to await collection by their relatives (see attachment 3).

• All patients are encouraged to make their own transport arrangements. Hospital transport will only be provided for patients who meet the agreed criteria (see section 7.5).



7.2.2 Complex Discharge

Complex discharges can be any of the following categories:

Patients with on-going Healthcare Needs • The Registered Nurse is responsible for completing the invite to the Social Worker as soon as it

is identified that the patient may have ongoing care needs. The invite is completed via the Electronic Patient Handover system (EPH).

• The continuing healthcare checklist (attachment 4) must be completed with the patient or relative / carer. For patients without capacity please refer to the Consent to Treatment Policy found on the Trust’s Policies and Procedures intranet site. Patients with short-term life expectancy can go through a fast track approval via the Complex Discharge Nurse Specialists (CDNS).

• Patients /relatives /carers who do not meet the criteria for continuing healthcare must be informed of the decision as soon as possible. The Registered Nurse must complete and submit a section 2 request for social care if they consider the patient will have ongoing care needs. The patient / relatives/carer must be informed they have a right to appeal against the decision. Advice and guidance on the appeal process is available via the CDNS.

Patients without Mental Capacity

• Where an adult patient does not have the capacity to give or withhold consent to plan for their discharge, clinicians and the multi-professional healthcare team should consider:

- Whether the patient had made an Advance Decision that may be valid and applicable to the proposed treatment, or had previously made their wishes and feelings known in other ways;

- Whether the patient had appointed an Attorney under a Lasting Power of Attorney (LPA) to consent or refuse the proposed treatment on their behalf, or whether anyone else is appointed to make treatment decisions on their behalf.

- Whether the patient requires the services of an Independent Mental Capacity Advocate (IMCA) to advocate on their behalf, when they have no family or friends who can be consulted, over potentially life-changing decisions. An IMCA is a specific type of advocate that will only have to be involved if there are no family who can be involved. An IMCA will not be the decision-maker, but the decision-maker will have a duty to take into account the information given by the IMCA.

- An IMCA will only be involved if: The decision is about serious medical treatment provided by the NHS. It is proposed that the patient be moved into long-term care of more than 28 days

in a hospital, or 8 weeks in a care home. Along-term move (8 weeks or more) to different accommodation is being

considered, for example, to a different hospital or care home. The proposed treatment is in the patient’s best interest.

The best interest checklist (attachment 5) must be completed and the patient must be able to answer all the questions

• It is the responsibility of the clinicians proposing a decision in the patient’s best interests to ensure that they comply with the Mental Capacity Act in reaching that decision and have regarded the Code of Practice. Failure to do so may leave them open to civil or criminal prosecution.



• Any decision to proceed with on-going treatment or placement in the patient’s best interests must be documented, along with the assessment of the patient’s capacity, why the health professional believes the treatment to be in the patient’s best interests, and that consultation has been undertaken with the involvement of people engaged in caring for the patient, or interested in their welfare.

• Any meetings in relation to the patient’s best interest should have representation from the wider multi-professional team. This should include the Consultant responsible for the patient’s care, or a nominated deputy who can make the appropriate decisions, the Senior Sister / Charge Nurse or their deputy, a Social Worker, and the patient if appropriate, or the patient’s representative. A record of the meeting and actions agreed should be clearly documented within the patient’s medical records.

• Where the consequences of having, or not having the treatments are potentially serious, a referral to the Court of Protection may be sought. If it is felt that this may be necessary, clinicians should contact the Risk Management Team who will take the necessary steps to achieve this.

• For further information or guidance, please refer to the Mental Capacity Policy and Consent to Examination and Treatment Policy on the Trust intranet.

Patients with on-going Safeguarding Concerns

• The discharge arrangements for any patient with on-going safeguarding concerns should be discussed amongst the wider multi-professional team. This should include the Consultant responsible for the patient’s care or a nominated deputy who can make appropriate decisions, the Senior Sister / Charge Nurse or their deputy, the Social Worker, and the patient if appropriate, or the patient’s representative.

• All decisions, outcomes and ongoing care needs should be clearly documented within the patient’s medical notes and the name of the Social Worker responsible for the patient’s ongoing needs.

• If a patient is admitted with or develops a grade 2 or above pressure ulcer it should be reported as a clinical incident and an IR1 completed. The principle should be to determine if the pressure ulcer was avoidable and if the care was neglectful. Refer to the Safeguarding Policy on the Trust intranet.

• The outcome of any safeguarding meetings should be shared with the appropriate agencies prior to the patient being discharged.e.g. Care Homes, G.P, District Nurses.

• It must be clearly documented on all discharge information for any patients who are known to wander off the ward and do not have capacity to be responsible for their own safety.

Discharging Patients to Residential/ Care Homes It is the responsibility of the Registered Nurse who is discharging the patient to provide the Residential/ Care Home with both written and verbal information upon discharge. This must occur for every patient irrespective if the patient is returning to their permanent place of residence It must be clearly documented on all discharge information for any patients who are known to wander off the ward and do not have capacity to be responsible for their own safety. • A copy of all ongoing or unresolved care plans must accompany the patient

Pressure Ulcer Documentation

• Whether hospital or Community acquired. • The size, grade and location of pressure ulcer. • For all grade 3 or 4 hospital acquired pressures ulcers it must be documented if a Root Cause

Analysis has been completed. • Treatment given. • Specialist equipment. • A body map wound care chart must be completed.



• 3-4 days’ supply of dressing should also be sent.

Indwelling Urinary Catheters • Date catheter inserted • Rationale for insertion

Discharging patients with no fixed abode • Patients who are homeless and have no ongoing health needs can present to their local housing

office and be assessed for vulnerability with a view to possible placement. Housing issues are not dealt with by Social Workers under usual circumstances, although they may be able to offer advice.

• The Registered Nurse must inform the Neighbourhood Office before the patient leaves the ward to inform them they are discharging a patient who is homeless.

• Birmingham City Council Housing Department has provided a dedicated Housing Officer to support hospital discharge across Heartlands, Good Hope and Solihull sites.

• Patients who are to be discharged to a Housing Office must be sent by hospital taxi before mid-

day so that an appropriate placement can be sought. Housing Offices are situated within Neighbourhood Offices.

• If a patient requires sheltered housing they will need to contact the Housing Office. A Housing Officer will either put their name on the housing transfer list or complete an application form. The patient would then have to wait for a vacancy.

• If patients need repairs carried out on their property and they are in rented accommodation, they should be referred to the Housing Association, appropriate Housing Office, or to their Landlord.

• Patients who own their own property and do not have funds to conduct the repairs should be referred to the Social Worker.

Delayed discharges

• Once the patient has been assessed as fit for discharge / transfer of care by the patient’s medical team, this is the date the patient should be discharged from the Trust.

• If the delayed discharge is due to social care then a section 5 needs to be completed and submitted to the Social Worker. In the first instance the Social Worker or the Duty Manager should be contacted by phone to be informed that a section 5 is to be submitted.

• Charges can be made against the relevant Social Services for each day the patient remains in hospital after being declared fit for discharge / transfer of care.

• All patients who are a delayed discharge must have a daily review on the progress to resolve the delay. This must incorporate the multi-disciplinary team and actions documented within the patient’s medical records.

• Any patient who is a delayed transfer of care (DTOC) appears on the situation report (sit rep) if a section 2 and section 5 have been issued and the patient is medically fit for discharge.

• All patients who appear on the DTOC situation report will be discussed and problem solved at the weekly JAM where all partners try to resolve the issues that are causing the patients’ discharge to be delayed from hospital. Any ward can escalate a patient to the JAM by contacting the Delayed Discharge administrator via Central Point.

• Any patients who are self-funding their own long term care arrangements and have exceeded their EDD need to be escalated through the above process.

• When self-funding patient’s choice is being decided, it is not unreasonable to provide the patient with an interim placement until the permanent or alternative choice becomes available.



Patients who self–discharge • The reasons for a patient wishing to self-discharge must be clarified and every reasonable

attempt made to resolve issues which will enable the patient to agree to stay in hospital. This may involve contacting the patient’s relatives / next of kin, friend, members of the relevant Clergy, or a representative from the Patient Advisory and Liaison Service (PALS).

• Patients who have capacity to make decisions will be given the self discharge form. • For patients that have an impairment of mind, brain or cognitive functioning must have an

assessment of their capacity (Mental Capacity Assessment) to make an informed decision. Assessment of capacity involves clinical judgment in the context of a legal framework.

• A competent adult has the right to refuse treatment and cannot be restrained and prevented from leaving the hospital. All risks associated with a failure to receive treatment and care must be explained to the patient. A full account of the assessment of the patient’s capacity, as well as all discussions with the patient, should be recorded on the patient’s medical notes. An adult is considered to have has capacity if he/she can:

- understand and retain, in simple language, what the medical treatment is, its purpose and nature, and the rationale;

- understand its principle benefits, risks and alternatives; - understand the consequences if not treated in this way; - retain the information long enough to come to a decision; - make a choice free of external pressure.

• If there is any suspicion that mental illness may be compromising the ability of the patient to make a rational decision, then a prompt psychiatric assessment maybe required.

• Involvement of other members of the multi-disciplinary team may succeed in persuading the patient to stay. As a minimum, the medical team in charge of the patient must be informed. Out of hours, the on call medical team would cover.

• If the patient wishes to self-discharge against advice then progresses towards discharge. The Registered Nurse in charge of the patient’s care will be responsible for arranging as safe a discharge as possible, as outlined in this Policy. This will include: medication, dressings, transportation, community/social service input, follow up appointments, access to home etc. All catheters, cannulae etc must be removed.

• Every reasonable effort should be made to ensure the patient arrives home safely. Where possible the patient should be accompanied home by a friend or relative.

• A safe discharge may, on occasion, include the arrangement of transportation. Hospital transport may not be available at short notice and the patient will be advised accordingly.

• If a safe discharge cannot be completed before the patient leaves the hospital then the following processes must be followed:

- inform the doctor responsible for the patients care; - inform the patient’s next of kin; - inform the patient’s GP; - complete an IR1 form and self discharge notification (see attachment 6) and forward to

the Senior Sister / Matron, and a copy would be forwarded to the Senior Nurse; - inform the First on Sister / Matron on call - irrespective of the final outcome of the patient’s wish to self discharge, the episode must

be fully documented in the patient’s clinical record.



Self-discharge of patients without mental capacity • The patient should have a fully documented assessment of their capacity. If it is then considered

to be in the best interests of the patient to remain at the hospital for necessary treatment to be administered, reasonable force may be used in order to restrain the patient under the Common Law doctrine of necessity.

• However, the decision to restrain the patient and prevent them from leaving the premises must be regularly and carefully reviewed by the medical team and the patient discharged appropriately as soon as possible.

• The authority to restrain an adult without mental capacity against their will should not be used where the patient requires treatment for their mental illness. If the treating doctor wishes to treat the patient for their mental illness, steps must be taken to detain the patient under the Mental Capacity Act 2005.

Patients who refuse to be discharged (Choice Directive Delayed Transfer of Care attachment 7)

• Where patients have been assessed as no longer requiring NHS inpatient care, they do not have the right to occupy indefinitely an NHS bed.

• If an individual continues to unreasonably refuse the interim care home or care package, the council is entitled to consider that it has fulfilled its statutory duty to assess and offer services and may then inform the individual, in writing, that they will need to make their own arrangements.

• This position also applies to the unreasonable refusal of a permanent care home, not just the interim care home or care package.

• It is recognised that patients have a right to choose where they are discharged to, including to a home of their own choice, but also that the best place for that decision to be made is in a non-acute environment. To this end, when a patient is ready for transfer to a nursing or residential care home, the Adults & Communities Team will do all they can to facilitate this transfer in a timely fashion.

• This transfer may be to an interim (temporary) care or nursing home whilst waiting for a home of choice, or to enable more time to consider options and to aid recovery. Information should reflect the rights of patients, whilst at the same time outlining the expectation upon patients and families (with support from community care teams) to organise arrangements for discharge and transfer to nursing or residential care homes as quickly as possible once declared medically fit and able to do so.

7.3 Discharge Medication/ Tablets to Take Out (TTO)

• TTO should be available at the point of discharge for all patients. • All TTO must be checked by the Registered Nurse with the patient against the patient’s current

in-patient prescription. • If TTO are not available at the point of discharge and the patient is unable to wait to collect them,

provisions need to be in place for the patient/ next of kin or nominated adult to collect the TTO’s from the clinical area either later the same day, or the following day. The identified adult collecting the TTO must be able to articulate any known allergies the patient may have and be able to relay information relating to the medication back to the patient.

• The supply of unlabelled medication from ward stock (medication placed in envelopes) contravenes the 1968 Medicines Act and must not occur.

• Under no circumstances should medication be sent out to patients via taxis. • When patients are to be discharged out of hours, every effort should be made to obtain

medication before the pharmacy has closed. • A limited range of pre-packed and labelled medication is available on site. The prescriber should

be contacted to see if this provides a suitable alternative. Senior nursing staff should have access to these medicines.



• Medication required close to the time of discharge can be administered prior to discharge and a supply for subsequent doses obtained the following day when the pharmacy is open.

• However, in circumstances where the supply of discharge drugs outside normal pharmacy hours is essential, and there are no discharge pre-pack arrangements in place that are appropriate for the patient’s needs, the prescriber must personally call the On-call Pharmacist to request dispensing of the discharge medication.

7.4 Documentation for Discharge

• All patients will receive a copy of the discharge letter. Indicating diagnosis, treatment/ significant investigations, medication and any further follow up whether in Out-Patients or via the patients G.P.

• A copy of the discharge letter will also be sent to the patients G.P • All patients will receive a copy of the nursing discharge checklist at the point of discharge • Any patients with ongoing care requirements e.g. Tissue Viability, Catheter Care Enteral

Feeding Regimes, Wound Management or any other complex care requirement, the Registered Nurse is responsible for ensuring a copy all ongoing care plans accompanies the patient at the point of discharge and is available to the primary care responsible for the patients ongoing care requirements.

7.5 Provision of Hospital Transport

• Wherever possible patients should be encouraged to make their own arrangements for transport upon discharge.

• Patient Transport Services should only be used for those who qualify Non emergency patient transport is only available to patients who have a medical need satisfying at least one of the following criteria:

• Stretcher Patients • Patients requiring oxygen therapy • Patients in wheelchairs • Patients with psychiatric or learning difficulties who are unable to use public transport • Patients who cannot walk without the continual support of another person or walking aid such as

a Zimmer frame • Patients who may experience side effects from treatment • Patients who are being discharged to another care setting • Patients with no means of private or public transport available will be given individual

consideration • Hospital transport must be booked 24 hours in advance of the discharge. • The clinical area must inform the ambulance service of any patients who require a stretcher for

their discharge as soon as possible so a risk assessment of access to the property can be conducted before the patient is discharged.

• Out of area ambulance bookings (including stretcher, two men, or wheelchair bookings) must be made at least 48 hours before the transport is required.

• The use of emergency transport same day bookings should only be used in exceptional circumstances, e.g. patients at the end of life who wish to go home.

• Discharges from Birmingham Heartlands & Solihull call 0121 415 6936 For Good Hope call 0121 507 4685 or Ext: 49950

7.6 Equipment Required for Home Discharge

Some patients for even a simple discharge may require equipment for home use. Dressing/Bandages’

• For wound care patients should be given 3 /4 days’ supply from the ward.



Urinary catheters or Incontinent Pads • Patients with should be provided with a 4 day supply, this may need to be increased if the patient

is discharged over a Bank Holiday period. Specialist Equipment e.g. Beds/Mattress’s • Are supplied direct from the manufacturer (Huntleigh or Montacalm) Oxygen Therapy • When arranging a supply of oxygen to support discharge complete the Home Oxygen Therapy

Order Form (attachment 8) Where possible a 3 day turnaround is required if discharge planning has not allowed sufficient time a next day supply of oxygen can be provided

Walking Aids • Sticks/ frames/ crutches are supplied by the physiotherapy

Special Diets/ Feeding Regimes • This includes any patient with NG/PEG/ Nasojejunal/Jejunostomy/ Button Gastrostomy, as well

as any patients on special diets e.g.mashable consistency, thickened fluids or supplements. • A copy of any feeding regime should be sent with the patient. • Feeding pumps and equipment will be supplied by the Nutrition Clinical Nurse Specialists. Along

with 10 days’ supply of any feeds prescribed. 7.7 Discharging Patients Out of Hours

• The majority of patients should be discharged before 8pm. • It is the responsibility of the healthcare professional to ensure that the patient is safe to be

discharged out of hours. • When elderly or vulnerable patients are discharged after 8pm, extra considerations need to be

made by the healthcare professional responsible for the discharge. This should be considered as a complex discharge

• The healthcare professional must ensure that the patient has access to their property, and that they are dressed appropriately to be discharged.

• It should be established that the patient has a relative / carer to receive them upon arrival. 7.8 Nurse / Therapist Facilitated Discharge

• The development of nurse or therapist led discharge is intended to provide patients and their relatives or carers with a quicker and more efficient discharge process.

• Any clinical areas that undertake Nurse or therapy led discharge must have locally approved guidelines led by the Head Nurse and staff must be able to demonstrate competence when initiating nurse or therapy led discharge

• The Registered Nurse or Therapist must work to an agreed management plan outlined by the medical consultant responsible for the patients care.

• The patient and their relative / carer will be informed that the patient will discharged from hospital by the Registered Nurse or Therapist.

• Nurse or Therapy led discharge will only be for those recognised as simple discharges. The simple discharge process outlined in section 7.2 must be adhered to.

• Only Registered Nurses and qualified Therapists can conduct the discharge. This cannot be delegated to pre-registration students or unqualified staff.

• Bank or agency staff are not permitted to expedite this discharge. • The Registered Nurse/Therapist must recognise and act upon those situations where it is

inappropriate for them to authorise discharge. They must escalate their concerns and document within the patient’s medical records.

• The Registered Nurse / Therapist must work within the Trust Policies and Procedures and within their own Professional Code of Conduct.



8. Responsibilities 8.1 Individual Responsibilities 8.1.1 Chief Executive The Chief Executive has overall accountability for ensuring the Trust meets all its responsibilities with regard to the standards outlined in this Policy. The responsibility for implementation, monitoring and renewal of this Policy is delegated to the Chief Nurse. 8.1.2 Chief Nurse The Chief Nurse has overall responsibility for the development, review and monitoring of this Policy. This can be delegated to the Head Nurses for each group. The Head Nurses will oversee the implementation of this Policy and supporting procedure and provide reports, as required, to the Trust Board in this regard. 8.1.3 Matrons Matrons are responsible for ensuring that nursing staff within their remit comply with the Discharge Policy. Matrons are responsible for ensuring that nursing staff within their remit are encouraged to access the Trust intranet regularly to ensure that that are familiar with current practices. 8.1.4 Senior Sisters / Charge Nurses Senior Sisters / Charge Nurses are responsible for:

• raising awareness of this Policy and its content with all staff members in their remit who may be involved in the discharge of patients, at local induction;

• attending any multi-disciplinary team meeting held to discuss patients with complex needs or safeguarding concerns, or delegate an appropriate deputy from the nursing team;

• ensuring any delayed discharges are escalated to the appropriate healthcare professional and reviewed daily until discharge is achieved.

8.1.5 Medical Staff The Consultant responsible for the patient’s care must ensure all patients have a recorded estimated date of discharge (EDD) in their medical notes. When the patients are medically fit for discharge, a member of the medical team will inform both the patient and the ward nursing staff, recording the information clearly in the patient record, and will ensure this data is recorded on the clinical notes intranet system. Details of the inpatient episode, on-going treatment and prescribed discharge medication will be recorded on the carbonated discharge letter form which is forwarded to pharmacy 24 hours in advance of discharge. The medical discharge letter should also include details informing staff of any newly diagnosed infections. Review of the patient is undertaken on the day of discharge unless:

• the criteria for discharge is clearly documented in the notes, i.e. “Home in the morning if apyrexial and no further vomiting overnight. Advise to consult GP if further symptoms”;

• local protocols for discharge of patients by nursing staff are in place.



8.1.6 Nursing Staff All newly qualified Registered Nurses must be able to expedite a simple discharge within the first six months of employment at HEFT. It is the responsibility of the Registered Nurse to identify and escalate any knowledge or skills deficit they have in undertaking a simple and complex discharge and escalating to their line manager. All patients will be assessed by the Registered Nurse for potential discharge needs prior to elective surgery at pre-admission clinic, or within 48 hours of unplanned admission. Initial assessment findings will be recorded on the discharge checklist (attachment1) and clearly identify:

• admitted onto HISS within one hour of discharge; • requirements for specialist nursing, Social Worker and therapist referral – identified referrals will

be made within one working day of the completion of the initial assessment; • transport requirements for discharge to be discussed with the patient and their relatives if

possible – patients requiring hospital transport arrangements should be made as soon as possible;

• the initial assessment will be reviewed and updated appropriately by the allocated ward nurse and other members of the multi-disciplinary team at each contact session;

• the Registered Nurse must inform the receiving ward, if a patient is transferred, of the discharge arrangements and any potential delays in their process.

8.1.7 Multi-Disciplinary Team The planning and implementation of an appropriate discharge plan for every patient is dependent upon good communication between all members of the multi-disciplinary team, the patient, their family and carers, accessing interpreting and advocacy services as appropriate. The patient, family and carers will be made aware of the Trust’s discharge process at the onset of the assessment process, kept informed of progress against discharge plans, and involved in decisions relating to discharge arrangements. 8.2 Board and Committee Responsibilities 8.2.1 Approval Committee The Matron’s Business Meeting will be responsible for the approval of this Policy.

8.2.2 Ratifying Board and Committee The Professional Governance Nursing Forum will be responsible for the ratification of this Policy. 9. Training Requirements All healthcare Practitioners involved in the discharge of patients should receive the relevant training via local induction programmes.



10. Monitoring and Compliance 10.1 Monitoring The monitoring of this Policy will be as detailed below

Criteria Mechanism Frequency Responsible Monitoring Committee

Duties (Nursing) Nursing care indicators Patient Experience metrics Complaints information

Monthly Monthly 6 monthly

Corporate Nursing PPI Team Safety and Governance (PPI Team)

EDs Committee Group Quality and Safety Committees Governance and Risk Committee

Defined Patient Groups

Discharge requirements of each patient group Documentation to accompany each patient Information to be given to the patient Discharge process out of hours

% of patients discharged before 1pm

Data collected via HISS Monthly

SDU input onto finance performance website

Clinical Director, Directorate Manager and Matron

Delayed transfer of care SITREP Look Forward Monthly Ward Manager CEO, Clinical

Directors, SHA

10.2 Compliance

• Any healthcare practitioner involved in the discharge of patients who is unable to comply with the policy must escalate their concerns via the Trust’s reporting system (IR1Forms) to their line manager or the duty manager whichever is the most appropriate.

• Failure to comply with the safe discharge of patients could result in disciplinary action. 11. Implementation This policy will be communicated through presentation:

• At the Matron’s monthly meeting; • At each site Senior Sisters meetings • At the Clinical Governance meeting; • Posted on the Trust intranet site; • Via communication e-mail to all staff for wide dissemination.

12. References

• Department of Health (2010) Ready to Go



13. Appendices Appendix 1: Patient Information on Discharge Appendix 2 Pre-Discharge & Discharge Checklist Appendix 3: Criteria for Discharge Lounge Appendix 4: NHS Continuing Healthcare Checklist Appendix 5: Best Interest Checklist Appendix 6: Self-Discharge Notification Appendix 7 Choice Directive / Delayed Transfer of Care Appendix 8 Home Oxygen Order Form 14. Attachments Attachment 1: Equality & Diversity – Policy Screening Checklist Attachment 2: Approval Checklist



Appendix 1: Patient Information on Discharge

Preparing to Go Home from Ward :___________

This leaflet provides specific information about preparing to go home from hospital.

When does planning for discharge start? Staff will start planning your discharge from hospital with you shortly after your admission to the ward, to ensure there are no unnecessary delays affecting your discharge home.

What does discharge planning involve? Before your discharge from hospital, doctors, nurses, pharmacists, therapists and social workers may need to discuss your individual needs. This may include the need for ongoing nursing care at home, rehabilitation, additional social support and specialist medical equipment and dressings. The ward staff will discuss with you an estimated date of discharge to help you and your relatives plan when you will return home. The estimated date of discharge may change depending on the timing of any investigations and how quickly you are recovering. Staff will keep you informed if this date changes.

What are the benefits of early planning for discharge? Early planning for discharge provides many benefits as it: • Enables staff to identify problems or concerns quickly and help you to deal with them so that your

discharge from hospital is not delayed. • Helps you and your family understand how to manage any anticipated problems. • Gives you an early indication of when you can expect to be discharged from hospital. • Provides you with more information about your care after discharge. • Allows you and your family to make plans. • Prevents unnecessary delays and reduces your length of stay in hospital. Without proper discharge planning, your stay in hospital may be extended unnecessarily, care packages may not be set up or insufficient support provided. Each of these could cause you to be re-admitted to hospital. We need you to help us plan for your discharge as soon as possible after admission.

Transport It is your responsibility to provide your own transport home. Where possible, please arrange to be collected during the morning. If you have any difficulties with providing your transport home please let staff know, so suitable arrangements can be made in advance to prevent delays. Ambulance transport is only available when there are special medical requirements, so please encourage relatives or friends to collect you.

When will I be discharged? You will be discharged home or transferred to a suitable alternative care setting as soon as you are medically fit for discharge, no longer need acute hospital care and adequate arrangements are in place. On the day of your discharge, during the morning you may be asked to transfer to the hospital discharge lounge. This will free your bed as early as possible in the day for another patient who may be waiting in A&E to be admitted into hospital.



About your medications

Prior to discharge you will be given a copy of the list of medication that you should take after you

leave hospital. A copy of this information will also be sent to your GP.

Pharmacy will routinely provide your medication on the ward ready-labelled for discharge and depending on how long you have been in hospital you will normally go home with at least 14 days supply of medication but may be as much as 41 days. You will need to contact your GP (at the earliest opportunity) for further supplies.

A member of staff will explain your medication to you. Please use this opportunity to discuss any

queries you may have about your medication.

If you have other medication at home and it is not listed on your discharge letter, then the hospital doctor does not want you to take this any longer. Please take these items to your GP/Pharmacy on your next routine visit, for safe disposal.

If you are admitted to hospital again, please bring all your medication with you.

What are my responsibilities?

Your involvement in your discharge is important. Please ensure that: • Keys & Clothes -You have suitable clothing for discharge and have access to your house keys if you

are going to your own home. • Medical Certificate -You let a member of staff know if you need a medical certificate. • Date of discharge – You tell staff if you anticipate problems with the date or time of your discharge. • Transport -You ask your family or a friend to collect you from hospital in the morning • Medications - Please let the pharmacist know if:

a) You don’t need certain medications as you already have an adequate supply at home b) You do NOT want child resistant containers

• You retain any documentation handed to you at your time of discharge is kept safe for future reference by appropriate professionals.

Do you anticipate any problems with your discharge arrangements?

If yes, please make a note of them below and please discuss these with a member of staff as soon as possible.

Who do I contact if I have any questions after my discharge from hospital? If you or your relatives have any questions about your discharge and follow-up, please contact a member of staff on the ward. The direct telephone numbers are:

0121 424 Ward ___________

If you feel unwell following discharge and think you may need medical treatment please contact your GP who can provide advice and if necessary, contact the hospital. Everyone involved in your care on the ward is committed to providing you with the best possible care and value your feedback



Please use this space to write down any questions you may want to ask: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___________________________________________________________________



Appendix 2: Pre Discharge & Discharge Checklist



Appendix 3: Criteria for Discharge Lounge The aim of the discharge Lounge is that the criteria specified should be as broad as possible in order to include as wide arrange of patients as possible. It is anticipated therefore that all adult patients for discharge should be referred to the lounge with minor exceptions. For further clarification see individual operational policy. Main Criteria for Discharge Lounge

• All adults whose discharge has been agreed up to 6.30pm. • Patients must be able to sit out in a high back or reclining chair without discomfort. • Patients who are medically stable and not requiring complex nursing care (Level 2 or above).

Exclusion criteria for transferring patients to the Discharge Lounge

• Patients who are not anticipated to leave before 19.00hrs. • Bed bound patients (patients who are only mobile using a hoist or similar equipment). • Patients who have a communicable infection. • Patients who are confused and wandering.

Patients from Emergency Department (E.D) and Assessment Areas

• Adult patients may be transferred from E.D or Assessment Areas where a decision not to admit has been made and the patient is waiting for transport home. Patients transferred from such areas must be:

- medically fit; - not requiring monitoring; - have their discharge arrangements in place prior to referral to the lounge.



Appendix 4: NHS Continuing Healthcare Checklist Notes 1. This Checklist is to help practitioners identify people who need a full consideration of whether they

have a primary health need and qualify for NHS Continuing Healthcare. Please note that referral for consideration for NHS Continuing Healthcare is not an indication of the outcome of the eligibility decision: this should also be communicated to the individual and their representative as appropriate.

2. We have based the Checklist on the Decision Support Tool. The notes on the Decision Support Tool,

and the National Framework guidance, will help you understand this tool, but we highly recommend that a practitioner who wants to use any of the tools should attend training using national training materials, and ensure that their Continuing Care Lead within their organisation is aware that they are using it, before starting.

3. The aim is that a variety of people, in a variety of settings, could refer individuals for a full

consideration of NHS Continuing Healthcare eligibility. For example, the tool could form part of the discharge pathway from hospital, a GP or a nurse could use it in an individual’s home, and Social Services workers could use it when carrying out a Community Care assessment. This list is not exhaustive, and in some cases it may be appropriate for more than one person to be involved.

4. Because of the intention to use the tool in a variety of settings, slight adjustments might be necessary

to align the tool with local procedures. For example, for record-keeping, a sheet with the relevant personal information for the individual should be attached. This may be the sheet provided with the Decision Support tool (or similar), or else the standard identifying sheet in use in the area. It is, however, important that the body of the tool remains the same.

5. This version of the Checklist incorporates slight changes based on learning from the PCTs who have

been testing the tools, and further discussions with stakeholders since the National Framework guidance was published on 26 June. This is the version that should be used from the implementation date of 1 October 2007.

6. Please compare the descriptions of need to the needs of the individual and tick the boxes as

appropriate. Consider all the descriptions. If the individual’s need meets or exceeds the description given, tick the box in the first column (column A). If there is need in some or all of these areas, but the level of need falls just below that described in the main statement, please tick the box in the second column (column B). If the individual clearly does not meet the described need, please tick the box in column C.

7. A full consideration of eligibility is required if there are: - two or more ticks in column A. - five or more ticks in column B; or one tick in A and four in B. - one tick in column A in one of the boxes marked with an asterisk (ie, the domains which

carry a priority level in the Decision Support Tool), with any number of ticks in the other two columns.

There may also be circumstances where you consider that a full consideration for NHS Continuing Healthcare is necessary even though the individual does not apparently meet the indicated threshold.



8. Whatever the outcome, you should record written reasons for the decision along with your signature and the date the Checklist was completed. You should inform the individual and/or carer of the decision with a clear explanation of the basis for the decision (written if appropriate). You should explain that if they feel a decision of ineligibility was incorrectly reached, they may request a full assessment, and that this request will be given due consideration, taking into account all the information available.



Name: PID: Address: Date of Birth:

Ward: A B C

Domain

Description Meets/ exceeds the described need

Borderline – nearly meets the described need

Clearly does not meet the described need

Behaviour* “Challenging” behaviour that poses a predictable risk to self or others. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.

Cognition High level of cognitive impairment which is likely to include marked short-term memory issues and maybe disorientation in time and place. The individual has a limited ability to assess basic risks with assistance but finds it extremely difficult to make their own decisions/choices, even with prompting and supervision.

Psychological/ Emotional

Mood disturbance or anxiety symptoms or periods of distress that has/have a severe impact on the individual’s health and/or wellbeing. OR Withdrawn from any attempts to engage them in support, care planning and daily activities.

Communication Unable to reliably communicate their needs at any time and in any way, even when all practicable steps to do so have been taken.

Mobility

In one position (bed or chair) but due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate. OR At a high risk of falls. OR



Involuntary spasms or contractures placing themselves and carers or care workers at risk.

A B C Domain




Nutrition Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to maintain airway. OR Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers. OR Nutritional status “at risk” and may be associated with unintended, significant weight loss. OR Problems relating to a feeding device (for example P.E.G.) that require skilled assessment and review.

Continence

Continence care is problematic and requires timely and skilled intervention.

Skin integrity

Open wound(s), pressure ulcer(s) with “full thickness skin loss involving damage or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule” which are not responding to treatment and require a minimum of daily monitoring/reassessment. OR A skin condition which requires a minimum of daily monitoring or reassessment. OR Specialist dressing regime in place which is responding to treatment.

Breathing * Is able to breathe independently through a tracheotomy, that they can manage themselves, or with the support of carers or care workers. OR CPAP (Continuous Positive Airways Pressure). OR Breathlessness due to symptoms of chest infections which are not responding to therapeutic treatment and limit all activities of daily living activities.



Drug Therapies & Medication: Symptom control*

Requires administration of medication regime by a registered nurse or care worker specifically trained for this task, and monitoring because of potential fluctuation of the medical condition or mental state, that is usually non-problematic to manage. OR - Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care.

A B C Domain




Altered States of Consciousness*

ASC that require skilled intervention to reduce the risk of harm.

Total from both pages



Please highlight the outcome indicated by the checklist: 1. Referral for full consideration for NHS Continuing Healthcare is necessary or 2. No referral for full consideration for NHS Continuing Healthcare is necessary Rationale for decision

Name(s) and signature(s) of assessor(s) Date

Please ensure all eleven care domains have a tick in one of the three boxes, A, B or C before completing the recommendation on this page and ensure there is an information sheet with the personal details necessary for identification attached.



Appendix 5: Best Interest Checklist MENTAL CAPACITY ACT 2005 Checklist for assessing “Best Interests” for patients aged 18 or above Patient’s Name: Date of Birth: Hospital Number: In determining a patient’s best interests, the person making the determination must not make it merely on the basis of the patient’s age, appearance, his/her condition or an aspect of his/her behaviour, which may lead others to make unjustified assumptions about what may be in the patient’s best interests. When considering whether life-sustaining treatment is in the best interests of the patient, one must not be motivated by a desire to bring about death. Please document clearly in the patient’s records, and/or on this document, your reasons for answering “yes” or “no” for any of the questions below. This form must be placed in the patient’s records. 1. Does the patient have “capacity” to make a decision about their discharge? YES/NO

If “yes” then the patient’s wishes must be accepted even if you do not consider that decision to be in the patient’s best interests. If “no” proceed to question 2. 2. a) Is it likely that the patient will at some time regain capacity in relation to the matter in

question? YES/NO If “yes” go to 2(b). if “no” proceed to questions 3 and 4.

b) If so will waiting make it likely that any irreversible mental or physical harm may arise? YES/NO If “yes” then proceed to questions 3 and 4. If “no” and it is reasonable to wait for this without jeopardising the patient’s position then you must do so. 3. Has the patient been encouraged to participate or helped (so far as reasonably practicable) to improve his/her ability to do so as fully as possible in any decision affecting him/her? YES/NO

If “yes” then proceed to questions 4. If “no” this step must be taken. 4. Has the patient made an Advance Decision and/or a Lasting Power of Attorney YES/NO If Yes then follow the Checklist for an Advance Decision and/or Lasting Power of Attorney If No then proceed to question 5



1 Have the following been considered in deciding what is in the best interest of the patient? YES/NO

So far as is reasonably ascertainable:

• The patient’s past and present wishes and feelings, in particular any relevant statement made when he/she had capacity.

• The patient’s beliefs and values which are likely to influence their decision-making if he/she had capacity.

• Other factors the patient is likely to have considered if able to do so. If practicable and appropriate to consult them as to what would be in the person’s best interests, the views of: • Any person named by the person as someone to be consulted on the matter in question or matters of

that kind. • Anyone engaged in caring for the patient or otherwise interested in their welfare. • Any donee of a Lasting Power of Attorney granted by the patient. • Any deputy appointed for the patient by the Court. • an IMCA (where there is no-one else to consult and serious medical treatment is proposed) I confirm I have understood and reviewed this checklist in respect of the above-named patient. ___________________________ _____________ __________________________________

Signature of Health Professional Date Name and position of Health Professional This checklist is only intended to provide guidance and a framework when considering best interests. Where there are any doubts concerning the person’s capacity to consent to or refuse the treatment o r where there is a disagreement about best interests further medical and/or legal advice should be sought. Notes: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________



______________________________________________________________________________________



Appendix 6: Self-Discharge Notification SELF DISCHARGE FROM HOSPITAL / REFUSAL OF TREATMENT

Name DOB PID Ward BHH/GH/SOL

The patient Is deemed competent and fulfils the following criteria: He/she can: �understand and retain in simple language what the medical treatment is, its purpose and nature, and the rationale �understand its principle benefits, risks and alternatives �understand the consequences of not being treated in this way �retain the information long enough to come to a decision �make an informed choice free of coercion In spite of full explanation and sufficient time to reconsider he/she has determined not to remain in hospital and receive recommended treatment ie: The specific risks and consequences of leaving hospital/ not receiving recommended treatment have been outlined, and the following risks have been emphasised: The following alternative arrangements have been offered/ made: Signed (patient) ________________________________________________Date___________ Signed (Healthcare Professional)____________________________________Date _________ Designation______________________________________________________ Signed (member of staff 2) Designation______________________________________________________ Date _________



Appendix 7: Choice Directive / Delayed Transfer of Care Purpose To ensure that patients who no longer require acute hospital care, but require residential/nursing, or home care, are discharged as soon as possible once medically fit and safe to transfer. The purpose is to minimise delays in discharge for all patients assessed as requiring long term Nursing or Residential Care Home placements. This includes the offer by the Local Authority of alternative and Interim beds. Produced as the result of a citywide agreement to include representatives from Birmingham Local Authority and all Birmingham Hospital and Community Trusts. Staff Involved in executing this directive: Discharge Teams, including Delayed Discharge Manager, Complex Discharge Nurse Specialists, Social Workers, Nursing and Medical Staff. The Consequence of Non-Adherence to the Policy

Potential delays in discharge Cause of complaint when the Trust is required to facilitate a discharge to a Care Home and

written information has not been given to appropriate relatives/carers.

Nb: Letters 1, 2 and 3 can be found on the Trust Intranet



Choice Directive Flow Chart

Upon arrival in hospital, general information leaflet regarding discharge is made available to every patient

LETTER 3 ISSUED 7 working days from LETTER 2 – and/or

patient/family declining Interim

LETTER 1 ISSUED (best practice is on start of social work assessment)

INDICATES PLACEMENT / HOME CARE PACKAGE

DOES NOT INDICATE PLACEMENT OR HOME CARE PACKAGE

NO LETTER ISSUED

LETTER 2 ISSUED 5 WORKING DAYS FROM LETTER 1



Appendix 8: Home Oxygen Order form



ADVISORY NOTES: Please give full contact details so that the oxygen supplier can contact you to resolve queries.This form should NOT be used where patients are experiencing problems with a current supply.Please use supplier 24/7 helpline to report these. Box 3: Please indicate name of Consultant (if applicable) and details of clinical contact. Box 5: You must complete Primary Care Trust (PCT) / or Local Health Board (LHB) Wales. The oxygen supplier will be invoicing the PCT/ LHB; therefore you should take care to enter the correct details so that payment can be made by the correct PCT / LHB (payment is based on the location of the patient’s GP’s main surgery, not the patient’s address). You must also send a copy order to the PCT / LHB for audit purposes. Box 6: Holiday order: If a patient requires oxygen at a UK holiday destination, at school or work, a secondary order form is required to provide oxygen in a location other than the patient’s home. Please ensure this order provides the correct delivery address, information about access / named person receiving equipment and, where appropriate, start and completion date of holiday. Note that a patient on holiday may require a different service. Consent: Patient consent is needed to provide personal information to the supplier to enable delivery of the service to be made - that is for the supplier to hold certain personal information about the patient. If consent has not been obtained, the supplier will be in breach of the Data Protection Act 1998. Box 7: An LTOT request will not automatically include provision of oxygen for use outside the home. If this is needed please also complete box 8. Box 8: Ambulatory oxygen: Adults and older children: Initial assessment must be performed in accordance with the clinical component of the home oxygen service. A 2 month assessment period is required so that hours of usage can be determined. Therefore it is suggested that initially 1-2 hours per day is ordered, allowing 7-14 hours of oxygen per week. If the usage changes then the hours per day can be increased or decreased by completing a new order. Infants: Children on LTOT will usually need ambulatory oxygen. An initial order of 3-4 hours per day is suggested, with review after 2 months. Box 9: Short burst oxygen: This will normally be ordered for symptomatic relief or breathlessness, in patients using oxygen for less than 2 hours per day. A static source of oxygen will be provided. Nasal cannulae will be appropriate for short burst oxygen. The usual flow rate is 2-4 litres per minute using a 24-28% mask. Box10: Emergency supply: Clinicians should order this service only where a patient requires an urgent supply of oxygen and has no oxygen supply at home. The supplier is required to deliver this service within 4 hours of receipt of the order. It should not be ordered for more than three days. To avoid the emergency tariff being charged longer than necessary, clinical staff will need to ensure that a second HOOF is completed for non-emergency supply at the same time, or as soon as possible after the emergency order is made. The emergency service should not be ordered where a patient has problems with an existing supply or has a back-up cylinder. The patient or carer should be advised to contact the supplier 24/7 helpline. Box 11: Hospital discharge: When arranging a supply of oxygen to support discharge, please give a contact name and ward telephone number and carer’s telephone number in boxes 2 & 3 so that the oxygen supplier can gain access to the patient’s home. If discharge planning has not allowed sufficient time for a viable 3 day response, a next day supply of oxygen can be provided (tick yes in Box 11) to prevent delayed discharge. If a 6 week temporary supply of oxygen is required prior to the stable LTOT assessment, this should be indicated in box 12. Box 12: Order review date: must be stated if patient is awaiting second assessment for LTOT or when ambulatory oxygen 2 month assessment period ends or if emergency oxygen has been ordered. Box 13: Please note any special needs e.g. language or disabilities. Box 14: Clinical codes: (As suggested by BTS) 01 Chronic obstructive pulmonary disease (COPD) 02 Pulmonary vascular disease 03 Severe chronic asthma 04 Primary pulmonary hypertension 05 Interstitial lung disease 06 Pulmonary malignancy 07 Cystic fibrosis 08 Palliative care 09 Bronchiectasis (Not cystic fibrosis) 10 Non-pulmonary palliative care 11 Chronic heart failure 12 Paediatric interstitial lung disease



13 Chronic neonatal lung disease 14 Neuromuscular disease 15 Paediatric cardiac disease 16 Neurodisability 17 Chest wall disease 18 Other primary respiratory disorder 19 Obstructive sleep apnoea syndrome 20 Other conditions Service categories: SERVICE CATEGORIES RESPONSE TIME DURATION OF PRESCRIPTION AMBULATORY CC1 Emergency 4 Hours Up to 3 daysNot applicable CC2 i) On discharge pending formal Next day between 8.00am Up to 4/5 weeks until the patient is able Not applicable assessment and 05.00pm to be formally assessed ii) Short burst 3 Days Long term Not applicable CC3 Long term oxygen therapy 3 Days Long term Not applicable CC4 Long term oxygen therapy and 3 Days Long term Yes standard ambulatory supply CC5 Standard ambulatory supply only 3 Days Long term Yes CC6 Long term oxygen therapy and 3 Days Long term Yes lightweight ambulatory supply CC7 Lightweight ambulatory supply only 3 Days Long term Yes Contacts Air Products Tel: 0800 373580 Fax 0800214709: North West, Yorks and Humberside, Leics, Northants & Rutland,Trent, Birmingham and Black Country, Shrops & Staffs, West Midlands, Wales, North East London , North West & Central London, South West Peninsula, Dorset & Somerset, Avon, Glos & Wilts. Allied RespiratoryTel 0500 823773 Fax 0800 781 4610 SW & SE London, Thames Valley, Hants & IOW, Kent & Medway, Surrey & Sussex BOC Vitalair Tel 0800 136603 Fax 0800 169 9989 Beds & Herts, Essex, Norfolk, Suffolk & Cambs. Linde Tel 0808 2020999 Fax 0191 497 4340 Co. Durham, Northumberland, Tyne and Wear, and Tees Valley.



Attachment 1: Equality and Diversity - Policy Screening Checklist Policy/Service Title: Policy & Procedure for Discharge Practices v5.2 Directorate: Corporate Nursing

Name of person/s auditing/developing/authoring a policy/service:

Aims/Objectives of policy/service:

Policy Content: • For each of the following check the policy/service is sensitive to people of different age, ethnicity, gender,

disability, religion or belief, and sexual orientation?

• The checklists below will help you to see any strengths and/or highlight improvements required to ensure that the policy/service is compliant with equality legislation.

1. Check for DIRECT discrimination against any group of SERVICE USERS:

Question: Does your policy/service contain any statements/functions which may exclude people from using the services who otherwise meet the criteria under the grounds of:

Response Action required

Resource implication

Yes No Yes No Yes No

1.1 Age? X X 1.2 Gender (Male, Female and Transsexual)? X 1.3 Disability? X 1.4 Race or Ethnicity? X 1.5 Religious, Spiritual belief (including other belief)? X 1.6 Sexual Orientation? X 1.7 Human Rights: Freedom of Information/Data

Protection X

If yes is answered to any of the above items the policy/service may be considered discriminatory and requires review and further work to ensure compliance with legislation.

2. Check for INDIRECT discrimination against any group of SERVICE USERS:

Question: Does your policy/service contain any statements/functions which may exclude employees from operating the under the grounds of:



Yes No Yes No Yes No 2.1 Age? X 2.2 Gender (Male, Female and Transsexual)? X 2.3 Disability? X 2.4 Race or Ethnicity? X 2.5 Religious, Spiritual belief (including other belief)? X 2.6 Sexual Orientation? X 2.7 Human Rights: Freedom of Information/Data

Protection X


TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION =



3. Check for DIRECT discrimination against any group relating to EMPLOYEES:

Question: Does your policy/service contain any conditions or requirements which are applied equally to everyone, but disadvantage particular persons’ because they cannot comply due to:



Yes No Yes No Yes No

3.1 Age? X 3.2 Gender (Male, Female and Transsexual)? X 3.3 Disability? X 3.4 Race or Ethnicity? X 3.5 Religious, Spiritual belief (including other belief)? X 3.6 Sexual Orientation? X 3.7 Human Rights: Freedom of Information/Data

Protection X


4. Check for INDIRECT discrimination against any group relating to EMPLOYEES:

Question: Does your policy/service contain any statements which may exclude employees from operating the under the grounds of:



Yes No Yes No Yes No 4.1 Age? X 4.2 Gender (Male, Female and Transsexual)? X 4.3 Disability? X 4.4 Race or Ethnicity? X 4.5 Religious, Spiritual belief (including other belief)? X 4.6 Sexual Orientation? X 4.7 Human Rights: Freedom of Information/Data

Protection X


TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION =

Signatures of authors / auditors: Date of signing:



Attachment 2: Equality Action Plan/Report Directorate:

Service/Policy:

Responsible Manager:

Name of Person Developing the Action Plan:

Consultation Group(s):

Review Date:

The above service/policy has been reviewed and the following actions identified and prioritised. All identified actions must be completed by: _________________________________________ Action: Lead: Timescale: Rewriting policies or procedures

Stopping or introducing a new policy or service

Improve /increased consultation

A different approach to how that service is managed or delivered

Increase in partnership working

Monitoring

Training/Awareness Raising/Learning

Positive action

Reviewing supplier profiles/procurement arrangements

A rethink as to how things are publicised

Review date of policy/service and EIA: this information will form part of the Governance Performance Reviews

If risk identified, add to risk register. Complete an Incident Form where appropriate.

When completed please return this action plan to the Trust Equality and Diversity Lead; Pamela Chandler or Jane Turvey. The plan will form part of the quarterly Governance Performance Reviews. Signed by Responsible Manager:

Date:

policy & procedure for discharge practices version 6

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