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Nurse Led Discharge

Miss Clare Tickner (Author)
Manager of Day Surgery Services
Royal Surrey County Hospital, Guildford

Ms Karen Barker
Patient Care Manager, Theatres & Associated Services
Hywel Dda NHS Trust (Pembrokeshire Division)

Ms Sue Blanks
Patient and Public Engagement Manager for Ashford and Shepway
Eastern and Coastal Kent Primary Care Trust, Dover

Mrs Clare Hammond
Ward Manager, Surgical Day Unit
University Hospital of North Staffordshire

Dr Anna Lipp
Consultant Anaesthetist and Day Surgery Lead,
Norfolk and Norwich University Hospital

Dr Ian Smith
Senior Lecturer in Anaesthesia
University Hospital of North Staffordshire

Mrs Jill Solly
Head of Primary/Secondary Care Interface, Strategic Development
Kings College Hospital Foundation Trust

Published May 2009

ISBN 978-1-908427-31-1

The successful and timely discharge of patients following day or short stay surgery is fundamental to achieving high levels of patient satisfaction and ensuring efficient service provision.

The process of discharge planning should be nurse led as this minimises delays and uses staff most efficiently. This process should begin prior to admission, usually at the pre-assessment appointment. Patients should be assessed using a range of physical, psychological and social criteria to ensure that they are appropriately prepared to follow a day or short stay surgical care pathway[1]. The use of a checklist at the point of discharge should represent the final documentation in this ongoing and interactive process.

This updated handbook contains advice from the British Association of Day Surgery on what we consider to be best practice, and on how to implement or update the guidelines in your work area.

Our recommended discharge criteria have been updated based on recent research findings and this handbook also includes an example of an updated checklist which we hope you will find helpful.

We have included a section which discusses the training and assessment needs of nurses fulfilling the ‘discharging nurse’ role and includes an example of written competency guidelines and an assessment tool.

The final section of this handbook suggests a number of indicators which may be used to audit the discharge process including the data which will be required and the standards which should be achieved.

The Council of BADS welcomes feedback from our members or others with experience in day or short stay surgery about any of the handbook series.

 

Although a post-operative review by both the operating surgeon and anaesthetist should be encouraged, assessment of when the patient is fit for discharge can, and should be performed by nursing staff using agreed protocols. These need to consider relevant social factors as well as a medical assessment of sufficient recovery for discharge.

All guidelines should address the following areas:

  • vital signs stable and comparable to that on admission
  • correct orientation as to time, place and person or comparable to that on admission
  • adequate pain control and supply of oral analgesia
  • understands how to use all medications supplied and has been given written information about these
  • ability to dress and walk where appropriate
  • minimal nausea, vomiting or dizziness
  • minimal bleeding or wound drainage
  • has passed urine if at high risk of retention - see below
  • has a responsible adult to take them home
  • has agreed to have a carer at home for next 24 hours
  • written and verbal instructions given about postoperative care
  • knows when to come back for follow up (if appropriate)
  • emergency contact number supplied

Recent Changes To Discharge Criteria

The oral intake of fluids is no longer a prerequisite prior to discharge home. Recent studies in both children and adults have demonstrated that patients who are strongly encouraged to drink prior to discharge are more likely to suffer from post-operative nausea & vomiting (PONV). Giving fluids intraoperatively reduces PONV, thirst, dizziness & drowsiness and thus allows earlier discharge. Oral intake is only necessary for selected patients, such as some diabetics, on a case by case basis[ii].

Voiding before discharge in patients with a low risk of urinary retention is also no longer considered necessary. Patients in this category should be asked to return to hospital if they are still unable to void 6-8 hours after discharge. Patient information leaflets with hints on managing difficulty voiding may be helpful for patients discharged before voiding.

Those at higher risk should have a bladder ultrasound examination performed to assess bladder volume and to determine the need for catheterisation. Handheld devices can be used by appropriately trained nurses in the day unit team and this will prevent delays[iii].

High risk patients include those who have had the following:

  • pelvic, genito-urinary rectal or inguinal hernia surgery
  • urinary catheterisation pre-operatively
  • history of urinary retention or difficulty with voiding
  • neuroaxial anaesthesia[iv].

An example of a discharge checklist reflecting these guidelines for inclusion in nursing documentation can be found in appendix B.

[1]Knottenbelt G, Van der Westhuizen J & Griffith N. Postoperative analgesia and discharge criteria for day surgery. Anaesthesia and Intensive Care Medicine 2007; 8(3)122-125.

[2]Gallagher J and Blackburn M. Tried and tested; the Verathon bladderscan. Journal of One Day Surgery. 2008; 18(3)66.

[3]Awad I and Chung F. Discharge criteria and recovery in ambulatory surgery. Day surgery Development and Practice-the International Association for Ambulatory Surgery 2006.

[4] Awad I and Chung F.  Discharge criteria and recovery in ambulatory surgery.  Day surgery Development and Practice-the International Association for Ambulatory Surgery 2006.

Regardless of how patient discharge is organised within individual units, the actual discharge process should create a climate in which patients and their carers understand their roles and responsibilities in on going care and therefore feel confident to go home. Written procedure-specific instructions are recommended as this reduces the possibility of information being forgotten or ignored and provides a valuable resource after discharge.

Specific discharge information should be prepared in readiness for each patient to ensure that discharge is as smooth and unrushed as possible. The communication skills of nurses in coordinating this process are therefore of utmost importance.

With the possible exception of a diagnosis, none of the information provided during the discharge process should be new. The practice of patients being given diagnostic information when still under the effects of anaesthetic should be avoided whenever possible. Uncertainty and anxiety about a diagnosis as a result of post-anaesthetic drowsiness will also interfere with the processing of other necessary discharge information. When this is unavoidable, nursing staff must ensure that information given is reinforced prior to discharge.

It is good practice, whenever possible; to include the patient’s identified carer in all pre-discharge assessment and information giving. Nursing staff must ensure that they assess both the patient and their carer’s understanding of their ongoing care responsibilities through structured questioning.

As a general guide, procedure specific information should encompass

  • medication, including specific instructions regarding prescribed analgesia, antiemetics or antibiotics
  • wound care (including drains) and when patient is able to bathe or shower
  • arrangements for dressing renewal and suture removal (if appropriate)
  • resuming normal activities, including return to work, sexual activities and exercise
  • what ‘normal’ symptoms may be expected and their duration
  • what symptoms may indicate a problem and what to do if they occur
  • contact telephone numbers for information or in an emergency
  • arrangements for follow-up (telephone and out-patients)

Please see appendix A for an example of a procedure specific information leaflet.

Guidelines for patient discharge within individual units require the consensus opinion of all involved in patient care, including anaesthetists, surgeons and nurses.

Such guidelines should not only address the generic criteria for discharge as suggested here, but should also consider discharge criteria for particular groups of patients.

These will address issues such as the minimum time span of stay for the patient prior to considering discharge (this is particularly pertinent when considering more invasive procedures, for example laparoscopic cholecystectomy, tonsillectomy and thyroid surgery).

Generic discharge criteria may also need to be adapted for particular procedures or patients: for example the patient who is unable to walk unaided from the unit following orthopaedic surgery to the foot. Common sense in such situations is clearly required and thus the individual surgical procedure or type of surgery undertaken may prompt additional specific criteria. It is vital that the discharging nurse is pragmatic in their approach and decision making.

Individual units may also wish to include a section in their guidelines offering advice to nursing staff on when to admit patients overnight and at what point to ask for a medical review. Patients who do not fulfil all of the generic criteria will not necessarily benefit from overnight admission, especially if they have already received maximal treatment for pain or nausea and vomiting. In these circumstances, patients who are willing to accept discharge and are confident in how to seek further help if required may be allowed to return to their own homes with a competent carer. Follow up telephone calls on the first post-operative day in these cases are good practice.

It is important that the guidelines are used once they have been agreed. Members of staff (anaesthetists, surgeons or nurses) who ignore them may call into question their own professional accountability as well as putting the reputation of a unit at risk. A robust process of assessing the competence of nursing staff in managing the discharge process may alleviate the fears of some clinical staff.

Nurse Led Discharge - Assessment of Competence

Nurse led discharge should only be undertaken by appropriately trained members of the day surgery team who have been deemed competent. Those undertaking this extended role should have completed a competency-based educational programme and have been assessed by a senior member of the day surgery staff.

It is important that any unit wishing to undertake nurse led discharge has a written protocol which outlines the standards which must be attained and the process which nursing staff must adhere to.

An example of a nurse led discharge protocol and competency assessment can be found in appendix C.

Nursing staff should be reassessed annually to ensure that levels of competence are maintained. The assessor should be confident that the nurse is competent in the discharge of patients from a representative range of specialties and following a variety of procedures.

The discharge of patients following minor procedures under local or regional anaesthetic may be competently undertaken by non-registered staff providing stringent guidelines are followed and a robust assessment process is in place[i]

[i] Tickner C. Health Care Assistant enabled discharge. Journal of One Day Surgery.2007; 17(4)106-9.

Regular audit of the discharge process should be undertaken and will ensure that it is being correctly applied and remains suitable for the procedures and patients being managed.

The Royal College of Anaesthetists suggests the following indicators for audit[vi]:

  1. Existence of discharge protocol
  2. % of patients who achieve agreed discharge criteria prior to discharge
  3. % of patients with pain scores indicating effective control of pain using analgesic methods which continue to be available after discharge
  4. % of patients who have written instructions on discharge
  5. % of patients who have a contact telephone number for a health professional on discharge
  6. % of patients who are satisfied with the arrangements for discharge
  7. % of patients in whom there is evidence that discharge home was not satisfactory for example due to readmission, early contact with a health professional or use of emergency contact number for reasons that auditor considers avoidable or unacceptable.

The proposed standard for best practice should be 100% for indicators 2-6 and as low as possible, ideally 0% for indicator 7.

Data should be collected from the discharge check-list and by telephoning patients at home 24 hours after discharge.

Common reasons for failure to reach the desired standards include

  • Failure to adhere to the agreed discharge policy
  • Inadequate verbal explanations
  • Misjudgement of the degree of pain likely to be experienced after discharge, particularly where local anaesthesia has been used and is still effective at time of discharge
  • Failure to realise social support was inadequate.

[vi]Royal College of Anaesthetists. Day Surgery Services. In: Colvin J R ed Raising the Standard 2006; 114-5.

iRoyal College of Nursing. Day Surgery Information-discharge planning 2004.

ii Knottenbelt G, Van der Westhuizen J & Griffith N. Postoperative analgesia and discharge criteria for day surgery. Anaesthesia and Intensive Care Medicine 2007; 8(3)122-125.

iii Gallagher J and Blackburn M. Tried and tested; the Verathon bladderscan. Journal of One Day Surgery. 2008; 18(3)66.

iv Awad I and Chung F. Discharge criteria and recovery in ambulatory surgery. Day surgery Development and Practice-the International Association for Ambulatory Surgery 2006.

v Tickner C. Health Care Assistant enabled discharge. Journal of One Day Surgery.2007; 17(4)106-9.

vi Royal College of Anaesthetists. Day Surgery Services. In: Colvin J R ed Raising the Standard 2006; 114-5.