Crank up the flow

Criteria-led discharge is still a developing system but it’s already helping nurses move patients out of surgical wards more quickly. 

The effectiveness of criteria-led discharge is being evaluated within a gastrointestinal surgical ward.

Flinders Medical Centre has adopted the approach in an effort to increase the flow of patients. Once patients meet set criteria, as determined by medical staff and supported by current evidence-based practice, they are discharged by senior nursing staff.

“This allows for a streamlined approach for high-flow patients within the ward, resulting in improved patient management and bed flow, whilst reducing the bed block from emergency,” Flinders acting clinical services coordinator Natasha White says. “As a division in the hospital, we’ve known that our discharge process could be improved, and are working towards improving that.”

White says the plan was to test the ward’s policies and procedures regarding the implementation and evaluation of the care given.

She says the new system has made the discharge process simpler. “It makes it more of a streamlined and holistic approach because the nursing staff are able to do the whole process of getting them ready for theatre, looking after them when they’ve returned and then discharging them once they’ve met that criteria,” White says.

The process was implemented due to a need for timelier and more efficient discharges, based on the backflow from the emergency department, the Monahan hospital performance review, and a government-initiated 90-day change project.

Previously established protocols were used to develop the criteria for discharges, including aspects such as ensuring a patient’s vital signs are normal and making sure the patient is ambulating OK, moving independently, tolerating food and fluids and managing pain. Patients must also have minimal wound discharge and know what to do if they have any problems.

To start the process, doctors nominate patients for a CLD release if they lack complications in theatre and handle surgery well. Patients who aren’t nominated are kept in hospital and medical staff review them.

White says the system also allows nursing staff to use their clinical skills and judgement, and “maintain a patient flow within the ward, because the patients are being discharged earlier”, and also allows patients to understand that they need to meet certain criteria, so they can work towards that.

She added that CLD also allows staff to attend to more acute patients waiting in the emergency department.

“What the other hospitals can learn from our implementation is that CLD in a short-stay surgical ward can be successful, and our results show that.” White explains that it’s easier to begin with a smaller cohort of patients, ensuring early results can be observed, rather than trialling in a general medical ward or with a difficult patient case.

Flinders designed its CLD program by reviewing literature on current best practice. This led to the development of audit questions, which allowed the staff to adjust the protocols based on patient cases.

The audits revealed issues with the new process. “No patients received the appropriate education on admission regarding procedure, expected length of stay, care on discharge and expected progress during their stay,” White says. Patients also didn’t understand that there was a chance they would be returning home reasonably quickly post-operatively, potentially without seeing a surgeon after their procedure.

“On a positive note, all patients were approved for discharge by a medical officer and had a condition-specific assessment completed; everyone involved in the CLD process had education, and there was a policy in place,” White says.

At that point, two senior nursing staff were enlisted to educate patients upon admission. As Bev Draper, Flinders’ clinical practice improvement officer, says, “Involving the patient in the decision-making process is pretty important and having them involved with that allays their anxiety.” This led to patients feeling further engaged and more comfortable.

Outside of the times the nurses were present, however, there were still patients who were not being educated. This led to the information being written into admission packs for patients. This latest approach has yet to be audited.

White says there have been improvements in performance indicators such as length of stay, time of discharge and readmission rates. In fact, there has been only one readmission, for probable cholangitis.

Draper says whilst CLD does have benefits, she doesn’t think it’s the only solution to improving the flow of the patient’s journey. “I think it may have merit but I think it has to be in conjunction with improving other processes as well,” she says.

She says issues were still being worked through and the process has not yet been implemented beyond gastrointestinal surgical patients, adding further extensive reviews are needed before implementation within other surgery groups.

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