Audit of

Abstract

Problem identified: The National Inpatient Experience Survey (NIES) conducted in the Mercy University Hospital in 2022 exposed poor quality of information sharing with patients and their families upon discharge. Discharge planning for elderly patients can reduce readmission rates and hospital length of stay (NICE 2018, Goncalves-Bradley et al. 2016). A reduction in days spent in hospital results in reduced cost of care (Goncalves-Bradley et al. 2016). Individualised discharge plans for inpatients improves patient and healthcare provider satisfaction (Goncalves-Bradley et al. 2016). Eighty percent of discharges from an acute hospital setting are considered simple and predictable (NICE 2018). For this reason, failure to communicate effectively is found to be the main cause of simple discharges being delayed (NICE 2018). Discharge planning is not standardised across healthcare settings in the NHS (NICE 2018); however, the Nursing and Midwifery Board of Ireland (NMBI) have set documentation standards in Irish hospitals (NMBI 2015). HIQA (2012) National Standards for Safer Better Healthcare promote sharing of timely and relevant information between the multidisciplinary team and services upon discharge. A Patient Discharge Plan checklist facilitates this in the acute setting. The HSE (2014) sets out nine steps to effective discharge planning in the National Guideline for Quality and Patient Safety. Step eight refers to “Use a discharge checklist 24‐48 hours before discharge” (HSE 2014). Discharge checklists are advised to enhance effective communication between the patient, members of the multi‐disciplinary team, hospital, primary and community service providers (HSE 2014). A discharge checklist can communicate actions taken and those still outstanding (HSE 2014). A re-audit of Patient Discharge Plans within the Careful Nursing Document was conducted. Design: Retrospective review of Healthcare Records (HCR) on 8 medical/surgical wards within 24-72 hours of patient discharge. Tool: NMBI Documentation Discharge Planning Metrix tool. Six indicators included. Collected by 1 person using the data collection tool which was piloted initially. Timeline: Seven consecutive days, 31st January – 7th February 2023. Inclusion/Exclusion Criteria: Include patients 65 years old and older. Quantitative data collected from checklist with some free text in Discharge Care Plan to supplement. Exclude day cases, patients who died and patients taking HCR to another clinical setting. Sample: Consecutive snapshot sampling. 36 HCR audited, approximately half of that week’s total Older Adult (OA) discharges (average of 70-75 OA discharged/week in MUH). Standard: HSE (2014) National Guideline for Quality and Patient Safety. 100% compliance to checklist completion required. Permission: Granted by ADON Bed Management and Quality and Risk Department in MUH. Discussed with Nursing Practice and Development (NPDU) and Discharge Planning Sub-Committee seeking to improve NIES result. GDPR and anonymity were upheld. Medical records number, date of birth and discharge destination recorded. Code sheet used. Results: 100% compliance with all 6 indicators was only achieved in 3 of 36 (8%) of audited HCR. There was 58% compliance with pre-discharge checklist completion (Indicator 1) which increased to 75% completion of Day of Discharge Checklist section (Indicator 2) highlighting discrepancies in timely documentation (see Figure 3). Sixty-three percent compliance with Standard 3 has disimproved since July 2022 audit where 72% compliance was noted. This audit used the same tool but general population over one week. Recommendations: Revise effectiveness/efficiency/conduciveness of discharge planning checklist documentation with the Documentation Committee and Nursing Practice and Development Unit. Make alterations to documentation/checklist and PPPG using feedback (HSE 2016 & Powell et al. 2015). Utilise Documentation Champions on the wards to remind clinicians (Powell et al. 2015). Use findings to focus ward-based education sessions with staff nurses on checklist areas requiring improvements (Powell et al. 2015). Limitations: Convenient snapshot sample method used may not represent the overall compliance. Current reduced nurse staffing levels and seasonal overcrowding of service may have allowed bias. Conclusions; Re-audit should be planned post checklist review and education delivery (approx. 6 months) rather than NMBI (2015) recommendation of annually. Since this audit in February 2023, Discharge Planning sub-committee have progressed with revising the Discharge Planning Checklist with the Documentation Committee and NPDU. Recommendations have been made to alter the information required to be more patient friendly. These alterations are due to go to print in June 2023. The findings of the audit will be utilised going forward to roll out education with new checklists on the wards to staff nurses and CNMs via Documentation Champions, the sub-committee and NPDU. A change in nursing practice is being implemented with the new checklists which includes nursing staff photocopying the checklist for each patient. The patient will take this checklist copy home upon discharge as a source of person-centred information with contact details of community supports and treatment plans outlined. The aim is that each ward will have photocopying facilities and each staff nurse/CNM will have access to this. This project is ongoing.