Criteria Led Discharge - The Irish Journey

Abstract

Problem: Improving patient flow and patient experience, reducing Average Length of Stay and readmissions to hospital are key policy and service objectives of the HSE, the National Acute Medicine Programme, and the Department of Health. Criteria Led Discharge (CLD) is an inter-disciplinary tool to support patient engagement in care planning and to support planned discharge from hospital by competent members of the interdisciplinary team without consultant review on day of discharge. The tool is a documented plan identifying the agreed milestones and criteria a patient must meet in order for discharge by planned date of discharge to be effected by a member of the multidisciplinary team. Aim: The overall aim was to test the model of CLD to inform the development of a National tool to support discharge planning for Acute Hospital Services in Ireland. A literature search of the published and grey literature was carried out to identify potential models to test in an acute hospital setting. The Australian NSW Government model was selected and testing of its applicabilitiy in an Irish setting Highlights and Timeline: Testing, measurement and change management in in one acute medical ward of a rural general hospital (Model 3). Pareto analysis of admissions over the previous year revealed COPD to be the most common cause of admission, highest average length of stay. Patients in this category experienced high levels of readmission within 30 days of discharge and never left hospital before 11am. Testing commenced on all COPD patients admitted under one physician to a single ward in March 2016 for nine months initially. This cohort of patients were considered to be that which would realise most benefits in saved bed days, increasing time at home for patients with chronic illness (Red to Green days) and improved access for patients awaiting a bed. Interdisciplianry improvement work-streams for education and competency development; Documentation Policy and Guideline development; Data and outcomes measurement and Patient and Staff experience were established. Multiple Plan, Do, Study Act cycles were conducted. Resources developed included patient and staff information leaflets, CLD Criteria sheets, operating procedure guidelines, staff CLD competency and inhaler technique education programmes, programme visibility boards, patient self management plans (sick day rules, referral processes to CIT and Pulmonary rehab and a ward pharmacy medication reconciliation service commenced. Outcome: By December of 2016 the low volumn of patients were insufficient to demonstrate that reductions in admissions and readmissions were attributable to CLD. Testing was then spread to an all COPD patients admitted to any ward in the hospital under all medical physicians. Learning: Difficulties experienced in recruiting patients for formal PREM and PROM data collection.Informal patient feedback indicates enhanced empowerment and self care ability following inclusion in care planning and monitoring of progress against planned discharge date. Critical success factors: Governance support and stakeholder engagement Education and programme visibility Creating Visibility of the QI programme Team learning from PDSA’s Data, and mode of presentation to demonstrate impact and outcomes Supporting teams in developing QI capacity Clinical and cultural fit Conclusion: Integrated interdisciplinary approaches to planning date of discharge, involving patients in CLD formulation and sign off, and the process of documentation had the potential to be adapted to the Irish setting. commitment by nursing staff was was achieved through education and information. Further testing to demonstrate impact on AvLOS, Readmission and Home by 11 is required and will continue into 2017. A national Model for CLD spread and implementation will be developed drawing upon the experience of this test