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NHS England and NHS Improvement
A clear plan for every person
• Clinical criteria for discharge
• Criteria led discharge
@PeteGordon68 #homefirst #wherebestnest
2 |2 |
Don’t over complicate things – keep it as
simple as you can
3 |3 |
Start with the patient (the person) and work backwards –
what would we want to know?
Why is a plan so important?
1. Do I know what is wrong with me or what is
being excluded?
2. What is going to happen now, later today and
tomorrow to get me sorted out?
3. What do I need to achieve to get home? ‘Back to
baseline’ is rarely a useful phrase.
4. If my recovery is ideal and there is no
unnecessary waiting, when should I expect to go
home?
4 |4 |
Practical question - where should the
plan be written?
5 |
• Home when stable
• Home when mobile
• Start discharge planning
• Home after weekend
• Medically fit for discharge
when back to baseline
• Recheck bloods tomorrow
Common phrases – how clear are they?
6 |
Are you thinking
what I’m thinking
Dr Day?
7 |
Example acute kidney injury (AKI)
8 |
Example: GI bleed
9 |
Example - pneumonia
10 |10 |
• Mobility e.g. can walk up to 10
metres (exercise tolerance = 25
metres but toilet 10 metres away)
#EndPJparalysis
• Eating and drinking
• Toilet
• What does the person really want
and have the risks been explained
to them and / or their family?
• Plan to assess at home wherever
possible #homefirst
Functional and emotional criteria are
also important
11 |
A clear plan
12 |12 |
• Purpose to the patient
• Expectations to the relative
• Consistency for the MDT
• Confidence for the junior Dr
• Continuity for the nurse
• Clarity for integrated discharge
teams, social care and
community colleagues
• Assurance for the trust
Clinical criteria and a clear plan gives
13 |
https://improvement.nhs.uk/documents/629/expected-date-of-
discharge-and-clinical-criteria-RIG.pdf
https://www.youtube.com/playlist?list=PL6rrXMWFEqXL5NsTFy7z
ylDbYsAlZWul1
ECIST1On line resources
14 |
What is criteria led discharge?
‘Criteria led discharge is a process where the clinical parameters for a
patient’s discharge are clearly defined. They are determined in
accordance with; a care pathway, a clinical protocol (condition specific)
or a bespoke discharge plan.
The consultant leading the care and the multi-professional team
must agree the criteria; these may be standardised for particular
procedures or conditions, however must always be adapted to provide
person centred discharge.
The patient should be actively involved in the process of criteria led
discharge. The patient's discharge can then be facilitated by a
competent member of staff once those the criteria have been met’.
Dr Liz Lees-Deutsch and Jane Robinson, 2018.
15 | https://improvement.nhs.uk/documents/2040/Criteria_led_discharge_principles.pdf
Dr Liz Lees-Deutsch
Jane Robinson
16 |
Is criteria led discharge safe?
• YES
• 4 articles Bowen at al, Gotz et al, Webster et al and
Kasthuri et al.
• Complication rates
• Readmissions
• These were dependent upon:
• Process used
• Patient selection (removal/reassessment)
• Attainment of goals
• Patient and carer involvement
Dr Liz Lees-Deutsch
17 |
Does criteria led discharge reduce length of stay?
• YES
• 3 studies where this was primary outcome (surgical). Plus
3 where outcome was an indirect result
• On time – by a specific time
• Reduced delays (46% delay to 5% delay)
• No increase in LOS
• Context specific – not generalisable (always localise the
approach)
Dr Liz Lees-Deutsch
18 |
What are the enablers for criteria led discharge?
• Executive support and policy is needed for criteria led
discharge
• Pre-audit of current process against outcomes measures
e.g. length of stay
• Release of clinical staff time to participate in changes
required
• Establishing a multi-disciplinary steering group (shared
vision)
• Identification of the patient populations that would benefit
• Develop clearly defined criteria & associated process with
documentation. Identify staff training needs (across
professional groups)
Dr Liz Lees-Deutsch
19 |
Key points:
•Implementing criteria-led discharge
requires a review of the whole discharge
process
•Criteria-led discharge should be integrated
with the usual discharge process
•Outcome measures must be in place
before a project starts so effectiveness can
be evaluated
•Implementation should help practitioners to
take charge of the revised discharge
process
•Success will come to those who can show
they can safely adapt elements of their
existing discharge process, with clear robust
discharge criteria
Dr Liz Lees-Deutsch
20 |
It’s always good to hear from others
Phase 1
Cambridge J
Phase 2
Cambridge L
Phase 3
Cambridge
M2
Phase 4
King’s C2
We Just Did It
Matrons - Paula Knights and Maria Jenner
December 2019
Goals of CLD
• Increased weekend transfers (discharge) of care
• Early decisions leading to smooth discharge
• Reduced length of stay
• Improved patient and staff experience
• Improved communication
• Transparency of discharge plan for MDT
• It supports clinical judgement
Being Clear on what CLD is:
Commonly misinterpreted as:
‘the transference of total responsibility for the
discharge decision from doctors to nurses’
Lees L. ‘Making Nurse-Led Discharge Work to Improve Patient Care’
Nursing Times Vol. 100 No. 37 September 2004
What did we do?
• Started a conversation
• Four meetings
Initial feedback before the launch
of CLD…
• “It’s another job for us to do” – It’s what we do
already.
• “It’s not about quality” – It’s all about quality.
• “I may miss discharging my patients” – nursing teams
are the last contact.
After the initial meetings we…
• Identified key team including junior Drs
• Developed SOP
• Developed CLD forms
• Agreed a launch date of 1 November 2019
• Agreed outcome measures
• Introduced board round stickers
• Formulated the rhythm of the process
Rhythm of the Process
• Identification on the board round
• Board round sticker completed by the consultant with
medical or functional criteria documented
• Huddle – CLD form/check list completed
• Matron/Manager Call helpline over weekends
• Follow up contact on Monday
• Review of patients not discharged
Story so far
• Positive feedback from MDT including junior doctors
• Steering group (terms of reference)
• Competency framework / training programme including
scenarios e.g. would you discharge this patient?
Project Data & Outcomes
• Shows a shift in discharge profile demonstrating
increased Friday and weekend discharges during
November 2019
Project Data & Outcomes
21+ spiked at 9 Patients on 22 October, and has
reduced to <5 in recent weeks.
THE STORY OF CLD – AVON WARD SWFT
Already doing
‘active specialty
pull’ since 2017
Clinicians and Risk
Risk averse culture
No one wants to
take risks
Discharge
when
therapy
happy
Discharge
after review
by doctor
How about shared
responsibility and
shared risks?
What if the
patient falls
at home?
What if the
patient is
readmitted?
Team attitudes conducive to CLD
• Flattened hierarchy within the team
• Respectful challenge is the norm and encouraged
• Every member of the team has jobs allocated which
they take responsibility for and jobs are allocated
fairly
• No member of the team leaves until all the jobs are
completed. If you finish your work you help others.
How did CLD come about?
• Identified weekend discharges had to wait for
medical review prior to discharge-causing
delays
• Nurses- ‘we can facilitate some discharges if
you tell us exactly what is needed’
• Potential for increase in 4-6 (weekend)
monthly discharges if planned well
Aims of CLD
Set criteria and
agree
Nurse / junior
doctor
discharges
No need to
WAIT for
anybody senior
• Piloted in September 2018
• Audit after 3 months (September-December
2018)
• Further amendments made based on result
• Action continued
PDSA – testing
Process:
Proforma developed for manual data capture of
patients that fit into the CLD audit
CRITERIA LED DISCHARGE - FRIDAY PM HANDOVER AUDIT PROFORMA
DATE:
SISTER/WARDMANAGERINCHARGE:
DOCTORINCHARGE:
PATIENT STICKER
WEEKEND
DISCHARGE
YES /NO BY NURSE BY DOCTOR
REASON FOR NO WEEKEND DISCHARGE
/COMMENTS
Criteria proforma adapted to meet Avon ward needs
Dashboard developed to monitor discharges
This sticker is inserted in medical notes to allow safe discharge once patient is medically stable.
Clinical Criteria for Discharge (CCD) written on (DATE) …………………………/ Aim home on (DATE) …………………………
If the following safe clinical criteria is met, the patient can be discharged home by: NURSE □ DOCTOR □.
If patient deteriorates or the criteria are not met, the patient should be escalated for review by the medical team
1. NEWS: Pulse:…………………………………
2. BP:…………………..………………..
3. RR:…………………..………………..
4. 02 Stats:…………………….……….
Temperature:……………………..
Name of Consultant in charge of care: ____________________________________
Name of Dr planning CCD: PRINT _________________________SIGN ___________________________
Dr / Nurse in charge is signing to
 agree that the above criteria is met and patient will be discharged □
 or discharge delayed as criteria is not met □
Print Name ________________________ Signature_________________
Date: ___________________Time : __________________________________
This sticker is inserted in medical notes to allow safe discharge once patient is medically stable.
Clinical Criteria for Discharge (CCD) written on (DATE) …………………………/ Aim home on (DATE) …………………………
If the following safe clinical criteria is met, the patient can be discharged home by: NURSE □ DOCTOR □.
If patient deteriorates or the criteria are not met, the patient should be escalated for review by the medical team
1. NEWS: Pulse:…………………………………
2. BP:…………………..………………..
3. RR:…………………..………………..
4. 02 Stats:…………………….……….
Temperature:……………………..
Name of Consultant in charge of care: ____________________________________
Name of Dr planning CCD: PRINT _________________________SIGN ___________________________
Dr / Nurse in charge is signing to
 agree that the above criteria is met and patient will be discharged □
 or discharge delayed as criteria is not met □
Print Name ________________________ Signature_________________
Date: ___________________Time : __________________________________CTMS No:________________________
The stickers have been modified
with time by the team.
• Start thinking of patients suitable for CLD on the Thursday
board round (All the team agree, challenged and are aware)
• Firm up the list on the Thursday ward round
• Make sure this is communicated to the patient and family on
Thursday
• TTOs done for those patients between Thursday afternoon
and Friday AM (tasks allocated)
• Check again on Friday board round
The Process…1
• Friday PM - CLD stickers with clear criteria put on patient
notes – Nurse Discharge or Medical discharge
• Complexity of the patient decided whether it was the nurse or
doctor and was allocated only after discussion and
acceptance from the team
• Monday morning – review list to check if any patients were
not discharged and why – Education and feedback to the
team
The process …2
Challenges/Hesitation - Avon
• Lack of confidence with CLD
• Lack of understanding: why the need to
change what is already working
• We are already doing well-CLD will be extra
work- are we setting ourselves to fail?
• Perhaps try it on a ward with much longer
LOS
• Variable confidence within Nurses
• Junior doctors felt it was more work
• Friday handovers – too long – unable to
complete TTOs
• Finding justifications to delay discharge as the
criteria missed slightly
• Long list for ‘Out of hours’ tasks generated by
the junior doctors
Barriers
Overcoming Barriers
• Variable confidence within
Nurses
• Junior doctors felt it was
more work
• Friday handovers – too long
– unable to complete TTOs
• Finding justifications to
delay discharge as the
criteria missed slightly
• Long list for ‘Out of hours’
tasks generated by the
junior doctors
• Shared risk
• Checking if confident
before putting the sticker
• Supporting junior doctors
when completing exception
reporting
• Allowing them to peel off
certain handovers when
not needed
• Helping them plan the
weekend work
Audit Outcomes
Criteria Led Discharge Audit
(Sept 2018 -Dec 2018) Results
Total no. highlighted for CLD 47
Number of patients discharged using criteria 36 (75%)
Failed d/c due to medical reasons 5 (10%)
Failed d/c due to social reasons* 4 (8.5%)
Failed d/c due to other/unknown** 2 (4.2%)
No. of CLD requiring medical review 13 (28%)
*Mostly POC/NH placement not ready to start
**e.g. Family concern over mobility/Therapy issue
CLD examples
CCF Excess alcohol
Outcomes a year into CLD practice
Emergency Admissions; Avon LOS
Active Diabetes
pull and POW Criteria Led
Discharge
2016/17 2017/18 2018/19 2019/20
Predicted 0 0 0 82
Recorded 73 100 125 62
0
20
40
60
80
100
120
140
160
NumberofWeekendDischargesfortheYear(NB
2019/20=5months)
Avon Weekend Discharges
Active Diabetes
pull and POW
Criteria Led
Discharge
25
Avon Total Discharges
2019/20 whole year prediction for total discharges is 1079 pts – a rise of over
20% to previous year
2016/17 2017/18 2018/19 2019/20
Predicted 0 0 0 630
Recorded 605 724 887 449
0
200
400
600
800
1000
1200
TotalNumberofAonDischargesfortheYear(NB
2019/20=5months)
Active Diabetes
pull and POW
Criteria Led
Discharge
163
Quote by Consultant..
Lessons Learned
CLD is a culture change – it is not about stickers only
CLD is not about weekend discharges only – Once the culture changes it has a
profound effect on week day discharges
CLD is a tool for ‘timely discharge’ and instrumental in LLOS
CLD is not about weekend or weekday discharges only – part of the ‘SAFER patient
flow bundle’
52 |52 |
Discussion

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Clinical criteria for discharge - ECIST webinar 06 02-20 (P Gordon)

  • 1. NHS England and NHS Improvement A clear plan for every person • Clinical criteria for discharge • Criteria led discharge @PeteGordon68 #homefirst #wherebestnest
  • 2. 2 |2 | Don’t over complicate things – keep it as simple as you can
  • 3. 3 |3 | Start with the patient (the person) and work backwards – what would we want to know? Why is a plan so important? 1. Do I know what is wrong with me or what is being excluded? 2. What is going to happen now, later today and tomorrow to get me sorted out? 3. What do I need to achieve to get home? ‘Back to baseline’ is rarely a useful phrase. 4. If my recovery is ideal and there is no unnecessary waiting, when should I expect to go home?
  • 4. 4 |4 | Practical question - where should the plan be written?
  • 5. 5 | • Home when stable • Home when mobile • Start discharge planning • Home after weekend • Medically fit for discharge when back to baseline • Recheck bloods tomorrow Common phrases – how clear are they?
  • 6. 6 | Are you thinking what I’m thinking Dr Day?
  • 7. 7 | Example acute kidney injury (AKI)
  • 9. 9 | Example - pneumonia
  • 10. 10 |10 | • Mobility e.g. can walk up to 10 metres (exercise tolerance = 25 metres but toilet 10 metres away) #EndPJparalysis • Eating and drinking • Toilet • What does the person really want and have the risks been explained to them and / or their family? • Plan to assess at home wherever possible #homefirst Functional and emotional criteria are also important
  • 11. 11 | A clear plan
  • 12. 12 |12 | • Purpose to the patient • Expectations to the relative • Consistency for the MDT • Confidence for the junior Dr • Continuity for the nurse • Clarity for integrated discharge teams, social care and community colleagues • Assurance for the trust Clinical criteria and a clear plan gives
  • 14. 14 | What is criteria led discharge? ‘Criteria led discharge is a process where the clinical parameters for a patient’s discharge are clearly defined. They are determined in accordance with; a care pathway, a clinical protocol (condition specific) or a bespoke discharge plan. The consultant leading the care and the multi-professional team must agree the criteria; these may be standardised for particular procedures or conditions, however must always be adapted to provide person centred discharge. The patient should be actively involved in the process of criteria led discharge. The patient's discharge can then be facilitated by a competent member of staff once those the criteria have been met’. Dr Liz Lees-Deutsch and Jane Robinson, 2018.
  • 16. 16 | Is criteria led discharge safe? • YES • 4 articles Bowen at al, Gotz et al, Webster et al and Kasthuri et al. • Complication rates • Readmissions • These were dependent upon: • Process used • Patient selection (removal/reassessment) • Attainment of goals • Patient and carer involvement Dr Liz Lees-Deutsch
  • 17. 17 | Does criteria led discharge reduce length of stay? • YES • 3 studies where this was primary outcome (surgical). Plus 3 where outcome was an indirect result • On time – by a specific time • Reduced delays (46% delay to 5% delay) • No increase in LOS • Context specific – not generalisable (always localise the approach) Dr Liz Lees-Deutsch
  • 18. 18 | What are the enablers for criteria led discharge? • Executive support and policy is needed for criteria led discharge • Pre-audit of current process against outcomes measures e.g. length of stay • Release of clinical staff time to participate in changes required • Establishing a multi-disciplinary steering group (shared vision) • Identification of the patient populations that would benefit • Develop clearly defined criteria & associated process with documentation. Identify staff training needs (across professional groups) Dr Liz Lees-Deutsch
  • 19. 19 | Key points: •Implementing criteria-led discharge requires a review of the whole discharge process •Criteria-led discharge should be integrated with the usual discharge process •Outcome measures must be in place before a project starts so effectiveness can be evaluated •Implementation should help practitioners to take charge of the revised discharge process •Success will come to those who can show they can safely adapt elements of their existing discharge process, with clear robust discharge criteria Dr Liz Lees-Deutsch
  • 20. 20 | It’s always good to hear from others
  • 21. Phase 1 Cambridge J Phase 2 Cambridge L Phase 3 Cambridge M2 Phase 4 King’s C2 We Just Did It Matrons - Paula Knights and Maria Jenner December 2019
  • 22. Goals of CLD • Increased weekend transfers (discharge) of care • Early decisions leading to smooth discharge • Reduced length of stay • Improved patient and staff experience • Improved communication • Transparency of discharge plan for MDT • It supports clinical judgement
  • 23. Being Clear on what CLD is: Commonly misinterpreted as: ‘the transference of total responsibility for the discharge decision from doctors to nurses’ Lees L. ‘Making Nurse-Led Discharge Work to Improve Patient Care’ Nursing Times Vol. 100 No. 37 September 2004
  • 24. What did we do? • Started a conversation • Four meetings Initial feedback before the launch of CLD… • “It’s another job for us to do” – It’s what we do already. • “It’s not about quality” – It’s all about quality. • “I may miss discharging my patients” – nursing teams are the last contact.
  • 25. After the initial meetings we… • Identified key team including junior Drs • Developed SOP • Developed CLD forms • Agreed a launch date of 1 November 2019 • Agreed outcome measures • Introduced board round stickers • Formulated the rhythm of the process
  • 26. Rhythm of the Process • Identification on the board round • Board round sticker completed by the consultant with medical or functional criteria documented • Huddle – CLD form/check list completed • Matron/Manager Call helpline over weekends • Follow up contact on Monday • Review of patients not discharged
  • 27. Story so far • Positive feedback from MDT including junior doctors • Steering group (terms of reference) • Competency framework / training programme including scenarios e.g. would you discharge this patient?
  • 28. Project Data & Outcomes • Shows a shift in discharge profile demonstrating increased Friday and weekend discharges during November 2019
  • 29. Project Data & Outcomes 21+ spiked at 9 Patients on 22 October, and has reduced to <5 in recent weeks.
  • 30. THE STORY OF CLD – AVON WARD SWFT Already doing ‘active specialty pull’ since 2017
  • 31. Clinicians and Risk Risk averse culture No one wants to take risks Discharge when therapy happy Discharge after review by doctor How about shared responsibility and shared risks? What if the patient falls at home? What if the patient is readmitted?
  • 32. Team attitudes conducive to CLD • Flattened hierarchy within the team • Respectful challenge is the norm and encouraged • Every member of the team has jobs allocated which they take responsibility for and jobs are allocated fairly • No member of the team leaves until all the jobs are completed. If you finish your work you help others.
  • 33. How did CLD come about? • Identified weekend discharges had to wait for medical review prior to discharge-causing delays • Nurses- ‘we can facilitate some discharges if you tell us exactly what is needed’ • Potential for increase in 4-6 (weekend) monthly discharges if planned well
  • 34. Aims of CLD Set criteria and agree Nurse / junior doctor discharges No need to WAIT for anybody senior
  • 35. • Piloted in September 2018 • Audit after 3 months (September-December 2018) • Further amendments made based on result • Action continued PDSA – testing
  • 36. Process: Proforma developed for manual data capture of patients that fit into the CLD audit CRITERIA LED DISCHARGE - FRIDAY PM HANDOVER AUDIT PROFORMA DATE: SISTER/WARDMANAGERINCHARGE: DOCTORINCHARGE: PATIENT STICKER WEEKEND DISCHARGE YES /NO BY NURSE BY DOCTOR REASON FOR NO WEEKEND DISCHARGE /COMMENTS Criteria proforma adapted to meet Avon ward needs Dashboard developed to monitor discharges This sticker is inserted in medical notes to allow safe discharge once patient is medically stable. Clinical Criteria for Discharge (CCD) written on (DATE) …………………………/ Aim home on (DATE) ………………………… If the following safe clinical criteria is met, the patient can be discharged home by: NURSE □ DOCTOR □. If patient deteriorates or the criteria are not met, the patient should be escalated for review by the medical team 1. NEWS: Pulse:………………………………… 2. BP:…………………..……………….. 3. RR:…………………..……………….. 4. 02 Stats:…………………….………. Temperature:…………………….. Name of Consultant in charge of care: ____________________________________ Name of Dr planning CCD: PRINT _________________________SIGN ___________________________ Dr / Nurse in charge is signing to  agree that the above criteria is met and patient will be discharged □  or discharge delayed as criteria is not met □ Print Name ________________________ Signature_________________ Date: ___________________Time : __________________________________
  • 37. This sticker is inserted in medical notes to allow safe discharge once patient is medically stable. Clinical Criteria for Discharge (CCD) written on (DATE) …………………………/ Aim home on (DATE) ………………………… If the following safe clinical criteria is met, the patient can be discharged home by: NURSE □ DOCTOR □. If patient deteriorates or the criteria are not met, the patient should be escalated for review by the medical team 1. NEWS: Pulse:………………………………… 2. BP:…………………..……………….. 3. RR:…………………..……………….. 4. 02 Stats:…………………….………. Temperature:…………………….. Name of Consultant in charge of care: ____________________________________ Name of Dr planning CCD: PRINT _________________________SIGN ___________________________ Dr / Nurse in charge is signing to  agree that the above criteria is met and patient will be discharged □  or discharge delayed as criteria is not met □ Print Name ________________________ Signature_________________ Date: ___________________Time : __________________________________CTMS No:________________________ The stickers have been modified with time by the team.
  • 38. • Start thinking of patients suitable for CLD on the Thursday board round (All the team agree, challenged and are aware) • Firm up the list on the Thursday ward round • Make sure this is communicated to the patient and family on Thursday • TTOs done for those patients between Thursday afternoon and Friday AM (tasks allocated) • Check again on Friday board round The Process…1
  • 39. • Friday PM - CLD stickers with clear criteria put on patient notes – Nurse Discharge or Medical discharge • Complexity of the patient decided whether it was the nurse or doctor and was allocated only after discussion and acceptance from the team • Monday morning – review list to check if any patients were not discharged and why – Education and feedback to the team The process …2
  • 40. Challenges/Hesitation - Avon • Lack of confidence with CLD • Lack of understanding: why the need to change what is already working • We are already doing well-CLD will be extra work- are we setting ourselves to fail? • Perhaps try it on a ward with much longer LOS
  • 41. • Variable confidence within Nurses • Junior doctors felt it was more work • Friday handovers – too long – unable to complete TTOs • Finding justifications to delay discharge as the criteria missed slightly • Long list for ‘Out of hours’ tasks generated by the junior doctors Barriers
  • 42. Overcoming Barriers • Variable confidence within Nurses • Junior doctors felt it was more work • Friday handovers – too long – unable to complete TTOs • Finding justifications to delay discharge as the criteria missed slightly • Long list for ‘Out of hours’ tasks generated by the junior doctors • Shared risk • Checking if confident before putting the sticker • Supporting junior doctors when completing exception reporting • Allowing them to peel off certain handovers when not needed • Helping them plan the weekend work
  • 44. Criteria Led Discharge Audit (Sept 2018 -Dec 2018) Results Total no. highlighted for CLD 47 Number of patients discharged using criteria 36 (75%) Failed d/c due to medical reasons 5 (10%) Failed d/c due to social reasons* 4 (8.5%) Failed d/c due to other/unknown** 2 (4.2%) No. of CLD requiring medical review 13 (28%) *Mostly POC/NH placement not ready to start **e.g. Family concern over mobility/Therapy issue
  • 46. Outcomes a year into CLD practice
  • 47. Emergency Admissions; Avon LOS Active Diabetes pull and POW Criteria Led Discharge
  • 48. 2016/17 2017/18 2018/19 2019/20 Predicted 0 0 0 82 Recorded 73 100 125 62 0 20 40 60 80 100 120 140 160 NumberofWeekendDischargesfortheYear(NB 2019/20=5months) Avon Weekend Discharges Active Diabetes pull and POW Criteria Led Discharge 25
  • 49. Avon Total Discharges 2019/20 whole year prediction for total discharges is 1079 pts – a rise of over 20% to previous year 2016/17 2017/18 2018/19 2019/20 Predicted 0 0 0 630 Recorded 605 724 887 449 0 200 400 600 800 1000 1200 TotalNumberofAonDischargesfortheYear(NB 2019/20=5months) Active Diabetes pull and POW Criteria Led Discharge 163
  • 51. Lessons Learned CLD is a culture change – it is not about stickers only CLD is not about weekend discharges only – Once the culture changes it has a profound effect on week day discharges CLD is a tool for ‘timely discharge’ and instrumental in LLOS CLD is not about weekend or weekday discharges only – part of the ‘SAFER patient flow bundle’

Editor's Notes

  1. Plan, do, study, act (PDSA) cycles to test an idea by trialling a change on a small scale and assess its impact, building upon the learning from previous cycles in a structured way before whole scale implementation
  2. Junior doctors felt it was more work: The consultants agreed that since it was a new process, they would support them until it was business as usual. So they supported the juniors in ‘exception reporting’ to the educational supervisor if they had to stay back. Once the juniors saw the value to the patients and the support they got, they stopped the reporting. They also learned incorporated it in their day time tasks. Friday handovers: There is a routine ward handover from the COW of the current week to the COW of the following week on a Friday. The CLD list was initially part of this handover. This long handover kept the juniors from doing the tasks. So the handover was split and the juniors were asked to attend only the CLD handover so the TTOs could be done in a timely way. Finding justifications to delay discharge as the criteria missed slightly – Monday morning review of the CLD list to educate and empower nurses and doctors to deviate safely from the criteria or escalate if necessary was introduced. Long list for Out of hours tasks generated by the junior doctors: The consultants took responsibility to challenge the worklist for the weekend teams. The list was minimised by removing unnecessary reviews, blood tests etc. which did not change management. The Out of hours work from the ward was monitored closely.  
  3. Junior doctors felt it was more work: The consultants agreed that since it was a new process, they would support them until it was business as usual. So they supported the juniors in ‘exception reporting’ to the educational supervisor if they had to stay back. Once the juniors saw the value to the patients and the support they got, they stopped the reporting. They also learned incorporated it in their day time tasks. Friday handovers: There is a routine ward handover from the COW of the current week to the COW of the following week on a Friday. The CLD list was initially part of this handover. This long handover kept the juniors from doing the tasks. So the handover was split and the juniors were asked to attend only the CLD handover so the TTOs could be done in a timely way. Finding justifications to delay discharge as the criteria missed slightly – Monday morning review of the CLD list to educate and empower nurses and doctors to deviate safely from the criteria or escalate if necessary was introduced. Long list for Out of hours tasks generated by the junior doctors: The consultants took responsibility to challenge the worklist for the weekend teams. The list was minimised by removing unnecessary reviews, blood tests etc. which did not change management. The Out of hours work from the ward was monitored closely.  
  4. Junior doctors felt it was more work: The consultants agreed that since it was a new process, they would support them until it was business as usual. So they supported the juniors in ‘exception reporting’ to the educational supervisor if they had to stay back. Once the juniors saw the value to the patients and the support they got, they stopped the reporting. They also learned incorporated it in their day time tasks. Friday handovers: There is a routine ward handover from the COW of the current week to the COW of the following week on a Friday. The CLD list was initially part of this handover. This long handover kept the juniors from doing the tasks. So the handover was split and the juniors were asked to attend only the CLD handover so the TTOs could be done in a timely way. Finding justifications to delay discharge as the criteria missed slightly – Monday morning review of the CLD list to educate and empower nurses and doctors to deviate safely from the criteria or escalate if necessary was introduced. Long list for Out of hours tasks generated by the junior doctors: The consultants took responsibility to challenge the worklist for the weekend teams. The list was minimised by removing unnecessary reviews, blood tests etc. which did not change management. The Out of hours work from the ward was monitored closely.  
  5. 75% of patients highlighted for discharge went home on the day planned. 28% of these needed a medical review to facilitate their discharge – either planned or unplanned. Some of these include patients admitted to Avon ward over the weekend (i.e. from Friday afternoon onwards) and therefore were not planned CLD discharges – medical review unavoidable in this circumstance