Discharge planning

Discharge planning

May 4, 2015 3
General medicine,general surgery,onthepods,pre-internship
Summary Writer:  Jenny Liu
Editor:  James Edwards
Interviewee:  Jenny Liu

James talks to Dr Jenny Liu about discharge planning tips on the wards.

About Dr Jenny Liu

Jenny is currently a resident medical officer at Royal Prince Alfred Hospital and a medical graduate from the University of New South Wales. Jenny has strong interests in translational research having completed a PhD in oncology. She is also passionate about medical education and an advocate for patient flow and discharge planning in the hospital system.

Discharge Planning

With Dr Jia (Jenny) Liu, Resident Medical Officer at Royal Prince Alfred Hospital, New South Wales, Australia

Case

You are rounding on your first week of internship on the respiratory team and you are seeing Mr Thomson, a 75-year-old man admitted with haemoptysis and found to have a new diagnosis of metastatic lung cancer. He’s had a complicated 30-day admission and received palliative radiotherapy for bony metastases, had an episode of delirium and urosepsis. His pain is improving after the palliative care team started him on multiple opioids, but he is still requiring oxygen. The consultant tells you ‘aim discharge in a few days.’

  • This patient has many issues – ideally discharge planning has started from the beginning of his admission, and not when the consultant states ‘aim for discharge’
  • Medications: He is on multiple opioids, so his discharge medications are going to be complicated
  • Social supports: He is an elderly man who has been in hospital for 30 days. It is possible that he may not be able to return home. It is important to look into whether he has support at home, what his independence with ADLs is and whether he needs further assistance
  • Complicated discharge summary: Multiple teams have been involved during the length of his stay, so it is important for you to ensure that the story is correct for ongoing continuity of care
  • Deconditioning and mobility: Given his long admission, his mobility may not have returned to baseline. It is possible that he may need rehabilitation or home modifications (if discharge home is appropriate). It is important to involve physiotherapy and occupational therapy early for discharge planning
  • End of life care planning: Given he has metastatic lung cancer, and that palliative care are involved, suggests that he has a terminal illness. It may be important to look at end-of-life care planning, perhaps the team approaching the patient/family about advanced care directives. If he was to become unwell again, is an acute hospital the most appropriate place for him to come back to, or would he and his family prefer to go to a hospice? Liaising with the palliative care team and their community team who would be very important
  • Home oxygen: He is still requiring oxygen and for many new interns organising home oxygen can be a daunting task. The logistics vary from hospital to hospital and depends on whether the patient can afford the out of pocket expenses or if they fulfil certain criteria
  • Organising follow-up appointments: Likely Mr Thomson will require further follow up with oncology, palliative care and respiratory teams, so it is important for you to liaise with those teams and find out what follow up arrangements are required
  • Educating patients and family: Educating the patient and family regarding all the above issues prior to discharge is important
  • Physiotherapy: important for assessing mobility, providing mobility aids, defining rehabilitation goals prior to going home/referral to rehabilitation
  • Occupational therapy: home modifications – e.g. rails, extra bathroom equipment etc to prevent falls, if this patient has back pain from his bony metastases, and reduced mobility from his long admission
  • Social work: need for emotional/psychosocial support, organising community care packages e.g. COMPACKs, organising financial support, assistance with transport to outpatient appointments e.g. with radiotherapy, oncology or palliative care
  • Dietitian: Important for many oncology patients who can be quite cachectic, the dietitian may provide advice about optimising nutrition in the setting of advanced cancer
  • Pharmacist: Advise on safety of medications, medication interactions. Some hospitals may also have a discharge liaison pharmacist who may be able to speak with patients with complicated regimes, e.g. recently started on warfarin, or multiple S8 medications and educating patients/families about taking these medications, when to use breakthroughs etc
  • Community palliative care nurses: Many patients seen by inpatient palliative care teams can link in with community palliative care nurses who see the patient in their homes after discharge. This can be organised with the aid of the palliative care team
  • Role of family conference: Given there are multiple allied health staff involved in this case, it can be helpful to organise a family conference to bring all the members of the multidisciplinary team together with the treating teams, patient and family so that everyone has a common understanding of the patient’s requirements and what is needed for safe discharge
  • Note: logistical issues with discharge planning are common!
  • Initially the ward NUM (nursing unit manager) is your best contact as they have had many years of experience on the wards, and may be able to refer you to the right contact
  • Palliative care team or respiratory team if involved for the patient may help provide advice for logistical issues with organising home oxygen
  • Discuss these issues with your registrar and/or consultant – as a JMO you are never expected to work alone!
  • Medications – organise ahead of time, e.g. pharmacy can get very busy on Friday afternoons. Try and order medications the day prior to the expected date of discharge. Ensure the patient and carer are educated about new medications or medication changes, and involve the ward pharmacist or discharge liaison pharmacists (where available)
  • Accurate and complete discharge summaries – can be difficult when starting a new term. It is always courteous to update discharge letters prior to finishing a term and hopefully your colleagues will return the favour
  • Social history not known early during admission, and delayed allied health involvement – involve allied health only when the patient is ‘medically cleared’ for discharge will delay discharges. As an intern, getting a social history early during admission can help identify flags that may delay discharge and will alert you to involve allied health early
  • Lack of communication about discharge planning – communicate about the estimated date of discharge and ensure patients and carers are on the same page as the medical team with regards to the estimated date of discharge
  • Communication – raise concerns regarding discharge dilemmas early on with your team and ward NUM
  • Be organised – start discharge summaries and medications scripts ahead of time
  • Involve allied health early in admission
  • Take a good social history early in admission
  • Liaise with the family and GP
  • Don’t be afraid to ask the registrar/consultant about the expected discharge date and ask about follow up appointments and medications needed on discharge

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Tags: #communication,#discharge,#discharge planning,#discharge summary,#end of life care planning,#home oxygen,#JMO,#NUM,#opioids

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