Published: 30/05/2002, Volume II2, No. 5807 Page 28 29
Patients often have to stay in hospital longer than planned, even on their day of discharge, because they are waiting to be collected or waiting for medicines to take home. This can have an impact on the running of wards that are always under pressure to admit new patients.
This is an important issue across the NHS and the challenge is to find solutions that will ensure quality of care, at the same time as making the most effective use of beds. Any delay in discharge will affect a trust's accident and emergency department and leave patients being nursed inappropriately on a trolley. Nursing patients in A&E, whether in a bed or on a trolley, denies them access to an environment conducive to the privacy, care and consultation to which they are entitled.
Government targets require trusts to aim for less than 1 per cent of emergency patients having a trolley wait of more than four hours, once the decision to admit them has been taken.We have found that the creation of a lounge for patients awaiting discharge can help free beds early on in the day.
The hospital initiated a review to identify areas that contributed to delays when transferring patients to their treatment ward. It found that patients who no longer required inpatient care occupied beds for the greater part of a day because their discharge arrangements were being finalised, or they were waiting for collection. This led to a backlog in A&E or the admissions unit until discharge in the afternoon and evening freed the beds.
In April 2001, it was decided to set up a discharge lounge in one of the elderly care wards where those waiting to leave can sit and wait in comfort. The lounge is situated on the ground floor with access to lifts and easy access for cars and ambulances. It cost£2,000 to set up and is equipped with armchairs, television and video. A bed and oxygen are available in case of emergencies.Meals and hot drinks are served. The average time patients spend in the lounge is two hours.
It is staffed by a full-time co-ordinator, who is an experienced nursing auxiliary. There is also a fulltime support worker. These staff are supported by the senior nurse on duty on the ward in which the lounge is situated. This registered nurse is available if an emergency occurs. The area is open from 10am until 6pm, closing after the last patient has been discharged. The running costs in the first year were£30,000.
All adult wards in the hospital now use the discharge lounge, but the most frequent use is by the six elderly care wards. The referring wards are responsible for ensuring patients have all their belongings and that whoever is collecting them is aware of the arrangements. They also make sure patients' drug charts and case notes are taken with them to the lounge and that any medicines required are taken home or have been ordered.
The discharge lounge staff are responsible for liaising with the hospital pharmacy, patients' families and the ambulance service, and ensuring that patients are provided with refreshments. The discharge lounge co-ordinator looks at patients' destinations and works with ambulance control to minimise repeated journeys. Patients are transferred to the lounge by the support worker or by hospital porters.Much time is saved as ambulance crews do not have to collect patients from several different areas of the hospital.
The target for the discharge lounge is to have an average throughput of 11 patients per day. This figure ensures financial viability of the lounge and is sufficient to impact at ward and department level in terms of reducing waiting times for emergency admissions. The annual target is a throughput of 2,750 patients. Over the last year, 3,037 patients have been discharged through the lounge. So with an average wait of two hours, we estimate that we have freed about 6,074 hours on the wards when beds are available for new admissions.
The aim of the lounge is to provide a comprehensive service. The referral system has been made as simple as possible. It is now completely paper free at ward level. A telephone call from a nurse or ward clerk is sufficient to initiate the system and ensure rapid transfer to the lounge.
Having achieved an effective process for referral, the role of the patient support worker has been reviewed. It now includes attending the referring ward, packing patients' property and transferring them to the lounge. This service reduces workload for both nursing and portering staff. It ensures that all property and necessary documentation is transferred with the patient.
Pharmacy services have been pivotal to the success of the lounge. An agreement has been negotiated in which the discharge lounge is given priority when dispensing medication for patients on their way home.
This rapid provision of medication has been supported by a development of the role of the pharmacist. A pharmacist or pharmacy technician now visits the lounge on a regular basis to talk to patients about their medications and check that they understand the dosage regime and the possible side effects. Anecdotal evidence suggests that patients are more at ease and willing to ask questions in the peaceful atmosphere of the lounge.
One area of inter-professional working that has been particularly successful is the effective liaison between lounge staff and the ambulance service. As patients are now at a central point, it is more straightforward to rationalise and co-ordinate journeys, therefore reducing the length of time patients wait for transport.
The discharge lounge has been operational for one year. The figures demonstrate that it is a well-used facility. Patients are rarely kept in a bed now because they are awaiting medication or transport.
The discharge lounge has also become a central point of communication between the wards discharging patients, the patient co-ordination centre, pharmacy and transport planning officers.
Our advice to managers considering setting up a discharge lounge would be:
produce a clear operational policy;
disseminate information as widely as possible;
produce a patient information leaflet;
choose an area with easy access;
ensure that the lounge becomes an integral part of the discharge procedure and is used by all appropriate patients.
The lounge has received visitors from other trusts considering a similar scheme and a discharge lounge web page is being developed in the interests of sharing best practice.We plan to review the patient experience and the impact of the lounge on waiting times.
Fiona Cowdell is lecturer practitioner, Beckie Lees is discharge co-ordinator and Michelle Wade is ward sister, Poole Hospital trust.
The establishment of a discharge lounge is believed to have reduced pressure on beds in the wards.
All adult wards refer patients to the lounge, where the average wait is two hours.
The establishment of the lounge has reduced delays for ambulance crews who no longer have to collect patients from several areas of the hospital.
Running costs for the first year were£30,000.
An agreement with the hospital pharmacy has been pivotal to the success of the scheme.