Ready, steady, go

Harrogate Health Care trust opened a discharge lounge in June last year on a trial basis as part of a package to cope with winter bed pressures. Although the majority of patients organise a fairly rapid departure from hospital, a significant number continue to occupy a bed for several hours before leaving. This often leads to new patients having to wait in accident and emergency or at home in anticipation of a bed becoming available later in the day.

Delays may be caused by patients waiting for ambulances, drugs to take home, relatives to pick them up, final advice from the dietician or physiotherapist, or for discharge documents.

Patients awaiting discharge may be sent to sit in day rooms. But this increases pressure on staff who have to look after new patients as well as those waiting for discharge. This, in turn, can lead to further delays in finalising discharge arrangements.

Moving patients due to be discharged to a dedicated area releases ward beds and leaves nurses free to attend to new patients. Patients and relatives benefit from having a dedicated nurse to address their needs. The innovation has been welcomed by patients who have used it. But referrals are spasmodic and the reluctance of some wards to use the discharge lounge must be addressed.

In choosing a site for the lounge, it was important to find an area that would maintain the patient's dignity, comfort and safety until final discharge from hospital without causing disruption to existing services. After looking at various possibilities, we settled on taking over half the rehabilitation waiting room next to the day hospital. We provided 10 comfortable chairs, with foot stools and bed tables, a coffee/tea and sandwich machine, a colour TV and a telephone. Books and magazines were also provided, and we made sure there was easy access to toilets and changing rooms and resuscitation equipment.

The next task was to look at staffing. It was essential to have a trained staff nurse, but two would have been prohibitively expensive. We decided to use one staff nurse from the nearby day hospital, together with a bank staff nurse. They would both work in the day hospital and cover the discharge lounge one at a time. The volunteer co-ordinator provided, at very short notice, a team of volunteers who would support the nurse. The volunteer helps by providing refreshments for patients, taking them to the toilet, talking to them or playing games, picking up medication and transferring patients' notes.

The next step was to develop protocols for admission from the wards and to liaise with the ambulance service, portering, pharmacy, and to inform all wards and departments of the procedures for accessing the unit.

The discharge lounge is available to everybody except children, terminally ill people, stretcher cases and patients with marked confusion or disruptive behaviour. The opening hours were originally 9am-4pm, Monday to Friday, but this was later changed to 10am-5pm to take account of the significant number of patients who are discharged from wards late in the afternoon.

The information recorded for audit purposes comprises: date and time of arrival; transferring ward; reason for transfer; time of discharge; length of stay; means of discharge - ambulance or own transport; any comments or problems.

Originally, ward clerks on each ward phoned the discharge liaison nurse with the names of patients due for discharge the following day. This has since been improved and transfers are now accepted on the day. The ward clerk ensures that relatives are aware of the transfer to the discharge lounge.

Relatives or carers are requested to take flowers and excess baggage home the night before. Patients are transferred to the discharge lounge at 10am with all their luggage clearly labelled. The ward daily return is completed with the patient's final destination via the discharge lounge (DL), plus the code for transfer home, for example 19, so it would read 19DL.

All arrangements have to be completed before patients go to the discharge lounge. After the ward nurse has explained the discharge plans and arrangements to the patient, the discharge letter is finalised and signed by the patient and carer. Case notes are placed in a sealed envelope, clearly labelled with the name of the place the notes are to be returned to. Patients can transfer to the lounge before they have been given their take-home drugs, provided the pharmacy is aware that these are to be sent to the discharge lounge.

Porters transfer all patients to the discharge lounge as soon as possible after they are notified by the ward, or discharge liaison nurse.

The lounge has proved popular with patients. We gave out 100 questionnaires to patients as they left the discharge lounge. A pre-paid envelope was provided and 89 were returned. The questionnaires asked whether patients had been comfortable, whether staff attitude and refreshments were satisfactory and whether relatives could locate the discharge lounge easily. The responses were very positive. Patients commented on the comfort and relaxed atmosphere.

Removing patients and carers from a busy ward where they feel in the way to an environment where they are the focus of attention has been widely welcomed. But referrals are spasmodic and appear to contradict what is happening on the hospital's wards. An evaluation of why patients were not being transferred revealed several factors. When the wards are in crisis and there are no beds, for example, staff have said they do not have time to discharge the patients to the lounge as they are too busy with admissions and critical care.

Some wards also appear to retain patients for other reasons, preventing further admissions. Medical wards have a reluctance to send patients with a history of chest pain, even though they are going home. These areas need to be addressed.

Staff on the wards have been reminded to transfer patients irrespective of whether the ward is quiet, thus ensuring the maximum possible use of the discharge lounge.

All patients waiting to go home should be sent to the discharge lounge - apart from the exceptions listed earlier.

When the discharge lounge becomes permanent, a small clinical area would be helpful to allow the nurse to change dressings and remove catheters, which would relieve pressure on the ward nurse. Also, more chairs with high seats are needed for elderly and orthopaedic patients.

The discharge lounge has maximised ward bed use. Patients spend their last hours at the hospital in a relaxed environment, where they feel valued as people again rather than as patients, and it has also given them the opportunity to discuss any lingering concerns.

The ambulance service has benefited from having most of its patients in one central holding area instead of being scattered over numerous wards. This increases efficiency.

The discharge lounge may help to avert a winter bed crisis. We have implemented other changes to speed up discharge, including, in conjunction with social services, weekly monitoring of delayed discharges, one-stop pre-admission clinics run by nurses, and extended ambulance cover to allow for discharge at weekends.

The discharge lounge has been a success, and 1998 will see it move to a permanent site. If weekend discharges become the norm we would consider keeping it open seven days a week.

We receive many requests for information from other trusts - the word has been spread by satisfied patients and a delighted ambulance team. Anyone thinking of setting up a discharge lounge should consider siting it near an existing unit, such as a day hospital. In this way, if the lounge is empty, staff can be working to benefit other patients. And the nurse in charge needs to be enthusiastic, constantly ringing round the wards to remind staff to send patients down. The use of volunteer support workers can keep costs down. Finally, it is important to evaluate the system and keep all staff informed of the results.