Consumer involvement
One of the key principles of CLD is including patients, their family and/or support person in the process. Information for patients and families about CLD is essential for successful implementation (ACI 2016).
Patients and their family/support person should:
- Actively participate in discharge planning, which should begin before the day of surgery.
- Be informed about their:
- Estimated Discharge Date (EDD).
- Criteria/milestones that need to be achieved to go home safely.
- Progress towards the discharge criteria/milestones.
- Receive written information outlining the CLD process.
The surgical team should inform the patient, their families or support person they:
- have been selected for CLD.
- may not be reviewed again by a member of the surgical team before discharge.
- will be discharged by a member of the Multidisciplinary Team who has the appropriate training and expertise.
Regular consumer feedback should be sought until CLD is embedded in usual practice and beyond to enable continuous quality improvement.
See the Appendix for examples of the CLD consumer leaflets and visual material for promotion on the ward (NHS 2017; NHS 2019b ACI 2016;NHS 2017).
Discharge policy and governance
A discharge policy must be in place to guide the introduction and governance of CLD. As a minimum, when developing a CLD policy and governance structure, the following needs to be considered:
- The context of your organisation.
- Current discharge policy.
- The processes for selecting suitable patients for CLD.
- Development of clinical criteria for discharge.
- Care pathways e.g: day surgery or Enhanced Recovery After Surgery (ERAS).
- Clinical protocols e.g.: escalation pathways for the deteriorating patient.
- Transfer and handover of patients
- Processes for escalating failure to meet discharge criteria/change in estimated discharge date.
- Staff training protocols to ensure ongoing staff competency to perform CLD.
- Discharge documentation requirements for the patient and discharge information for GP, other community providers and specialists.
- Consumer information.
(NHS 2019b)
Governance structures need to be in place to support ongoing continuous improvement during the introduction of CLD and for sustainability long term. This ensures both effective and sustainable CLD processes. See Appendix 2 for an example policy.
Patient selection
Patients should be identified ‘as suitable’ for CLD prior to, or on admission. This will depend on their clinical stability and complexity of their clinical condition. (NHS 2019b).
Generic exceptions to CLD include:
- High-risk patients.
- Patients who are medically unstable.
- Patients who require a medical decision.
- Those waiting to be referred to another specialist.
(NHS 2019b)
Extra consideration about suitability should also be given to patients:
- With inadequate support or safety concerns at home.
- Who require in-depth allied health review.
These patients may still be suitable for CLD but will require additional planning and development of individualised milestones and discharge criteria.
For planned surgery, identifying patients who are suitable for CLD may commence prior to admission, however, this needs to be confirmed post-surgery to ensure that there haven’t been any unexpected surgical complications that could affect suitability for CLD (ACI 2016; NHS 2019b).
Health services that have introduced CLD in planned surgery cohorts have found opt-out systems more effective than opt-in. In the opt-out approach, the surgical team identifies patients who are not suitable and revokes their participation in CLD.
CLD documentation and handover
The CLD plan must be documented in the patient’s medical records. This should include:
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The EDD should be clearly documented and communicated with the patient and all members of the multidisciplinary team. This should be reviewed regularly and updated as required. Health services introducing CLD have found that documenting the EDD on a patient communication board helps improve communication and discharge planning with patients and their families.
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The Surgical Team in charge of the patient’s care must document the criteria, including clear clinical parameters, that must be met before a patient can be safely discharged (NHS 2019b; NHS 2019c).
The criteria will be either:
- Group criteria: specific to a group of patients, in accordance with agreed clinical protocols or care pathways. (Suitable for simple planned surgery e.g. day surgery cases).
- Individualised criteria: based on clinical complexity and need (e.g., for patients with multiple complex health needs). Clearly defined and documented by Surgical/Medical team.
- Combination of Group and individualised criteria: based on clinical need (Suitable for most planned surgery procedures and uncomplicated patients).
The approach taken depends on the clinical setting and nature of patient discharge, such as simple or complex discharges (NHS 2019b).
Criteria for planned surgery patients can often be established preadmission, for example in a preadmission clinic, to facilitate discharge planning prior to admission. However, it is crucial to review and adjust these criteria as necessary after surgery.
When establishing “minimal group criteria” for a patient cohort, all relevant parties, including all craft groups and consumers, must collaborate. The specific groups involved will depend on the clinical setting and patient cohort. (NHS, 2017)
Examples of CLD documentation and criteria for discharge can be found at Appendix 3
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It is important to provide information to the patient and their family/support person that will support their transition to home.
Information should include:
- Medication plan.
- What is expected post-surgery.
- What the patient can do to relieve symptoms.
- When and where to seek help.
- Any changes to the patient routine e.g. mobility restrictions or diet changes.
- Follow up appointments and where to go for more information.
This should be provided in plain language and explained to the patient. Appendix 4 provides a template that can be adapted to meet local needs.
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Effective communication is vital for ensuring safe and high-quality care (ACSQHC 2023). To enhance care continuity and reduce readmission risks, patients should receive a printed discharge summary before leaving hospital. Additionally, a comprehensive summary should be sent to the GP, primary care providers, and other involved specialists within 48 hours.
For planned surgery patients this should include:
- Postoperative thromboembolism prevention plan.
- Medicines on discharge including duration and plan for restarting paused medications. A downloadable interactive medicines recorded for consumers can be found at Resources | Safer Care
- Ceased medicines including reason for ceasing.
- Clinical recommendations (this should include any follow-up care required and who is responsible e.g: wound review/removal of sutures etc, follow-up of pending results).
- Follow-up appointments – when, where and with whom? Who is responsible for booking them.
- Selected investigation results.
- Any limitations the patient has e.g. movement/mobility restrictions.
- When and where to seek support if a complication occurs.
(ACSQHC 2017)
Sometimes, a written discharge summary isn't enough. For instance, if a patient was unable to be discharged using CLD due to medical
complications needing extra support from the primary care team, a more detailed handover might be necessary. This could involve a phone call to the GP.
To ensure the discharge summary is sent to the correct person it is important to confirm GP and/or other provider details with the patient upon admission.
Please review the National Guidelines for On-Screen Presentation of Discharge Summaries | Australian Commission on Safety and Quality in Health for further information about discharge summaries.
Systems to monitor and escalate care
Internal procedures for escalating clinical concerns are essential for safe and effective CLD (NHS 2017). EDD and the progress of the patient against the discharge criteria should be reviewed daily. If the patient becomes medically unstable or unsuitable for CLD, a clear escalation process to the surgical/medical team should be followed and clearly documented. CLD thrives in a truly multidisciplinary team environment. The use of regular multidisciplinary team meetings/huddles to keep all relevant staff informed of the patient’s wishes and progress towards their discharge criteria and EDD helps to ensure patients remain on track to achieve their milestones and offers the opportunity to escalate any concerns (NHS 2017). Staff conducting CLD need to know how and whom to escalate any concerns about the patient’s actual suitability for discharge
Education and training
Involving frontline staff from the onset of CLD introduction facilitates effective planning, education, and training. Tailored training by experienced practitioners, supported by senior clinicians, is crucial for safe effective CLD.
Training to undertake CLD needs to be service or setting specific and contingent on the individual experience and expertise of the registered practitioner (NHS 2019b).
Upon completion of training, a CLD-trained multidisciplinary team member should be able to:
- Locate and read CLD protocol/policy.
- Discuss the benefits of CLD for:
- The patient, their family/support person
- All staff
- The organisation
- Discuss the expectations of the health professional within the CLD process.
- Discuss the required authorisation from surgical/medical team for CLD to occur and identify where this required information is documented.
- Discuss the surgical review requirements for a patient on a CLD pathway, including escalation of care considerations. This should include a discussion of when a patient may not be suitable for CLD or when the EDD may change.
- Demonstrate discussion with the patient, their family/support person explaining the CLD process.
- Highlight some of the issues that may need addressing when discharging a patient via CLD.
- Discuss the discharge follow up required and how this is arranged.
(NHS 2019b)
An example of a staff competency worksheet and an example of staff promotional material are available in Appendix 5.
Reviewed 01 November 2024