Dr. David Tomlinson, BSc, FRCP, Clinical Systems Engineer
Philippa Robinson, BSc, RGN, Director of Service Improvement and Strategy
Vivienne Rhodes, MBA, RGN, Director of Operations
Kate Silvester, BSc, MBA, FRCOphth, National Lead for Clinical Systems Improvement
Lisa Hollins, BSc, Head of Flow Redesign
Kate Grimes, BSc, MSc, Director of Development

To reduce the variability of the discharge process for patients on an orthopaedic ward at University Hospital Lewisham.

• Number of patients discharged each day from the ward
• Average length of stay for 80 percent of patients discharged each week from the ward

The number of patients discharged each day from the orthopaedic ward showed considerable day-to-day variation with no or very few patients discharged on Saturdays and Sundays. The average length of stay (LOS) varied from 7 to 14 days depending upon the day of the week the patient was admitted.

• Surgeons and/or nurses discussed expected LOS with patient at pre-admission clinic
• Expected LOS recorded in patient notes and nursing notes
• Multidisciplinary team working emphasized
• Improved communication across the multidisciplinary team by the use of an order sheet
• Clear communication of discharge plans to patient and across the multidisciplinary team
• Pre-emptive discharge by senior ward nurse if patient met specified criteria
• Discharge patients on Saturdays and Sundays
• Clear care pathways in place for common conditions

By focusing on the discharge process, the orthopaedic team increased the average number of discharges each day and reduced the average LOS for 80 percent of patients from 13 days to 4 days.

Lessons Learned:

• Giving patients an expected length of stay before admission gave them and the ward nursing staff a clear goal to work towards.
• Senior nursing staff were empowered to set target discharge dates on admission if medical staff had not already done so.
• Use of single A4 sheet order sets to promote communication across the multidisciplinary team ensured that all team members were aware of what had and had not been done as the admission progressed and allowed the ward manager to keep an overview of the patient’s progress towards a satisfactory discharge.
• Senior nursing staff were empowered to discharge patients whose postoperative progress satisfied specific requirements set for that individual patient.
• Ensuring that patients who were waiting for transport (hospital or relative) were transferred to the discharge lounge before 1000 [10:00 AM] to free up the bed before the anticipated demand from emergency admissions, which occurs after 1400 [2:00 PM].
• Encouraging Saturday and Sunday discharges for ambulant self-caring patients to free up beds for emergency admissions over the weekend.

Dr. David Tomlinson, Clinical Systems Engineer
South East London Strategic Health Authority
david.tomlinson@selondon.nhs.uk

[Storyboard presentation at IHI's National Forum, December 2004]