Elective Surgery Programme Implementation Support Guide

look at it within the context of an integrated care pathways, both of which might be expected to
derive greater benefits from discharge planning.
In 2008, the HSE published, „A Code of Practice for Integrated Discharge Planning‟. (4) In it they
endorsed
Integrated discharge planning – and as part of an overall Integrated Care Plan (See
Chapter 1)
Pre-admission assessment for all patients
The starting of discharge planning as soon as possible in the patient journey
Discharge planning being the responsibility of healthcare providers in partnership with
the patient, their family or carers
The need for a Discharge Co-ordinator
Nurse (or other healthcare professional) facilitated discharge
The need for close liaison between the hospital and primary and community care
In 2009, the Offices of the Nursing Services Director of the HSE published, The Guideline for
Nurse/Midwife Facilitated Discharge Planning. (5) This excellent document highlights many of
the points set out in the process outlined below and includes Discharge Tracking Form
(APPENDIX 1), a helpful Patient Information Leaflet (APPENDIX 2), a Discharge Checklist
(APPENDIX 3), and a Discharge Transfer Communication Record (APPENDIX 4) which have,
by kind permission, been reproduced here.
The Discharge Process
Before admission
As part of the Surgical Care Plan See (Chapter1 – APPENDIX 1) the length of hospital
stay should be estimated, discussed and agreed with the patient and family and
documented.
At the Pre-admission assessment clinic the discharge plan should be confirmed taking
into account the patient‟s pre-admission abilities in relation to their post discharge issues
so as to optimise health status with the support of primary care and all relevant AHP
services (Medical Social Worker, Occupational Therapy, Physiotherapy, Dietitian) before
planned admissions.
The surgical team and the pre-admission assessment clinic should keep each other, and
the bed management department, informed if patients are highlighted as potentially
complicated discharges so that a discharge destination can be identified, where
possible, and also to avoid multiple complex discharges occurring on the same day.
92 Model of Care for Elective Surgery