Continuity of care
High hospital readmission rates at South Canterbury District Health Board (SCDHB) indicated that there was room for improvement in the discharge process. Some patients may have been discharged too soon or without suitable arrangements in place for their care in the community. A team of Timaru-based Nursing students undertook research into discharge planning to find out how it could be done more effectively.
They looked at what was happening at Timaru Hospital, working with the Associate Director of Nursing and with the Allied Health Nurse, a qualified physiotherapist. The students also examined some international models of discharge planning to help identify the opportunities for improvement. They recommended adoption of a checklist and a bedside poster with a traffic light system, that will clearly communicate which specialist/s the patient needs to see before discharge and track progress. Such specialists might include a physiotherapist, occupational therapist or social worker. The students designed these resources for the SCDHB.
They also learned that nurses can be too risk-averse, referring patients for specialist advice as a matter of course when in fact that might not be needed. A decision to refer can also be revisited if the patient's situation improves while waiting for the specialist. There is an opportunity to reduce hospital time if nurses are encouraged to trust their own judgement.