Emergency Care Improvement Support Team (ECIST) - slide set from criteria led discharge webinar (6th Jan 2020)

1. NHS England and NHS Improvement
A clear plan for every person
• Clinical criteria for discharge
• Criteria led discharge
@PeteGordon68 #homefirst #wherebestnest

2. 2 |2 |
Don’t over complicate things – keep it as
simple as you can

3. 3 |3 |
Start with the patient (the person) and work backwards –
what would we want to know?
Why is a plan so important?
1. Do I know what is wrong with me or what is
being excluded?
2. What is going to happen now, later today and
tomorrow to get me sorted out?
3. What do I need to achieve to get home? ‘Back to
baseline’ is rarely a useful phrase.
4. If my recovery is ideal and there is no
unnecessary waiting, when should I expect to go
home?

4. 4 |4 |
Practical question - where should the
plan be written?

5. 5 |
• Home when stable
• Home when mobile
• Start discharge planning
• Home after weekend
• Medically fit for discharge
when back to baseline
• Recheck bloods tomorrow
Common phrases – how clear are they?

6. 6 |
Are you thinking
what I’m thinking
Dr Day?

7. 7 |
Example acute kidney injury (AKI)

8. 8 |
Example: GI bleed

9. 9 |
Example - pneumonia

10. 10 |10 |
• Mobility e.g. can walk up to 10
metres (exercise tolerance = 25
metres but toilet 10 metres away)
#EndPJparalysis
• Eating and drinking
• Toilet
• What does the person really want
and have the risks been explained
to them and / or their family?
• Plan to assess at home wherever
possible #homefirst
Functional and emotional criteria are
also important

11. 11 |
A clear plan

12. 12 |12 |
• Purpose to the patient
• Expectations to the relative
• Consistency for the MDT
• Confidence for the junior Dr
• Continuity for the nurse
• Clarity for integrated discharge
teams, social care and
community colleagues
• Assurance for the trust
Clinical criteria and a clear plan gives

13. 13 |
https://improvement.nhs.uk/documents/629/expected-date-of-
discharge-and-clinical-criteria-RIG.pdf
https://www.youtube.com/playlist?list=PL6rrXMWFEqXL5NsTFy7z
ylDbYsAlZWul1
ECIST1On line resources

14. 14 |
What is criteria led discharge?
‘Criteria led discharge is a process where the clinical parameters for a
patient’s discharge are clearly defined. They are determined in
accordance with; a care pathway, a clinical protocol (condition specific)
or a bespoke discharge plan.
The consultant leading the care and the multi-professional team
must agree the criteria; these may be standardised for particular
procedures or conditions, however must always be adapted to provide
person centred discharge.
The patient should be actively involved in the process of criteria led
discharge. The patient's discharge can then be facilitated by a
competent member of staff once those the criteria have been met’.
Dr Liz Lees-Deutsch and Jane Robinson, 2018.

15. 15 | https://improvement.nhs.uk/documents/2040/Criteria_led_discharge_principles.pdf
Dr Liz Lees-Deutsch
Jane Robinson

16. 16 |
Is criteria led discharge safe?
• YES
• 4 articles Bowen at al, Gotz et al, Webster et al and
Kasthuri et al.
• Complication rates
• Readmissions
• These were dependent upon:
• Process used
• Patient selection (removal/reassessment)
• Attainment of goals
• Patient and carer involvement
Dr Liz Lees-Deutsch

17. 17 |
Does criteria led discharge reduce length of stay?
• YES
• 3 studies where this was primary outcome (surgical). Plus
3 where outcome was an indirect result
• On time – by a specific time
• Reduced delays (46% delay to 5% delay)
• No increase in LOS
• Context specific – not generalisable (always localise the
approach)
Dr Liz Lees-Deutsch

18. 18 |
What are the enablers for criteria led discharge?
• Executive support and policy is needed for criteria led
discharge
• Pre-audit of current process against outcomes measures
e.g. length of stay
• Release of clinical staff time to participate in changes
required
• Establishing a multi-disciplinary steering group (shared
vision)
• Identification of the patient populations that would benefit
• Develop clearly defined criteria & associated process with
documentation. Identify staff training needs (across
professional groups)
Dr Liz Lees-Deutsch

19. 19 |
Key points:
•Implementing criteria-led discharge
requires a review of the whole discharge
process
•Criteria-led discharge should be integrated
with the usual discharge process
•Outcome measures must be in place
before a project starts so effectiveness can
be evaluated
•Implementation should help practitioners to
take charge of the revised discharge
process
•Success will come to those who can show
they can safely adapt elements of their
existing discharge process, with clear robust
discharge criteria
Dr Liz Lees-Deutsch

20. 20 |
It’s always good to hear from others

21. Phase 1
Cambridge J
Phase 2
Cambridge L
Phase 3
Cambridge
M2
Phase 4
King’s C2
We Just Did It
Matrons - Paula Knights and Maria Jenner
December 2019

22. Goals of CLD
• Increased weekend transfers (discharge) of care
• Early decisions leading to smooth discharge
• Reduced length of stay
• Improved patient and staff experience
• Improved communication
• Transparency of discharge plan for MDT
• It supports clinical judgement

23. Being Clear on what CLD is:
Commonly misinterpreted as:
‘the transference of total responsibility for the
discharge decision from doctors to nurses’
Lees L. ‘Making Nurse-Led Discharge Work to Improve Patient Care’
Nursing Times Vol. 100 No. 37 September 2004

24. What did we do?
• Started a conversation
• Four meetings
Initial feedback before the launch
of CLD…
• “It’s another job for us to do” – It’s what we do
already.
• “It’s not about quality” – It’s all about quality.
• “I may miss discharging my patients” – nursing teams
are the last contact.

25. After the initial meetings we…
• Identified key team including junior Drs
• Developed SOP
• Developed CLD forms
• Agreed a launch date of 1 November 2019
• Agreed outcome measures
• Introduced board round stickers
• Formulated the rhythm of the process

26. Rhythm of the Process
• Identification on the board round
• Board round sticker completed by the consultant with
medical or functional criteria documented
• Huddle – CLD form/check list completed
• Matron/Manager Call helpline over weekends
• Follow up contact on Monday
• Review of patients not discharged

27. Story so far
• Positive feedback from MDT including junior doctors
• Steering group (terms of reference)
• Competency framework / training programme including
scenarios e.g. would you discharge this patient?

28. Project Data & Outcomes
• Shows a shift in discharge profile demonstrating
increased Friday and weekend discharges during
November 2019

29. Project Data & Outcomes
21+ spiked at 9 Patients on 22 October, and has
reduced to <5 in recent weeks.

30. THE STORY OF CLD – AVON WARD SWFT
Already doing
‘active specialty
pull’ since 2017

31. Clinicians and Risk
Risk averse culture
No one wants to
take risks
Discharge
when
therapy
happy
Discharge
after review
by doctor
How about shared
responsibility and
shared risks?
What if the
patient falls
at home?
What if the
patient is
readmitted?

32. Team attitudes conducive to CLD
• Flattened hierarchy within the team
• Respectful challenge is the norm and encouraged
• Every member of the team has jobs allocated which
they take responsibility for and jobs are allocated
fairly
• No member of the team leaves until all the jobs are
completed. If you finish your work you help others.

33. How did CLD come about?
• Identified weekend discharges had to wait for
medical review prior to discharge-causing
delays
• Nurses- ‘we can facilitate some discharges if
you tell us exactly what is needed’
• Potential for increase in 4-6 (weekend)
monthly discharges if planned well

34. Aims of CLD
Set criteria and
agree
Nurse / junior
doctor
discharges
No need to
WAIT for
anybody senior

35. • Piloted in September 2018
• Audit after 3 months (September-December
2018)
• Further amendments made based on result
• Action continued
PDSA – testing

36. Process:
Proforma developed for manual data capture of
patients that fit into the CLD audit
CRITERIA LED DISCHARGE - FRIDAY PM HANDOVER AUDIT PROFORMA
DATE:
SISTER/WARDMANAGERINCHARGE:
DOCTORINCHARGE:
PATIENT STICKER
WEEKEND
DISCHARGE
YES /NO BY NURSE BY DOCTOR
REASON FOR NO WEEKEND DISCHARGE
/COMMENTS
Criteria proforma adapted to meet Avon ward needs
Dashboard developed to monitor discharges
This sticker is inserted in medical notes to allow safe discharge once patient is medically stable.
Clinical Criteria for Discharge (CCD) written on (DATE) …………………………/ Aim home on (DATE) …………………………
If the following safe clinical criteria is met, the patient can be discharged home by: NURSE □ DOCTOR □.
If patient deteriorates or the criteria are not met, the patient should be escalated for review by the medical team
1. NEWS: Pulse:…………………………………
2. BP:…………………..………………..
3. RR:…………………..………………..
4. 02 Stats:…………………….……….
Temperature:……………………..
Name of Consultant in charge of care: ____________________________________
Name of Dr planning CCD: PRINT _________________________SIGN ___________________________
Dr / Nurse in charge is signing to
 agree that the above criteria is met and patient will be discharged □
 or discharge delayed as criteria is not met □
Print Name ________________________ Signature_________________
Date: ___________________Time : __________________________________

37. This sticker is inserted in medical notes to allow safe discharge once patient is medically stable.
Clinical Criteria for Discharge (CCD) written on (DATE) …………………………/ Aim home on (DATE) …………………………
If the following safe clinical criteria is met, the patient can be discharged home by: NURSE □ DOCTOR □.
If patient deteriorates or the criteria are not met, the patient should be escalated for review by the medical team
1. NEWS: Pulse:…………………………………
2. BP:…………………..………………..
3. RR:…………………..………………..
4. 02 Stats:…………………….……….
Temperature:……………………..
Name of Consultant in charge of care: ____________________________________
Name of Dr planning CCD: PRINT _________________________SIGN ___________________________
Dr / Nurse in charge is signing to
 agree that the above criteria is met and patient will be discharged □
 or discharge delayed as criteria is not met □
Print Name ________________________ Signature_________________
Date: ___________________Time : __________________________________CTMS No:________________________
The stickers have been modified
with time by the team.

38. • Start thinking of patients suitable for CLD on the Thursday
board round (All the team agree, challenged and are aware)
• Firm up the list on the Thursday ward round
• Make sure this is communicated to the patient and family on
Thursday
• TTOs done for those patients between Thursday afternoon
and Friday AM (tasks allocated)
• Check again on Friday board round
The Process…1

39. • Friday PM - CLD stickers with clear criteria put on patient
notes – Nurse Discharge or Medical discharge
• Complexity of the patient decided whether it was the nurse or
doctor and was allocated only after discussion and
acceptance from the team
• Monday morning – review list to check if any patients were
not discharged and why – Education and feedback to the
team
The process …2

40. Challenges/Hesitation - Avon
• Lack of confidence with CLD
• Lack of understanding: why the need to
change what is already working
• We are already doing well-CLD will be extra
work- are we setting ourselves to fail?
• Perhaps try it on a ward with much longer
LOS

41. • Variable confidence within Nurses
• Junior doctors felt it was more work
• Friday handovers – too long – unable to
complete TTOs
• Finding justifications to delay discharge as the
criteria missed slightly
• Long list for ‘Out of hours’ tasks generated by
the junior doctors
Barriers

42. Overcoming Barriers
• Variable confidence within
Nurses
• Junior doctors felt it was
more work
• Friday handovers – too long
– unable to complete TTOs
• Finding justifications to
delay discharge as the
criteria missed slightly
• Long list for ‘Out of hours’
tasks generated by the
junior doctors
• Shared risk
• Checking if confident
before putting the sticker
• Supporting junior doctors
when completing exception
reporting
• Allowing them to peel off
certain handovers when
not needed
• Helping them plan the
weekend work

43. Audit Outcomes

44. Criteria Led Discharge Audit
(Sept 2018 -Dec 2018) Results
Total no. highlighted for CLD 47
Number of patients discharged using criteria 36 (75%)
Failed d/c due to medical reasons 5 (10%)
Failed d/c due to social reasons* 4 (8.5%)
Failed d/c due to other/unknown** 2 (4.2%)
No. of CLD requiring medical review 13 (28%)
*Mostly POC/NH placement not ready to start
**e.g. Family concern over mobility/Therapy issue

45. CLD examples
CCF Excess alcohol

46. Outcomes a year into CLD practice

47. Emergency Admissions; Avon LOS
Active Diabetes
pull and POW Criteria Led
Discharge

48. 2016/17 2017/18 2018/19 2019/20
Predicted 0 0 0 82
Recorded 73 100 125 62
0
20
40
60
80
100
120
140
160
NumberofWeekendDischargesfortheYear(NB
2019/20=5months)
Avon Weekend Discharges
Active Diabetes
pull and POW
Criteria Led
Discharge
25

49. Avon Total Discharges
2019/20 whole year prediction for total discharges is 1079 pts – a rise of over
20% to previous year
2016/17 2017/18 2018/19 2019/20
Predicted 0 0 0 630
Recorded 605 724 887 449
0
200
400
600
800
1000
1200
TotalNumberofAonDischargesfortheYear(NB
2019/20=5months)
Active Diabetes
pull and POW
Criteria Led
Discharge
163

50. Quote by Consultant..

51. Lessons Learned
CLD is a culture change – it is not about stickers only
CLD is not about weekend discharges only – Once the culture changes it has a
profound effect on week day discharges
CLD is a tool for ‘timely discharge’ and instrumental in LLOS
CLD is not about weekend or weekday discharges only – part of the ‘SAFER patient
flow bundle’

52. 52 |52 |
Discussion