The Discharge Process

Hi everyone,

I was recently chatting to a friend whos mother was admitted into hospital for a surgical procedure.  He mentioned that although the discharge process went smoothly enough, it was a pretty overwhelming experience, not only for his mother, but also himself.  Talking to him about it, I realised that the discharge process could be pretty full on for someone who isn't use to it (like most of the general population apart from those working in the health field!).  This made me look at how I discharge patients, and how I could make them more comfortable and relaxed about their transition home.  

I work within a rehabilitation ward which sees a lot of orthopaedic patients post surgery, so to make life a bit easier, for this post I'm going to relate it back to someone who has had a total hip replacement (THR).  Everyone loves a good case study so let me introduce you to Mary who is a 69 year old woman who is day 9 following a left THR.  She was pre-morbidly active, playing golf twice a week, attended to her own shopping and activities of daily living and lived alone in a single story home.  She spent 4 days in a surgical ward before being transferred to us in rehab.  It has been a pretty straightforward recovery so it's looking like Mary will be going home in a few days time.  

Can anyone see any potential issues with her discharge so far?  I feel a few of you would be saying 'well, she lives alone and she has had surgery... is she going to be able to cope being alone on discharge?'  We need to find this out ASAP so if needed, we can start to arrange services for her on her discharge home.  How do we find this out?  Well we observe her with performing activities of daily living, we ask her how she thinks she is going, we can ask her family if they have any concerns and we can ask other health professionals involved in her care, in particular, Occupational Therapists.  

For those of you who are unfamiliar with caring for patients following a THR, they can have quite strict precautions regarding movement which may include a 90 degree bending restriction.  This can make showering, dressing and bending over to pick things up virtually impossible without either an aid such as a pick up stick, or assistance from another person.  Therefore we need to make sure Mary can do these activities by herself before we send her off home where she lives alone.    

Mary might also be concerned about her wound.  As well all know, different surgeons have different preferences regarding wound closure and consequently, wound management for each individual will be attended accordingly.  We need to look at Mary's wound and identify any potential issues for discharge.  Will she need district nurses to come and visit her for wound management?  Can she visit her local GP for a wound review?  Is it as simple as Mary herself taking off her dressing in a few days time because it's all healed up?  We need to determine this as early in her admission as possible so we can make any arrangements needed as well as informing Mary and her family on these arrangements.    

We also need to educate Mary on her pain management on discharge.  This must be done throughout her admission process so we don't overload her with information on the day she goes home!  We want her to be in control of her pain and aware of pain management strategies (such as heat, ice, pacing exercises) and also use of analgesic medications.  We may also want to educate family members on this as well if Mary might need some assistance at home with this.

Another thing Mary must be aware of (and that nurses LOVE to talk about) is bowel management.  We don't want Mary getting home and becoming constipated because we told her to regularly take the analgesic medications which have now bound her up!

Then we also have to look at the 'housekeeping' details of discharge.  This can be arranging follow up appointments, ensuring Mary has all of her scans and X-rays with her, that she has no valuables in the hospital anywhere, that she understands what medications she is taking, any exercises she must be doing and most importantly, that she has someone to come and pick her up!

On the day of discharge, it's important to go over all these details with Mary again to make sure she understands, which if we have been educating her during her stay on the ward, she should be able to recite everything back to us nearly word for word!  It's a good time as well if her family are present to go over these details with them.  As my friend who I mentioned earlier in the post said, it's a pretty overwhelming experience!  And one of our goals during the discharge process should be to alleviate any anxiety the patient and their family may have on leaving the hospital.

What do you think?  Have I missed anything that you do?  Let me know :) 

Feel free to also check out the links below.  These have a bit more info on the discharge process and also what carers of patients can do to make this a less overwhelming experience.

Next Step in Care website

NSW Government Health - Going home from hospital

Caregiver - Hospital discharge planning guide