Generalised discharge process mapping

During the interviews, participants were asked to describe the discharge process at their hospital. This alongside prompts from the researcher elicited a discussion of a step-by-step discharge process at each hospital. From gathering and analysing the data, it was found that the general discharge process was similar in all hospitals. Minor differences were found in the members of staff who undertook each step in the process, or in those hospitals who had implemented innovative discharge processes to improve discharge as discussed within the individual themes.

This phase of the PoW aimed to identify the current discharge process and evaluate it.

It was important to get to the root of the problems at discharge and one way of helping to do this was to map the process out. Not only does mapping out the process help to clarify a complicated multistage process, it also helps to identify areas where improvements can be made. The steps involved in the discharge process are mapped in the form of a flowchart (see Figure 4-1), based on the standard discharge processes for all hospitals that participated in the study. This is a generic process that could be applied to each hospital that participated in the interviews, and therefore does not take into account any innovative schemes, any steps in the process from hospitals that did not take part, or any emergency situations. Subsequently, this model is applicable to the hospitals that participated in this phase, however individual hospitals across the UK may show minor variance from this generalised model.

The stages where issues were identified within the discharge process have been highlighted on this generalised model, using the findings discussed throughout this chapter. The shaded areas on the flowchart represent the stages in the discharge process where problems were identified in the findings.

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This map of the discharge process in combination with the findings around where issues arise in the process will provide the foundation for the development of the new model of care.

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Figure 4-1 – Generalised discharge process in acute hospitals across North West England showing issues identified by pharmacists

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A stepwise discussion of the generalised discharge process is detailed below. The labelled roman numerals refer to the individual steps of the discharge process, as seen in Figure 4-1.

(i) After a medical review, when a patient is deemed medically fit, a consultant or other senior medic will make the decision to discharge the patient. The patient is told at this point that they can be discharged.

(ii) After the decision to discharge has been made, a discharge prescription (TTO) and summary of the inpatient episode are written. This is traditionally carried out by a doctor involved in the patient’s care during the admission. This may also be carried out by a non-medical prescribing pharmacist.

(iii) The ward based pharmacy team are made aware that the discharge prescription is written. If there is no ward based pharmacy team, this communication will be with the pharmacist in the pharmacy dispensary.

(iv) The next stage is the verification of the discharge prescription by a pharmacist, to ensure that the medication prescribed at discharge is complete, safe and all required information is included. The pharmacist identifies if there are any issues with the discharge prescription and contacts the prescriber to rectify them if applicable.

(v) A full list of the patient’s medication is documented on the discharge prescription, but only those required will be supplied. The patient’s medication on the ward is compared with the medication listed on the discharge prescription. The patient will usually then be asked what medication they have at home and the discharge prescription will be annotated to say which, if any of the medications need supplying on discharge. This role is usually by the ward pharmacy team, i.e. the technician, or pharmacist if a technician is not available. In some cases, nursing staff will be involved in asking the patients about their medication supplies at home, or they may send any medication to the

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pharmacy dispensary for checking there. This would only be if the ward based pharmacy team was not available.

(vi) Dispensing the required medication for discharge is traditionally done in the pharmacy dispensary, although if the facilities are available, it can be done on the ward. Regardless of where the prescription is dispensed, a member of the pharmacy team, usually pharmacy assistant or technician, will label and dispense the required medication on the discharge prescription.

(vii) A suitably qualified member of the pharmacy team will then perform an accuracy check to ensure that the correct medication, quantities and directions for use have been supplied for the patient.

(viii) For discharge prescriptions dispensed in the pharmacy dispensary, the completed discharge prescription is delivered to the ward by the pharmacy team, a porter or collected by nursing staff from the ward. For those dispensed on the wards, no delivery is required as the medication will be ready on the ward.

(ix) Once the medication and completed discharge summary is ready on the ward, and any other arrangements have been put in place, the patient can then be prepared for discharge. The discharge medications are checked against the prescription and the patient is counselled, usually by the nurse.

(x) The patient is then discharged with a copy of the discharge summary and medication.

(xi) The completed summary including the prescription is sent to the patient’s GP and the community pharmacy if appropriate. Other healthcare professionals may also be sent a copy on an individual patient need basis, for example a district nurse or the care home.

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