CHAPTER 52. Discharge Planning
Extended Observation, Home and Follow-Up Care
Susan Fossum
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Describe guidelines for extended care and observation.
2. Describe the best times for planning patient discharge.
3. Identify appropriate discharge instructions that should be provided to the patient and family/caregiver.
4. Describe guidelines for discharging the ambulatory surgical patient.
5. List postdischarge follow-up techniques.
I. DISCHARGE PLANNING
A. Definition
1. Discharge plan individualized to meet specific patient needs; involving patient and family as active participants along with interdisciplinary team
a. Ambulatory surgical patient needs
b. Extended care/observation patient needs
c. Patient transferred to long-term care facility
d. Postdischarge follow-up.
2. To ensure safe and efficient discharge process
3. Assessment findings will guide interventions.
4. Ensure implementation of cost containment strategies.
5. Implement measures to improve patient outcomes and satisfaction.
B. Process includes:
1. Identification
2. Assessment
3. Goal setting
4. Planning
5. Coordination
6. Implementation
7. Evaluation
C. Initially takes the form of patient assessment
D. Primary goal for ambulatory patient—in a minimal period, patient will be:
1. Clinically stable, “home ready,” “fit for discharge”
a. Hemodynamically stable
b. Mental status returned to baseline
c. Pain at a manageable level
d. Minimal nausea/vomiting
2. Safely discharged
3. Returned to “preprocedure” level of function
E. Extended observation level of care
1. Admission criteria
a. Clinically stable but needing extended care
b. Awaiting transportation home
c. Patients with no caregiver
d. Patients having procedures requiring extended observation/interventions
(1) Risk for bleeding
(2) Pain management
(3) Postoperative nausea and vomiting
(4) Dizziness
2. Provide follow-up for extended care as indicated.
a. Ongoing assessment and management
b. Medication management
c. Review of discharge instructions as appropriate
d. Safe transfer of care including structured handoff process
3. Extended observation staffing
a. Two competent personnel, one of whom is an RN possessing competence appropriate to the patient population
b. One RN to 3 to 5 patients
c. Additional registered nurse and support staff as dependent on:
(1) Patient acuity
(2) Patient census
(3) Physical facility
F. Discharge planning should begin as soon as possible.
1. Individualized to patient-specific identified needs
a. Cognitive ability
b. Pain assessment
c. Medication history
d. Laboratory and diagnostic testing
e. Cultural and language preferences
f. Advanced directive
2. Starts at the time patient is scheduled for the procedure or hospital admission
3. Discussed at the time of the preadmission visit
a. Comprehensive history is key tool in discharge planning.
b. Type/duration of surgery/anesthesia taken into consideration
c. Available support systems conducive to home management discussed
d. Identification and resolution of physiological home care problems
(1) Fall risk assessment
(2) Physical barriers that impede normal activities of daily living
(a) Ability to shower
(b) Mobility in home environment (stairs, tub, etc.)
(3) Equipment needed (crutches, canes, wheelchair, continuous passive machine, wound vac, etc.)
(4) Supplies needed (dressings, medications, etc.)
4. Review and reinforce plan in preoperative holding unit.
a. Obtain comprehensive nursing history (if not done previously) to include:
(1) Personal coping deficits
(2) Family and community support available
(3) Geographic isolation
(4) Physical limitations
5. Planning discussed in phase II/extended observation with patient/next caregiver before discharge
G. Discharge planning addresses:
1. Safe home environment
2. Availability of responsible adult caregiver
3. Safe transportation home
a. Two responsible persons when transporting infant or child, one to attend to child while other drives vehicle
b. Place child in appropriate-sized car seat or with seat belt.
4. Safe transfer of care to next responsible caregiver
5. Access to medical care after discharge
6. Postsurgical issues: pain management, complications, resuming of daily activities, work, school, etc.
H. Guidelines for discharge of ambulatory surgical patients include:
1. Organizational guidelines
a. The Joint Commission
b. Accreditation Association for Ambulatory Health Care
c. Ambulatory Surgery Center Association
d. American Society of PeriAnesthesia Nurses
e. American Society of Anesthesiologists
f. American College of Surgeons
2. Institutional guidelines
a. Detailed process developed in consultation with and approved by:
(1) Nursing
(2) Anesthesia
(3) Medical Staff
3. Process includes:
a. Protocols
b. Policies
c. Collaborative practices
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